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The nurse should counsel the client to keep the total cholesterol level under 200 mg/dL. This will aid in the prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life. Options 3 and 4 are elevated values and place the client at risk for cardiovascular disease. Although option 1 is a low cholesterol level, option 2 identifies the realistic value to assist in preventing cardiovascular disease. 2. Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL. 3. Creatine kinase (CK) is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CK from skeletal muscle. The BB band reflects CK from the brain. There is no MK band. 4. The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. 5. The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A level of 2.4 ng/mL exceeds the therapeutic range and indicates toxicity. The most important action is to notify the physician, who may give further orders about holding further doses of digoxin. Option 3 is incorrect because the level is not normal. The next dose should not be administered because the serum digoxin level exceeds the therapeutic range. Checking the client’s last pulse rate is not incorrect but may have limited value in this situation. Depending on
the time that has elapsed since the last assessment, a current assessment of the client’s status may be more useful. 6. The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client’s aPTT is within the therapeutic range, and the dose should remain unchanged. 7. The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 1 is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. Options 2, 3, and 4 are within the normal range. 8. Foods that are lower in sodium include fruits and vegetables (option 4), because they do not contain physiological saline. Highly processed or refined foods (options 1 and 3) are higher in sodium unless their food labels specifically state “low sodium.” Saltwater fish and shellfish are high in sodium. 9. Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat food. 10. Pt with hypertension foods Smoked foods are high in sodium. Options 1, 2, and 4 are fruits and vegetables that are low in sodium. 11. When performing cardiopulmonary resuscitation (CPR) on an adult client, the sternum is depressed 1½ to 2 inches. Options 1 and 2 identify compression depths that would be ineffective in an adult. Option 4 identifies a depth that could cause injury to the client. 12. When performing cardiopulmonary resuscitation (CPR) on adults, the ratio of chest compressions to breaths is 30:2. 13. Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and 1
Cardio Rationales Saunders associated symptoms). Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. 14. Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain. 15. On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet). 16. Metformin (Glucophage) needs to be withheld 48 hours before and 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 options 1, 2, and 3 do not need to be withheld 48 hours before and after cardiac catheterization. 17. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Digoxin will further decrease the client’s heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Continuing to monitor the client delays necessary intervention. 18. Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia.
Strict sodium restrictions are reserved for clients with severe symptoms. 19. Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. 20. Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart. 21. Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway. 22. Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering 23. The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias. 24. Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. 25. Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. Elevated temperature and white blood cell
Cardio Rationales Saunders count after 3 to 4 days postoperatively usually indicate infection. 26. The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or glomerulonephritis. 27. The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 and 4 will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed. 28. Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. 29. 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 higher than 100 beats/min. 30. Motion artifact, or “noise,” can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and cable disconnection. 31. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate
between 140 and 180 impulses/min. The rhythm is regular. 32. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. 33. First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is contraindicated. 34. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. Options 1, 2, and 3 will not assist in terminating the dysrhythmia. 35. The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. 36. Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each
Cardio Rationales Saunders QRS complex. The atria quiver, which can lead to thrombi formation. 37. Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm. Options 2, 3, and 4 are incorrect descriptions of this procedure. 38. Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. 39. Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. Lidocaine may be given subsequently but is not required before defibrillation. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. 40. The client may be defibrillated up to three times in succession. The energy levels used are 200, 300, and 360 J for the first, second, and third attempts, respectively. 41. After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation.
42. The nurse or rescuer puts two large adhesive patch electrodes on the client’s chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if defibrillation is necessary. 43. An automatic internal cardioverterdefibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes related to ventricular tachycardia. 44. In the first several hours after insertion of a permanent or a temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client’s activities of the arm on the side of the insertion site. 45. Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. 46. Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with hook and wires via multiple small incisions in the leg. 47. Hypersensitivity or a sensation of “pins and needles” in the surgical limb may indicate temporary or permanent nerve injury 4
Cardio Rationales Saunders following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported. 48. The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger’s disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component. 49. Raynaud’s disease responds favorably to eliminating caffeine from the diet and cessation of smoking. Medications may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms still could occur with the use of air conditioning and during periods of cooler weather. 50. After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any other postoperative client. 51. An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block. 52. This test is an alternative to the exercise thallium-201 scan. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as should bronchodilators such as theophylline. Theophylline may decrease the effects of dipyridamole. The client does not have to avoid the items identified in options 2, 3, and 4.
53. Blood pressure should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Finally, two or more BP readings should be averaged 54. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Therefore, options 2, 3, and 4 are incorrect interpretations. 55. Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant. 56. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the “heart beating” in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. 57. Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of renal failure. Renal failure can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. The nurse monitors hourly intake and output and notes the results of daily blood urea nitrogen and creatinine levels. Urine output lower than 30 to 50 mL/hr is reported to the physician. 58. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is 5
Cardio Rationales Saunders evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. 59. The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea, vomiting, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias. Options 1, 2, and 3 are unrelated to digoxin therapy. 60. The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea, vomiting, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias. Options 1 Client allegoric to iodine, 2 client with DM, and 3 client has a biological porcine valve are unrelated to digoxin therapy. 61. Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. 62. The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Aminocaproic acid is the antidote for thrombolytic therapy. Potassium chloride is administered for a potassium deficit. 63. The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client’s control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. 64. Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. 65. The client is experiencing an anaphylactic reaction to streptokinase, which is allergenic. The infusion should be stopped, the physician
notified, and the client treated with epinephrine, antihistamines, and corticosteroids. 66. The antidote to warfarin sodium (Coumadin) is vitamin K and should be readily available for use if excessive bleeding or hemorrhage occurs. Aminocaproic acid is the antidote for thrombolytic agents. Protamine sulfate is the antidote for heparin. Potassium chloride is administered to treat potassium deficit. 67. Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the physician before initiating therapy. 68. The ACLS nurse would place one gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse would then place the electrode paddles over the pads. Options 1, 3, and 4 identify incorrect positions. 69. The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days following the procedure. Prolonged standing and sitting increase the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same reason. 70. The jaw thrust without the head tilt maneuver is used when head and/or neck trauma is suspected. This maneuver opens the airway while maintaining proper head and neck alignment, thus reducing the risk of further damage to the neck. Option 1 is incorrect. In situations requiring CPR, the client will be unconscious. Option 4 is also incorrect. Additionally, it is unlikely that the nurse will be able to obtain these data. 71. Fruits and vegetables, except avocado, olives, and coconut, contain minimal amounts of fat. 6
Cardio Rationales Saunders 72. TSS is caused by infection and is often associated with tampon use. Disseminated intravascular coagulation is a complication of TSS. Options 1, 3, and 4 are unrelated to the etiology of TSS. 73. Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory BP greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade. 74. Foot care instructions for the client with peripheral arterial disease are the same instructions as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program, such as Buerger-Allen exercises, or unless venous stasis is also present. 75. Captopril is an antihypertensive medication (angiotension-converting enzyme inhibitor). Orthostatic hypotension can occur in clients taking this medication. Clients are advised to avoid standing in one position for long periods of time, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension such as dizziness, lightheadedness, weakness, and syncope. An increased intake of water could actually aggravate the hypertension. 76. The sodium level can increase by the use of several types of products including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water, as well as some mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, and demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. The client would avoid consuming mineral water. 77. Arterial ulcers have a pale, deep base and are surrounded by tissue that is cool with trophic changes such as dry, skin and loss of hair.
Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A venous stasis ulcer is one that has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion. A stage 1 ulcer indicates a reddened area with an intact skin surface. 78. Standard management for the client with DVT includes bed rest for 5 to 7 days, limb elevation, relief of discomfort with warm moist heat, and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol). 79. Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis that results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removal of the vein with the use of a hook and wires applied through multiple small incisions in the leg. 80. A sensation of pins and needles, or feeling as though the surgical limb is falling asleep, may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. Options 1, 2, and 3 are inaccurate responses. 81. A PASG may be useful in the treatment of hypovolemic shock associated with traumatic injury to provide circulatory assistance. The device is used only as a temporary measure until definitive treatment is given because it can compromise blood flow to the lower half of the body. The critical nursing assessment includes monitoring the vascular status of the lower extremities. Although options 1, 3, and 4 may be components of the nursing assessment, these actions are not part of the
Cardio Rationales Saunders critical assessment required with use of a PASG 82. The normal LAP is 1 to 10 mm Hg. Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure is recorded as an average (mean) pressure, rather than as a systolic or diastolic pressure. Options 2, 3, and 4 are incorrect. 83. The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL for females. A critical value is one that is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. Option 2 is the only option that identifies a normal level. 84. Raynaud’s disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client needs to make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. Options 2 and 3 are incorrect. It is not necessary to wear gloves for all activities. 85. In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Option 2 specifies infrequent care intervals, so it is not the priority intervention. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. 86. IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of the IABP is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary edema. 87. Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to
aid in the diagnosis of a myocardial infarction. The test is not used to diagnose congestive heart failure, ventricular tachycardia, or atrial fibrillation. 88. The client with uncontrolled atrial fibrillation with a ventricular rate higher than 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. 89. The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function. 90. Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever. 91. The client should be instructed to take quinidine sulfate exactly as prescribed. The client should not chew the sustained-release capsules or open the capsules and mix them with food. The client should be instructed to wear a medical identification bracelet or tag and to continue taking digoxin as prescribed. Quinidine sulfate is administered for atrial flutter or fibrillation only after the client has been digitalized. 92. The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second 93. VT is associated with a significant decrease in cardiac output. Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac 8
Cardio Rationales Saunders output. Although options 1, 2, and 3 may be a component of the assessment, the first action would be to determine responsiveness of the client. 94. Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client’s behavior as boredom or as either understanding or not understanding the material provided at the teaching session. 95. The recommended INR range for oral anticoagulant therapy is 2.0 to 3.0, but this value may vary with the goals of therapy. A recommended INR range with mechanical prosthetic heart valve is 2.5 to 3.5, and for survivors of acute myocardial infarction (MI), 2.5 to 3.5. 96. The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart’s apex. 97. The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client. 98. Pressure should be applied to the site after an arterial blood gas specimen is drawn. The blood pressure in the artery is higher than in the veins, so applying pressure to the punctured artery is necessary to control bleeding. Covering the site with gauze may protect the site but would not control bleeding. Heat (by application of warm packs) causes
vasodilation, which would increase bleeding to the site. Exercise would increase circulation to the area. 99. The MM fraction of creatine kinase (CK-MB) is specific in determining the presence of MI. The CK-MM reflects injury to skeletal muscle. The WBC count would most likely be elevated in the client with an MI. The BUN is unrelated to this disorder. 100.Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client with MI. Although monitoring mental status is a component of the nurse’s assessment, it is not the priority after administration of morphine sulfate. The nurse would monitor the client’s respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature also is not associated with the use of this medication. 101.Nitroglycerin tablets are administered one tablet every 5 minutes, for a total of three tablets per episode of chest pain, so long as the client maintains a systolic blood pressure of 100 mm Hg or higher. Increasing the flow rate of oxygen may be prescribed by the physician but would not be the next nursing action. If three nitroglycerin tablets did not relieve the client’s chest pain, the physician needs to be notified. It is premature to call the client’s family. 102.After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart. 103.A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia.
Cardio Rationales Saunders Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI. 104.If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. Although options 1, 3, and 4 all may be components of the assessment, none of these questions would be the initial assessment question in this client. 105.The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian. 106.The signs and symptoms of hyperkalemia relate to the effect of potassium on the myocardial muscle. These include changes noted on the electrocardiogram (ECG), such as tall and peaked T waves, prolonged PR interval, widening of the QRS complex, shortening of the QT interval, and disappearance of the P wave. Other cardiac signs and symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia. 107.In the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client also may exhibit a flat T wave. Options 1, 3, and 4 are cardiac monitor findings that would be noted in the client with hyperkalemia. 108.When a client has CHF, the goal is to reduce fluid accumulation. One way that this is accomplished is sodium reduction. Ham, cheese (and most cold cuts), and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium. 109.Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance,
obesity, and response to stress are contributing modifiable risk factors to CAD. Age greater than 40 is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. 110.To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital following an MI. All of the options except option 1 indicate that the client will be successful in these areas. 111.Standard home care instructions for a client with this nursing diagnosis include among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload 112.Each of the options indicates a positive outcome on the part of the client. However, option 1 would most likely indicate progress if the client had a nursing diagnosis of imbalanced nutrition. Option 2 would be a satisfactory outcome for disturbed sleep pattern. Both options 3 and 4 relate to the nursing diagnosis of activity intolerance. However, the question asks about progress. Option 4 is more action-oriented and therefore is the better choice. 113.Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client. 114.The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client should wear rubber-soled, supportive shoes, such as athletic training shoes. The client should receive nothing by mouth after 1
Cardio Rationales Saunders bedtime, or for a minimum of 2 hours before the test. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result. 115.The client is taught to immediately report chest pain or any unusual sensations. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site 116.The client can best determine fluid status at home by weighing himself on a daily basis. Increases of 2 to 3 pounds in a short time period are reported to the physician. The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of bed flat is therefore avoided. The client does not modify medication dosages without consulting the physician. 117.It is common for the client to feel fatigued after the cardiac catheterization procedure. Other pre-procedure teaching points include that the procedure is done in a darkened cardiac catheterization room. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection. 118.Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if used continuously. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias. An apnea monitor detects apnea
episodes, such as when the client has stopped breathing briefly. 119.The NG tube should remain in place until the client has bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is normal for NG tube drainage to be Hematest negative. The abdomen is likely to be slightly distended after surgery, and it also is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery. 120.The client undergoing thoracentesis usually sits in an upright position, with the anterior thorax supported by pillows, or leaning over an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion. Any form of side-lying position will cause fluid to accumulate under that side, which is inaccessible to the physician. The dorsal recumbent position also is an inaccessible position. 121.Furosemide is a non–potassium-sparing diuretic, and insufficient replacement of potassium may lead to hypokalemia. Although the glucose, sodium, and magnesium levels may be monitored, these laboratory values are not specific to administering furosemide. 122.Chest pain is assessed using the standard pain assessment parameters, such as, characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually becomes worse on inspiration. 123.Stable angina is triggered by a predictable amount of effort or emotion. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and
Cardio Rationales Saunders incapacitating and is refractory to medical therapy. 124.A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. Tall, peaked T waves may indicate hyperkalemia. The development of Q waves indicates myocardial necrosis. An ECG taken during a pain episode is intended to capture ischemic changes, which also includes ST-segment elevation or depression. 125.Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously has caused the pain, and to take the medication at the first sign of chest discomfort. 126.Prinzmetal’s angina results from spasm of the coronary vessels and is treated with calcium channel blockers. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. β-Blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not specifically indicated. 127.Chest pain that is unrelieved by rest and three doses of nitroglycerin administered 5 minutes apart may not be typical anginal pain but may signal myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the first 24 hours after MI, it is imperative that the client receive emergency cardiac care. A physician’s office is not equipped to treat MI. Communication with the family or home care agency delays client treatment, which is needed immediately. 128.The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes,
and frequently is accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. 129.Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thereby reducing preload, afterload, and myocardial work. This also accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of continuous direct arterial pressure (intra-arterial) monitoring, the nurse should use an automatic noninvasive blood pressure monitor. Options 1, 3, and 4 are not specifically associated with the administration of intravenous nitroglycerin. 130.On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet. 131.Thrombolytic agents are used to dissolve existing thrombi, and the nurse must monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes “hematesting” secretions for occult blood. Option 1 is the only option that indicates the presence of blood. 132.The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client’s cardiovascular risk is similar to that of a person who never smoked. Options 2, 3, and 4 are incorrect. 133.Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy (Lasix). A cough due to respiratory infection does not necessarily indicate that heart failure is worsening. 1
Cardio Rationales Saunders 134.Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client’s condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.) Wheezes and rhonchi are not associated with pulmonary edema. 135.Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressure, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when it is administered intravenously. Options 2, 3, and 4 are unrelated to the action of morphine sulfate 136.Urine output of greater than 30 mL/hr indicates adequate perfusion to the kidneys, so the other organs are most likely equally perfused. Classic cardiovascular signs of cardiogenic shock include low blood pressure and tachycardia. The CVP rises as the effects of the backward blood flow of the left ventricular failure became apparent. Arrhythmias commonly occur as a result of decreased oxygenation to the myocardium and are not a favorable sign. 137.Acetazolamide is a carbonic anhydrase inhibitor that contains sulfonamide properties. Before administration of this medication, the client should be assessed for an allergy to sulfonamides because the medication is contraindicated if an allergy exists. The client also should be monitored during therapy for an allergic reaction and for photosensitivity. 138.Vital signs that remain near baseline indicate good cardiac reserve with exercise. Options 1 and 3 are incorrect because they represent changes from normal values to abnormal ones. Blood pressure decrease by more than 10 mm Hg is not a sign that indicates tolerance of
activity. Only the respiratory rate remains within the normal range. Additionally, it reflects a minimal increase. 139.The client should alert any health care provider about the history of infective endocarditis before any procedure that involves instrumentation. The provider should place the client on prophylactic antibiotics. Antibiotics should be taken for the full course of therapy. The client should notify the physician if chest pain worsens or if dyspnea or other symptoms occur. The client should use a soft toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for bacterial infection. 140.The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, discouraging leg-crossing, avoiding use of the knee gatch on the bed, performing passive and active ROM exercises, and omitting placement of pillows in the popliteal space. Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. 141.Typical discharge activity instructions for the first six weeks include instructing the client to lift nothing heavier than 5 pounds, to not drive, and to avoid any activities that cause straining. The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining. These limitations are to allow for sternal healing, which takes approximately 6 weeks 142.Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. 143.Sinus arrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and
Cardio Rationales Saunders with respiration. Cardiac output is not affected. 144.Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Each of the incorrect options has a recognizable complex that appears on the monitoring screen. 145.Procainamide is an antiarrhythmic that may be used to treat ventricular arrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac glycoside; metoprolol is a betaadrenergic blocking agent; verapamil is a calcium channel–blocking agent. 146.PVCs are considered dangerous when they are frequent (more than 6/min), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client’s cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly arrhythmias. 147.Medication-specific teaching points for quinidine sulfate include to take the medication exactly as prescribed; not to chew the tablets; to take with food if stomach upset occurs; to wear a medical identification (e.g., Medic-Alert) bracelet or tag; and to have periodic checks of heart rhythm and blood counts. The client should not stop taking a prescribed medication unless specifically ordered by the physician. 148.Correct procedure for CPR with two rescuers includes a compression-to-ventilation ratio of 30:2. With adults, compressions are performed at a depth of 1.5 to 2 inches. The 30:2 compression-ventilation ratio yields an effective rate of 12 breaths/min. With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital. 149.Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and
arrhythmia detection. Airway, however, is always the highest priority. 150.Clients with an ICD usually continue to receive antiarrhythmic medications after discharge from the hospital. The nurse should stress the importance of continuing to take these medications as prescribed. The nurse should provide clear instructions about the purposes of the medications, dosage schedule, and side effects to report. Options 1, 3, and 4 are correct statements regarding this implantable device. 151.If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted. A demand pacemaker fires only when needed and should therefore discharge only when no electrical activity is occurring in the client’s own heart. 152.The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, Homans’ sign, and increased calf circumference in the affected extremity. Pedal pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication. 153.Standard management of the client with deep vein thrombosis includes bed rest for possibly 5 to 7 days, limb elevation, relief of discomfort with warm moist heat and analgesics as needed, anticoagulant therapy, and monitoring for signs of pulmonary embolism. Ambulation is contraindicated, because it increases the likelihood of dislodgment of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism. 154.Buerger’s disease is a vascular occlusive disease that affects the medium and small arteries and veins. Smoking is highly detrimental to the client with Buerger’s 1
Cardio Rationales Saunders disease, so stopping smoking completely is recommended. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients with Burger’s disease, symptoms are relieved or alleviated once smoking stops. Options 1, 2, and 4 are not specifically associated with the lifestyle changes required in this disorder. 155.Prosthetic valves require long-term anticoagulation to prevent clots from forming on the “foreign “ tissue implanted in the client’s body. Anticoagulation therapy requires clients to avoid any trauma or potential means of causing bleeding, such as use of straight razors. Options 2, 3, and 4 are not specifically related to postoperative care after prosthetic valve replacement. Option 2 relates to a client taking a diuretic. Option 3 relates to a client with a pacemaker. Option 4 is necessary in the immediate postoperative period. 156.Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of a heating pad directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further. 157.The client recovering from cardiogenic shock secondary to a myocardial infarction will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated myocardial infarction. The complication of cardiogenic shock will increase recovery period for healing. Paced activities with planned rest periods will decrease the chance of experiencing angina or delayed healing. Options 1, 3, and 4 are not related to the instructions needed after this diagnosis. 158.Exercise is an integral part of the rehabilitation program. It is necessary for
optimal physiological functioning and psychological well-being. Postoperative physical rehabilitation must be progressive with planned periods of rest. Exercise tolerance is judged by the client’s response, such as heart rate and endurance. Options 1, 2, and 3 identify appropriate client activities. Option 4 lacks planned periods of rest, and the client has grouped too many activities in a brief period of time, which will decrease endurance. Also, exercise after meals can decrease the client’s tolerance because of shunting of blood to the gastrointestinal tract for digestion. 159.The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure. 160.The nursing interventions for the client with an intra-aortic balloon pump are the same as for any client who has had cardiovascular surgery. The peripheral circulation to the affected limb is monitored for signs of occlusion, such as coolness, mottling, pain, tingling, and decreased or absent distal pulse. Adverse changes are reported immediately. 161.Hypertension increases the workload of the left ventricle, because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time, this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Left-sided heart failure is characterized by pulmonary signs and symptoms, because the lungs lie behind the left side of the heart from the perspective of circulation. 162.The myocardial layer of the heart is damaged when the client experiences a myocardial infarction. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral pericardium are outer layers that protect the heart from injury and infection. 1
Cardio Rationales Saunders 163.The mitral valve separates the left atrium from the left ventricle. Options 2, 3, and 4 describe the aortic, tricuspid, and pulmonic valves, respectively. 164.The aortic valve separates the aorta from the left ventricle. Options 1, 3, and 4 describe the mitral, tricuspid, and pulmonic valves, respectively 165.The primary effect of a decreased blood pressure is reduced blood flow to the myocardium. This in turn decreases the oxygenation to cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase in response to this change, not decrease. The effects of tissue ischemia will lead to decreased contractility over time. 166.The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization, and move back during repolarization. Depolarization is responsible for cardiac contraction. Options 1 and 2 are unrelated to calcium levels. Elevated calcium levels can lead to urinary stone formation. 167.The SA node is responsible for initiating electrical impulses that are conducted through the heart. The impulse leaves the SA node, travels down through internodal and interatrial pathways to the AV node. From there, impulses travel through the bundle of His to the right and left bundle branches, and then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction system. The ability of this specialized tissue to generate its own impulses is called automaticity. 168.The left coronary artery divides into the anterior descending artery and the circumflex artery, providing blood for the left atrium and left ventricle. The right coronary artery supplies the right atrium and right ventricle. Options 1, 2, and 3 are correct.
169.The cardiac cycle consists of contraction and relaxation of the heart muscle. The heart normally sends out about 5 L of blood every minute to the body. 170.The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Options 3 and 4 indicate an increase in fluid volume. Although the BP will decrease, it is not the earliest indicator. 171.The diaphragm of the stethoscope is placed over the skin at the mitral area to listen to the apical pulse. S1 (lub) and S2 (dub) should be distinguished. The pulse should be counted for a full minute. 172.Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope. 173.Found in the peripheral arteries and veins, α1adrenergic receptors cause a powerful vasoconstriction when stimulated. Options 1, 2, and 4 describe β1-, β2-, and α2-adrenergic receptors, respectively. 174.The normal cardiac output for the adult can range from 4 to 8 L/min and varies greatly with body size. The heart normally pumps 5 L of blood every minute. 175.The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the physician. Options 1, 2, and 3 are incorrect because the heart rate of 52 beats/min is not normal. 176.The client’s symptoms are the direct result of the body’s attempt to meet the metabolic demands of the body during exercise. An adequate cardiac output is needed to maintain perfusion to the vital organs of the body. With exercise, these demands increase, and the heart must beat faster (increased heart rate) 1
Cardio Rationales Saunders and harder (increased stroke volume) to achieve this. Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output by body surface area. 177.The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The RCA supplies the right side of the heart, including the atrium and ventricles. The circumflex coronary artery bifurcates from the left coronary artery, and supplies the left atrium and the lateral wall of the left ventricle. The PDA supplies the posterior wall of the heart. 178.Hypothermia decreases the heart rate and blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, with drops in both the heart rate and the blood pressure. 179.Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. The sympathetic nervous system stimulation has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis. 180.Dopaminergic receptors are found in the renal blood vessels and in the nerves. When these are stimulated, they dilate renal arteries and help modulate release of this neurotransmitter. Renal artery dilation helps to improve urine output by increasing blood flow through the kidneys. Epinephrine and norepinephrine affect the α and β receptors in the body. Serotonin is a local hormone that is released from platelets after an injury. It constricts arterioles but dilates capillaries. 181.With ventricular tachycardia in a stable client, the nurse assesses airway, breathing, and circulation; administers oxygen; and confirms the rhythm via a 12-lead ECG. The physician is contacted and antiarrhythmics may be prescribed. With pulseless ventricular tachycardia, the physician or a specially
trained nurse must immediately defibrillate the client or initiate CPR followed by defibrillation as soon as possible. 182.The first heart sound (S1) is heard loudest at the lower left sternal border or the apex of the heart. The apex is located at the fifth intercostal space at the left midclavicular line. Therefore, options 1, 2, and 3 are incorrect. 183.Hyperkalemia can cause tall peaked or tented T waves on the ECG. Levels of potassium of 5.1 mEq/L or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels. 184.In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is normal and constant. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second in duration, and the QRS interval is 0.06 to 0.10 second in duration. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. 185.This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The physician or an advanced cardiac life support (ACLS)-qualified nurse or other health care provider must immediately defibrillate the client. If a defibrillator is not readily available, CPR is initiated until the defibrillator arrives. Options 1, 3, and 4 are incorrect actions and delay life-saving treatment. 186.This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant or may occur with myocardial ischemia or MI; congestive heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, which is a diuretic that causes the excretion of potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 1 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has signs and symptoms of MI.
Cardio Rationales Saunders 187.In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. 188.Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, “pitting” edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen. 189.Ferrous sulfate is an iron preparation and the client is instructed to take the medication with orange juice or another vitamin C–containing product, to increase the absorption of the iron. Milk and eggs inhibit the absorption of the iron. Tomato juice is highest in vitamin C from the options presented. 190.MUGA is a radionuclide study used to detect myocardial infarction, decreased myocardial blood flow, and left ventricular function. A radioisotope is injected intravenously. Therefore, a signed informed consent is necessary. The procedure does not use radiopaque dye. Therefore, allergies to iodine and shellfish are not a concern. A Foley catheter and CVP line are not required. 191.Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy. Options 1 and 2, although important, are not directly related to the issue of safety.
192.Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Exercise and fluid restriction will not alleviate tachycardia. Option 2 will not decrease the heart rate. Additionally, the pulse should be taken more frequently than each shift. 193.Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular arrhythmias after the countershock. The client typically receives a dose of an intravenous sedative or antianxiety agent. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 50 to 100 J. During the procedure, any oxygen is removed temporarily, because oxygen supports combustion, and a fire could result from electrical arcing. 194.For cardioversion procedures, the defibrillator is charged to the energy level ordered by the physician. Countershock usually is started at 50 to 100 joules. Options 2, 3, and 4 are incorrect. 195.The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. 196.Postdischarge instructions typically include avoiding tight clothing or belts over AICD insertion sites, rough contact with the AICD insertion site, electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert physicians or dentists to the presence of the device, because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should 1
Cardio Rationales Saunders follow the specific advice of a physician regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment. 197.Triamterene is a potassium-sparing diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocadoes, bananas, fresh oranges, mangoes, nectarines, papayas, and prunes. 198.The client with deep vein thrombosis requires bedrest to prevent embolization of the thrombus due to skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and compression stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler’s position. The nurse avoids providing foods rich in vitamin K such as dark green leafy vegetables because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used to prevent DVT only, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism. 199.Spironolactone is a potassium-sparing diuretic, and the client should avoid foods high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client does not need to avoid foods that contain calcium, magnesium, or phosphorus while taking this medication. 200.The particular isoenzymes that are affected after acute myocardial infarction are LDH1 and LDH2. The LDH level begins to elevate about 24 hours after myocardial infarction and
peaks in 48 to 72 hours. Thereafter, it returns to normal, usually within 7 to 14 days. 201.Chicken breast has 70 mg of sodium, compared with 457 for cottage cheese, 700 mg for grilled cheese, and 800 mg for beef bouillon. 202.The sound that the nurse hears is the first heart sound, S1. The first heart sound (S1) is created by the closure of the mitral and triscupid valves (atrioventricular [AV] valves). It marks the onset of systole (ventricular contraction). When auscultated, the first heart sound (S1) is softer and longer than the second heart sound (S2). S1 is low in pitch and is best heard at the left lower sternal border or the apex of the heart. Disease and stiffened AV valves (as in rheumatic heart disease) may augment S1; rhythms of asynchrony between the atria and ventricles (as in atrial fibrillation and with AV block) cause variable intensity of S1. Phonetically, if a typical heartbeat, composed of the heart sounds S1 and S2, is auscultated as “lub-dup,” S1 is the “lub.” To assess S1, the nurse should assist the client to a supine position (the head of the bed may be elevated slightly if necessary). The second heart sound (S2) is related to closure of the pulmonic and aortic (semilunar) valves and is heard best with the diaphragm at the aortic area. Phonetically, it is the “dup” of the “lub-dup” of a typical heartbeat (the first heart sound, S1, is the “lub”). It signifies the end of systole and the onset of diastole (ventricular filling). S2 is characteristically shorter and higher pitched than the first heart sound (S1). Diastolic filling sounds or gallops (S3, the third heart sound, and S4, the fourth heart sound) are produced when compliance of either or both ventricles is decreased. S3 is termed ventricular gallop and S4 is referred to as atrial gallop. The S3 heart sound (a gallop sound) occurs in early diastole, during passive, rapid filling of the ventricles. The S4 sound occurs in the later stage of diastole, during atrial contraction and active filling of the ventricles. It is a soft, low-pitched sound and is heard immediately before S1. 1
Cardio Rationales Saunders 203.PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy 204.The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options 1, 2, and 4 are incorrect. 205.Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure (BP), accompanied by pulsus paradoxus (a drop in inspiratory BP by greater than 10 mm Hg). 206.The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan with the client. 207.The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The client is overweight, which is a contributing risk factor. The client’s nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the client’s major modifiable risk factors. 208.Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client’s legs increases venous return to the heart, increasing cardiac workload. The supine position increases respiratory effort and decreases
oxygenation. This increases cardiac workload. Seasonings may be high in sodium. 209.Raynaud’s disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted. Peripheral pulses may be normal, absent, or diminished.
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