1)       Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?

1. Decrease anxiety
2. Enhance myocardial oxygenation
3. Administer sublingual nitroglycerin
4. Educate the client about his symptoms

2)       Medical treatment of coronary artery disease includes which of the following procedures?

1. Cardiac catherization
2. Coronary artery bypass surgery
3. Oral medication therapy
4. Percutaneous transluminal coronary angioplasty

3)       Which of the following is the most common symptom of myocardial infarction (MI)?

1. Chest pain
2. Dyspnea
3. Edema
4. Palpitations

4)       Which of the following symptoms is the most likely origin of pain the client described as knifelike chest pain that increases in intensity with inspiration?

1. Cardiac
2. Gastrointestinal
3. Musculoskeletal
4. Pulmonary

5)       Which of the following blood tests is most indicative of cardiac damage?

1. Lactate dehydrogenase
2. Complete blood count (CBC)
3. Troponin I
4. Creatine kinase (CK)

6)       What is the primary reason for administering morphine to a client with an MI?

1. To sedate the client
2. To decrease the client’s pain
3. To decrease the client’s anxiety
4. To decrease oxygen demand on the client’s heart

7)       Which of the following conditions is most commonly responsible for myocardial infarction?

1. Aneurysm
2. Heart failure
3. Coronary artery thrombosis
4. Renal failure

8)       Which of the following complications is indicated by a third heart sound (S₃)?

1. Ventricular dilation
2. Systemic hypertension
3. Aortic valve malfunction
4. Increased atrial contractions

9)       After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs?

1. Left-sided heart failure
2. Pulmonic valve malfunction
3. Right-sided heart failure
4. Tricupsid valve malfunction

10)   What is the first intervention for a client experiencing MI?

1. Administer morphine
2. Administer oxygen
3. Administer sublingual nitroglycerin
4. Obtain an ECG

11)   Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?

1. Beta-adrenergic blockers
2. Calcium channel blockers
3. Narcotics
4. Nitrates

12)   What is the most common complication of an MI?

1. Cardiogenic shock
2. Heart failure
3. arrhythmias
4. Pericarditis

13)   With which of the following disorders is jugular vein distention most prominent?

1. Abdominal aortic aneurysm
2. Heart failure
3. MI
4. Pneumothorax

14)   Toxicity from which of the following medications may cause a client to see a green-yellow halo around lights?

1. Digoxin
2. Furosemide (Lasix)
3. Metoprolol (Lopressor)
4. Enalapril (Vasotec)

15)   Which of the following symptoms is most commonly associated with left-sided heart failure?

1. Crackles
2. Arrhythmias
3. Hepatic engorgement
4. Hypotension

16)   In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client?

1. Diabetes
2. Pulmonary emboli
3. Renal failure
4. Right-sided heart failure

17)   Which of the following symptoms might a client with right-sided heart failure exhibit?

1. Adequate urine output
2. Polyuria
3. Oliguria
4. Polydipsia

18)   Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractibility?

1. Beta-adrenergic blockers
2. Calcium channel blockers
3. Diuretics
4. Inotropic agents

19)   Stimulation of the sympathetic nervous system produces which of the following responses?

1. Bradycardia
2. Tachycardia
3. Hypotension
4. Decreased myocardial contractility

20)   Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output?

1. Angina pectoris
2. Cardiomyopathy
3. Left-sided heart failure
4. Right-sided heart failure

21)   Which of the following heart muscle diseases is unrelated to other cardiovascular disease?

1. Cardiomyopathy
2. Coronary artery disease
3. Myocardial infarction
4. Pericardial effusion

22)   Which of the following types of cardiomyopathy can be associated with childbirth?

1. Dilated
2. Hypertrophic
3. Myocarditis
4. Restrictive

23)   Septal involvement occurs in which type of cardiomyopathy?

1. Congestive
2. Dilated
3. Hypertrophic
4. Restrictive

24)   Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy?

1. Heart failure
2. Diabetes
3. MI
4. Pericardial effusion

25)   Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?

1. Pericarditis
2. Hypertension
3. MI
4. Heart failure

26)   In which of the following types of cardiomyopathy does cardiac output remain normal?

1. Dilated
2. Hypertrophic
3. Obliterative
4. Restrictive

27)   Which of the following cardiac conditions does a fourth heart sound (S₄) indicate?

1. Dilated aorta
2. Normally functioning heart
3. Decreased myocardial contractility
4. Failure of the ventricle to eject all of the blood during systole

28)   Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?

1. Antihypertensives
2. Beta-adrenergic blockers
3. Calcium channel blockers
4. Nitrates

29)   If medical treatments fail, which of the following invasive procedures is necessary for treating cariomyopathy?

1. Cardiac catherization
2. Coronary artery bypass graft (CABG)
3. Heart transplantation
4. Intra-aortic balloon pump (IABP)

30)   Which of the following conditions is associated with a predictable level of pain that occurs as a result of physical or emotional stress?

1. Anxiety
2. Stable angina
3. Unstable angina
4. Variant angina

31)   Which of the following types of angina is most closely related with an impending MI?

1. Angina decubitus
2. Chronic stable angina
3. Noctural angina
4. Unstable angina

32)   Which of the following conditions is the predominant cause of angina?

1. Increased preload
2. Decreased afterload
3. Coronary artery spasm
4. Inadequate oxygen supply to the myocardium

33)   Which of the following tests is used most often to diagnose angina?

1. Chest x-ray
2. Echocardiogram
3. Cardiac catherization
4. 12-lead electrocardiogram (ECG)

34)   Which of the following results is the primary treatment goal for angina?

1. Reversal of ischemia
2. Reversal of infarction
3. Reduction of stress and anxiety
4. Reduction of associated risk factors

35)   Which of the following interventions should be the first priority when treating a client experiencing chest pain while walking?

1. Sit the client down
2. Get the client back to bed
3. Obtain an ECG
4. Administer sublingual nitroglycerin

36)   Myocardial oxygen consumption increases as which of the following parameters increase?

1. Preload, afterload, and cerebral blood flow
2. Preload, afterload, and renal blood flow
3. Preload, afterload, contractility, and heart rate.
4. Preload, afterload, cerebral blood flow, and heart rate.

37)   Which of the following positions would best aid breathing for a client with acute pulmonary edema?

1. Lying flat in bed
2. Left side-lying
3. In high Fowler’s position
4. In semi-Fowler’s position

38)   Which of the following blood gas abnormalities is initially most suggestive of pulmonary edema?

1. Anoxia
2. Hypercapnia
3. Hyperoxygenation
4. Hypocapnia

39)   Which of the following is a compensatory response to decreased cardiac output?

1. Decreased BP
2. Alteration in LOC
3. Decreased BP and diuresis
4. Increased BP and fluid retention

40)   Which of the following actions is the appropriate initial response to a client coughing up pink, frothy sputum?

1. Call for help
2. Call the physician
3. Start an I.V. line
4. Suction the client

41)   Which of the following terms describes the force against which the ventricle must expel blood?

1. Afterload
2. Cardiac output
3. Overload
4. Preload

42)   Acute pulmonary edema caused by heart failure is usually a result of damage to which of the following areas of the heart?

1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle

43)   An 18-year-old client who recently had an URI is admitted with suspected rheumatic fever. Which assessment findings confirm this diagnosis?

1. Erythema marginatum, subcutaneous nodules, and fever
2. Tachycardia, finger clubbing, and a load S₃
3. Dyspnea, cough, and palpitations
4. Dyspnea, fatigue, and synocope

44)   A client admitted with angina compains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first?

1. Activate the resuscitation team
2. Open the client’s airway
3. Check for breathing
4. Check for signs of circulation

45)   A 55-year-old client is admitted with an acute inferior-wall myocardial infarction. During the admission interview, he says he stopped taking his metoprolol (Lopressor) 5 days ago because he was feeling better. Which of the following nursing diagnoses takes priority for this client?

1. Anxiety
2. Ineffective tissue perfusion; cardiopulmonary
3. Acute pain
4. Ineffective therapeutic regimen management

46)   A client comes into the E.R. with acute shortness of breath and a cough that produces pink, frothy sputum. Admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38 breaths/minute. The client’s medical history included DM, HTN, and heart failure. Which of the following disorders should the nurse suspect?

1. Pulmonary edema
2. Pneumothorax
3. Cardiac tamponade
4. Pulmonary embolus

47)   The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first?

1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute.
2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order.
3. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin.
4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).

48)   When developing a teaching plan for a client with endocarditis, which of the following points is most essential for the nurse to include?

1. “Report fever, anorexia, and night sweats to the physician.”
2. “Take prophylactic antibiotics after dental work and invasive procedures.”
3. “Include potassium rich foods in your diet.”
4. “Monitor your pulse regularly.”

49)   A nurse is conducting a health history with a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure?

1. Recent URI
2. Nutritional anemia
3. Peptic ulcer disease
4. A-Fib

50)   A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician’s office. The nurse would plan on having which of the following medications readily available for use?

1. Diltiazem (Cardizem)
2. Digoxin (Lanoxin)
3. Propranolol (Inderal)
4. Metoprolol (Lopressor)

51)   A nurse caring for a client in one room is told by another nurse that a second client has developed severe pulmonary edema. On entering the 2^nd client’s room, the nurse would expect the client to be:

1. Slightly anxious
2. Mildly anxious
3. Moderately anxious
4. Extremely anxious

52)   A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on Digoxin (Lanoxin), a nurse checks the client’s most recent:

1. Digoxin level
2. Sodium level
3. Potassium level
4. Creatinine level

53)   A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for 2 hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:

1. Hypovolemia
2. UTI
3. Glomerulonephritis
4. Acute renal failure

54)   A nurse is preparing to ambulate a client on the 3^rd day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?

1. Encourage the client to cough and deep breathe
2. Premedicate the client with an analgesic
3. Provide the client with a walker
4. Remove telemetry equipment because it weighs down the hospital gown.

55)   A client’s electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is:

1. Normal sinus rhythm
2. Sinus bradycardia
3. Sinus tachycardia
4. Sinus dysrhythmia

56)   A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because:

1. It is uncomfortable for the client, giving a sense of impending doom.
2. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.
3. It is almost impossible to convert to a normal sinus rhythm.
4. It can develop into ventricular fibrillation at any time.

57)   A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for:

1. Thrombocytopenia and weight gain
2. Anorexia, nausea, and visual disturbances
3. Diarrhea and hypotension
4. Fatigue and muscle twitching

58)   A client with angina complains that the angina pain is prolonged and severe and occurs at the same time each day, most often in the morning, On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

1. Stable angina
2. Unstable angina
3. Variant angina
4. Nonanginal pain

59)   The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following?

1. Obtaining an infusion pump for the medication
2. Monitoring BP q4h
3. Monitoring urine output hourly
4. Obtaining serum potassium levels daily

60)   Aspirin is administered to the client experiencing an MI because of its:

1. Antipyrectic action
2. Antithrombotic action
3. Antiplatelet action
4. Analgesic action

61)   Which of the following is an expected outcome for a client on the second day of hospitalization after an MI?

1. Has severe chest pain
2. Can identify risks factors for MI
3. Agrees to participate in a cardiac rehabilitation walking program
4. Can perform personal self-care activities without pain

62)   Which of the following reflects the principle on which a client’s diet will most likely be based during the acute phase of MI?

1. Liquids as ordered
2. Small, easily digested meals
3. Three regular meals per day
4. NPO

63)   An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:

1. Left ventricular atrophy
2. Irregular heartbeats
3. peripheral vascular occlusion
4. Pacemaker placement

64)   Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
2. Activity intolerance related to increased cardiac output.
3. Decreased cardiac output related to structural and functional changes.
4. Impaired gas exchange related to decreased sympathetic nervous system activity.

65)   Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?

1. Risk for infection related to stasis of alveolar secretions
2. Impaired skin integrity related to pressure
3. Activity intolerance related to pump failure
4. Constipation related to immobility

66)   Captopril may be administered to a client with HF because it acts as a:

1. Vasopressor
2. Volume expander
3. Vasodilator
4. Potassium-sparing diuretic

67)   Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drugs desired effect?

1. 5 to 10 minutes
2. 30 to 60 minutes
3. 2 to 4 hours
4. 6 to 8 hours

68)   Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet?

1. Apples
2. Tomato juice
3. Whole wheat bread
4. Beef tenderloin

69)   The nurse finds the apical pulse below the 5^th intercostal space. The nurse suspects:

1. Left atrial enlargement
2. Left ventricular enlargement
3. Right atrial enlargement
4. Right ventricular enlargement

ANSWERS

1. 2. Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygenation, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but administration isn’t the first priority. Although educating the client and decreasing anxiety are important in care delivery, neither are priorities when a client is compromised.
2. 3. Oral medication administration is a noninvasive, medical treatment for coronary artery disease. Cardiac catherization isn’t a treatment, but a diagnostic tool. Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments.
3. 1. The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after an MI. Palpitations may result from reduced cardiac output, producing arrhythmias.
4. 4. Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only increases with movement. Cardiac and GI pains don’t change with respiration.
5. 3. Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren’t detectable in people without cardiac injury. Lactate dehydrogenase (LDH) is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury.
6. 4. Morphine is administered because it decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety while causing sedation, but it isn’t primarily given for those reasons.
7. 3. Coronary artery thrombosis causes an inclusion of the artery, leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn’t cause an MI. Renal failure can be associated with MI but isn’t a direct cause. Heart failure is usually a result from an MI.
8. 1. Rapid filling of the ventricle causes vasodilation that is auscultated as S_3. Increased atrial contraction or systemic hypertension can result in a fourth heart sound. Aortic valve malfunction is heard as a murmur.
9. 1. The left ventricle is responsible for most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn’t function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right sided heart failure.
10. 2. Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and nitro are also used to treat MI, but they’re more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI.
11. 1. Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).
12. 3. Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common complication of an MI. Cardiogenic shock, another complication of an MI, is defined as the end stage of left ventricular dysfunction. This condition occurs in approximately 15% of clients with MI. Because the pumping function of the heart is compromised by an MI, heart failure is the second most common complication. Pericarditis most commonly results from a bacterial or viral infection but may occur after the MI.
13. 2. Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. JVD isn’t a symptom of abdominal aortic aneurysm or pneumothorax. An MI, if severe enough, can progress to heart failure, however, in and of itself, an MI doesn’t cause JVD.
14. 1. One of the most common signs of digoxin toxicity is the visual disturbance known as the “green-yellow halo sign.” The other medications aren’t associated with such an effect.
15. 1. Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both right- and left-sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system.
16. 4. The most accurate area on the body to assess dependent edema in a bed-ridden client is the sacral area. Sacral, or dependent, edema is secondary to right-sided heart failure.
17. 3. Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria.
18. 4. Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output.
19. 2. Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. The other symptoms listed are related to the parasympathetic nervous system, which is responsible for slowing the heart rate.
20. 4. Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn’t cause weight gain, nausea, or a decrease in urine output.
21. 1. Cardiomyopathy isn’t usually related to an underlying heart disease such as atherosclerosis. The etiology in most cases is unknown. CAD and MI are directly related to atherosclerosis. Pericardial effusion is the escape of fluid into the pericardial sac, a condition associated with Pericarditis and advanced heart failure.
22. 1. Although the cause isn’t entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy or the first few months after birth. The condition may result from a preexisting cardiomyopathy not apparent prior to pregnancy. Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a strong familial tendency. Myocarditis isn’t specifically associated with childbirth. Restrictive cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually myocardial.
23. 3. In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum—not the ventricle chambers—is apparent. This abnormality isn’t seen in other types of cardiomyopathy.
24. 1. Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with pericarditis.
25. 4. These are the classic signs of failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances, and a flushed face. MI causes heart failure but isn’t related to these symptoms.
26. 2. Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. All of the rest decrease cardiac output.
27. 4. An S₄ occurs as a result of increased resistance to ventricular filling after atrial contraction. The increased resistance is related to decreased compliance of the ventricle. A dilated aorta doesn’t cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An S₄ isn’t heard in a normally functioning heart.
28. 2. By decreasing the heart rate and contractility, beta-blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Antihypertensives aren’t usually indicated because they would decrease cardiac output in clients who are already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-blockers; however, they aren’t as effective as beta-blockers and cause increased hypotension. Nitrates aren’t used because of their dilating effects, which would further compromise the myocardium.
29. 3. The only definitive treatment for cardiomyopathy that can’t be controlled medically is a heart transplant because the damage to the heart muscle is irreversible.
30. 2. The pain of stable angina is predictable in nature, builds gradually, and quickly reaches maximum intensity. Unstable angina doesn’t always need a trigger, is more intense, and lasts longer than stable angina. Variant angina usually occurs at rest—not as a result of exercise or stress.
31. 4. Unstable angina progressively increases in frequency, intensity, and duration and is related to an increased risk of MI within 3 to 18 months.
32. 4. Inadequate oxygen supply to the myocardium is responsible for the pain accompanying angina. Increased preload would be responsible for right-sided heart failure. Decreased afterload causes increased cardiac output. Coronary artery spasm is responsible for variant angina.
33. 4. The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition, with variant angina, the ECG shows ST-segment elevation. A chest x-ray will show heart enlargement or signs of heart failure, but isn’t used to diagnose angina.
34. 1. Reversal of the ischemia is the primary goal, achieved by reducing oxygen consumption and increasing oxygen supply. An infarction is permanent and can’t be reversed.
35. 1. The initial priority is to decrease the oxygen consumption; this would be achieved by sitting the client down. An ECG can be obtained after the client is sitting down. After the ECGm sublingual nitro would be administered. When the client’s condition is stabilized, he can be returned to bed.
36. 3. Myocardial oxygen consumption increases as preload, afterload, renal contractility, and heart rate increase. Cerebral blood flow doesn’t directly affect myocardial oxygen consumption.
37. 3. A high Fowler’s position promotes ventilation and facilitates breathing by reducing venous return. Lying flat and side-lying positions worsen the breathing and increase workload of the heart. Semi-Fowler’s position won’t reduce the workload of the heart as well as the Fowler’s position will.
38. 4. In an attempt to compensate for increased work of breathing due to hyperventilation, carbon dioxide decreases, causing hypocapnea. If the condition persists, CO₂ retention occurs and hypercapnia results.
39. 4. The body compensates for a decrease in cardiac output with a rise in BP, due to the stimulation of the sympathetic NS and an increase in blood volume as the kidneys retain sodium and water. Blood pressure doesn’t initially drop in response to the compensatory mechanism of the body. Alteration in LOC will occur only if the decreased cardiac output persists.
40. 1. Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Because the client is at high risk for decompensation, the nurse should call for help but not leave the room. The other three interventions would immediately follow.
41. 1. Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled by the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole.
42. 3. The left ventricle is responsible for the majority of force for the cardiac output. If the left ventricle is damaged, the output decreases and fluid accumulates in the interstitial and alveolar spaces, causing pulmonary edema. Damage to the left atrium would contribute to heart failure but wouldn’t affect cardiac output or, therefore, the onset of pulmonary edema. If the right atrium and right ventricle were damaged, right-sided heart failure would result.
43. 1. Diagnosis of rheumatic fever requires that the client have either two major Jones criteria or one minor criterion plus evidence of a previous streptococcal infection. Major criteria include carditis, polyarthritis, Sydenham’s chorea, subcutaneous nodules, and erythema maginatum (transient, nonprurtic macules on the trunk or inner aspects of the upper arms or thighs). Minor criteria include fever, arthralgia, elevated levels of acute phase reactants, and a prolonged PR-interval on ECG.
44. 1. Immediately after establishing unresponsiveness, the nurse should activate the resuscitation team. The next step is to open the airway using the head-tilt, chin-lift maneuver and check for breathing (looking, listening, and feeling for no more than 10-seconds). If the client isn’t breathing, give two slow breaths using a bag mask or pocket mask. Next, check for signs of circulation by palpating the carotid pulse.
45. 2. MI results from prolonged myocardial ischemia caused by reduced blood flow through the coronary arteries. Therefore, the priority nursing diagnosis for this client is Ineffective tissue perfusion (cardiopulmonary). Anxiety, acute pain, and ineffective therapeutic regimen management are appropriate but don’t take priority.
46. 1. SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink, frothy sputum are late signs of pulmonary edema.
47. 4. The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don’t require immediate attention). The lowest priority is the 89-year-old with end stage right-sided heart failure, who requires time consuming supportive measures.
48. 1. The most essential teaching point is to report signs of relapse, such as fever, anorexia, and night sweats, to the physician. To prevent further endocarditis episodes, prophylactic antibiotics are taken before and sometimes after dental work, childbirth, or GU, GI, or gynecologic procedures. A potassium-rich diet and daily pulse monitoring aren’t necessary for a client with endocarditis.
49. 3. 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.
50. 2. 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 (calcium channel blocker) and propranolol and metoprolol (beta blockers) have a negative inotropic effect and would worsen the failing heart.
51. 4. Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering.
52. 3. The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.
53. 4. 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 BUN and creatinine levels. The client may need medications such as dopamine (Intropin) to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis.
54. 2. 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 1 and 3 will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed.
55. 1.
56. 4. 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. Client’s frequently experience a feeling of impending death. Ventricular tachycardia is treated with antidysrhythmic medications or magnesium sulfate, cardioversion (client awake), or defibrillation (loss of consciousness), Ventricular tachycardia can deteriorate into ventricular defibrillation at any time.
57. 2. The first signs and symptoms of digoxin toxicity in adults include abdominal pain, N/V, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias.
58. 3. Stable angina is induced by exercise and is relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity and rest, is less predictable, and is often a precursor of myocardial infarction. Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often in the morning.
59. 1. IV nitro infusion requires an infusion pump for precise control of the medication. BP monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
60. 2. Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason ASA is administered to the client experiencing an MI is its antithrombotic action.
61. 4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.
62. 2. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.
63. 1. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle.
64. 1 and 3. HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs. Therefore, greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition, this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically, these clients have an ejection fraction of less than 50% and poorly tolerate activity. Activity intolerance is related to a decrease, not increase, in cardiac output. Gas exchange is impaired. However, the decrease in cardiac output triggers compensatory mechanisms, such as an increase in sympathetic nervous system activity.
65. 3. Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with HF and pulmonary edema, nor is constipation related to immobility.
66. 3. ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.
67. 1. After IV injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.
68. 2. Canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet. BRING ON THE STEAK!
69. 2. A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.