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med surg cardiac exam
ATI med surg cardiac exam
Total Questions : 50
Showing 10 questions Sign up for moreA client has undergone diagnostic testing and received a diagnosis of sinus bradycardia. Which interventions are most appropriate and should be included in the client's plan of care? (SELECT ALL THAT APPLY)
Explanation
A. Assessing for acute pain is unnecessary. Sinus bradycardia is not typically associated with acute pain unless another condition, such as myocardial infarction, is present.
B. Monitoring fluid volume excess is incorrect. Sinus bradycardia is not directly related to fluid overload; however, fluid status may need to be monitored in clients with underlying cardiac conditions.
C. Prevention of falls is correct. Bradycardia can lead to dizziness, hypotension, and syncope, increasing the risk of falls.
D. Monitoring heart rate and rhythm is correct. Continuous monitoring is essential to detect any worsening bradycardia or associated arrhythmias.
E. Assessing for neurologic changes is correct. Bradycardia can reduce cerebral perfusion, leading to symptoms such as confusion, dizziness, or syncope.
A nurse is caring for a client with heart failure who takes furosemide (Lasix) 20 mg daily at home and is receiving 40 mg of furosemide (Lasix) IV daily in the hospital. The nurse is aware that this patient is at risk for which electrolyte imbalance?
Explanation
A. Hypernatremia is incorrect. Furosemide can cause hyponatremia rather than hypernatremia due to increased sodium excretion.
B. Hypocalcemia is incorrect. While loop diuretics can cause some calcium loss, hypocalcemia is less common than hypokalemia.
C. Hypokalemia is correct. Furosemide is a loop diuretic that increases potassium excretion, leading to a risk of hypokalemia, which can cause muscle weakness, arrhythmias, and other complications.
D. Hyperkalemia is incorrect. Furosemide promotes potassium excretion, making hyperkalemia unlikely.
A nurse is caring for a patient with a history of hypertension. The client reports compliance with the prescribed thiazide medication but is complaining of generalized weakness and palpitations. The nurse should monitor the client for which potential complications of diuretics?
Explanation
A. Hyperkalemia is not a typical complication of thiazide diuretics. Instead, they promote potassium loss, increasing the risk of hypokalemia.
B. Hypoglycemia is not directly associated with thiazide diuretics. These medications may affect glucose tolerance but do not cause low blood sugar.
C. Seizures are not a common adverse effect of thiazide diuretics. While severe electrolyte imbalances could contribute to neurological symptoms, they are not the primary concern in this scenario.
D. Cardiac dysrhythmias can result from hypokalemia, a common side effect of thiazide diuretics. Potassium is essential for normal cardiac conduction, and low levels can lead to palpitations, weakness, and potentially life-threatening arrhythmias.
A nurse is providing discharge teaching to a client diagnosed with infective endocarditis with vegetation on the tricuspid valve. Which of the following instructions should the nurse include?
Explanation
A. Avoiding sick contacts is generally a good practice, but it is not the primary concern for a client with infective endocarditis. The focus is on preventing bacterial infections that could enter the bloodstream and affect the heart valves.
B. Prophylactic antibiotics are required before dental and invasive procedures to prevent bacterial endocarditis recurrence. The bacteria that cause infective endocarditis can enter the bloodstream through procedures that involve mucosal surfaces.
C. Discontinuing antibiotics when feeling better is incorrect. Infective endocarditis requires a full course of IV antibiotics, often lasting 4 to 6 weeks, to fully eradicate the infection and prevent complications.
D. Avoiding physical activity for six months is unnecessary unless the client has severe cardiac complications. However, clients should monitor for symptoms such as fatigue and consult their provider before engaging in strenuous activities.
A nurse is caring for a client diagnosed with heart failure and atrial fibrillation. The client reports feeling palpitations and shortness of breath. The nurse is aware that clients with atrial fibrillation are at risk for which complication?
Explanation
A. Hypertensive crisis is not a direct complication of atrial fibrillation. It is typically caused by uncontrolled hypertension rather than arrhythmias.
B. Cardiogenic shock can occur in severe heart failure but is not a primary complication of atrial fibrillation.
C. Embolic cerebral vascular accident (stroke) is a major risk for clients with atrial fibrillation. The irregular atrial contractions allow blood to pool in the atria, increasing the risk of clot formation. If a clot dislodges, it can travel to the brain and cause a stroke.
D. Flash pulmonary edema is a complication of acute decompensated heart failure but is not directly caused by atrial fibrillation.
A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?
Explanation
A. First-degree AV block is characterized by a prolonged PR interval but does not typically present with irregular palpitations or a pulse deficit.
B. Sinus tachycardia causes a rapid but regular rhythm, whereas atrial fibrillation is irregularly irregular.
C. Atrial fibrillation is the correct answer. It is characterized by an irregular heart rate, absence of distinct P waves on an ECG, and a pulse deficit due to ineffective atrial contractions leading to incomplete ventricular filling.
D. Sinus bradycardia presents as a slow, regular heart rate rather than a rapid, irregular rhythm with a pulse deficit.
A nurse is caring for a client in a critical care unit who is 4 hours post-operative coronary artery bypass surgery. The nurse performs the reassessment and suspects the client may be developing a pericardial effusion. What assessment findings would the nurse note in this case?
Explanation
A. A new systolic murmur is more indicative of valvular dysfunction or a septal defect rather than pericardial effusion.
B. Diminished breath sounds may be associated with atelectasis or pleural effusion but are not a hallmark finding of pericardial effusion.
C. Diminished heart sounds occur due to fluid accumulation in the pericardial sac, which muffles heart tones and is a key sign of pericardial effusion.
D. Increased blood pressure is not characteristic of pericardial effusion. Instead, pericardial effusion can lead to cardiac tamponade, which typically causes hypotension.
A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?
Explanation
A. A high HDL level (above 60 mg/dL) is protective against cardiovascular disease and does not contribute to hypertension.
B. A regular exercise routine is beneficial for cardiovascular health and helps lower blood pressure rather than increasing it.
C. Benazepril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension rather than causing it.
D. Obstructive sleep apnea (OSA) is a known risk factor for hypertension due to intermittent hypoxia and increased sympathetic nervous system activity, which contribute to elevated blood pressure.
A nurse is caring for a client with a possible acute myocardial infarction (AMI). The electrocardiogram (ECG) shows no ST segment elevations or depression. The nurse is aware that an elevation of which lab result will determine if there has been cardiac injury?
Explanation
A. Elevated troponins are the most specific and sensitive markers for myocardial injury. Troponin I and Troponin T levels rise within a few hours of an AMI and remain elevated for days, confirming cardiac damage.
B. Elevated hemoglobin is not an indicator of cardiac injury. Hemoglobin levels are used to assess oxygen-carrying capacity and anemia.
C. Elevated B-type natriuretic peptide (BNP) is a marker for heart failure, not acute myocardial infarction.
D. Elevated creatine kinase (CK), particularly CK-MB, can indicate muscle injury, including cardiac injury, but it is less specific than troponins for diagnosing AMI.
A nurse is caring for a client who is receiving intravenous heparin therapy for deep vein thrombosis. The nurse evaluates for side effects of this drug by observing for:
Explanation
A. Pruritus is not a common side effect of heparin therapy. While allergic reactions can occur, they are not the primary concern.
B. Petechiae are a sign of bleeding, which is a major side effect of heparin therapy. Heparin increases the risk of bleeding by inhibiting clot formation, and petechiae may indicate early signs of hemorrhage.
C. Confusion is not directly associated with heparin therapy unless it results from severe bleeding leading to hypoxia or shock.
D. A slowing pulse rate is not a known adverse effect of heparin. Instead, monitoring for signs of bleeding, such as bruising, hematuria, and petechiae, is the priority.
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