Nokea
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
- A. An 80-year-old male with a history of asthma
- B. A 32-year-old Asian-American male with colorectal cancer
- C. A 45-year-old American Indian female with diabetes mellitus
- D. A 53-year-old postmenopausal woman who is on hormone therapy
Correct Answer: C
Rationale: The incidence of coronary artery disease and hypertension is higher in American Indians than in other populations. Diabetes mellitus further increases the risk for cardiovascular disease in any population, making the 45-year-old American Indian female with diabetes mellitus the client with the greatest risk.
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A nurse monitors a client 2 hours after a cardiac catheterization. Which findings would require immediate action? (Select all that apply.)
- A. Blood pressure of 142/88 mm Hg
- B. Serum potassium of 2.9 mEq/L
- C. Warmth and redness at the site
- D. Expanding hematoma
- E. Rhythm changes on the cardiac monitor
Correct Answer: B,D,E
Rationale: Hypokalemia (2.9 mEq/L), an expanding hematoma, and rhythm changes are serious complications requiring immediate action. Slightly elevated blood pressure and warmth/redness (if not severe) are less urgent in the immediate post-procedure period.
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.)
- A. Thrombophlebitis
- B. Stroke
- C. Pulmonary embolism
- D. Myocardial infarction
- E. Cardiac tamponade
Correct Answer: A,C,E
Rationale: Right-sided heart catheterization carries risks of thrombophlebitis, relationships pulmonary embolism, and cardiac tamponade. Stroke and myocardial infarction are more commonly associated with left-sided catheterizations.
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
- A. A 30-year-old female who describes her pain as a dull ache with numbness in her fingers
- B. A 40-year-old male who reports moderate pain that is worse on inspiration
- C. A 53-year-old female who reports substantial pain that radiates to her abdomen
- D. A 36-year-old female who reports substantial pain that radiates to her jaw
Correct Answer: D
Rationale: Substantial chest pain radiating to the jaw is a classic symptom of myocardial infarction, requiring immediate assessment. Pain described as dull, related to inspiration, or radiating to the abdomen is less specific for acute cardiac events.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse suspect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node, resulting in an increased heart rate. A heart rate of 120 beats/min is indicative of tachycardia, which is a compensatory mechanism for low blood pressure.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
- A. Elevate the leg and apply a sandbag to the entrance site
- B. Increase the flow rate of intravenous fluids
- C. Notify the provider immediately
- D. Document the finding as left pedal pulse of +1
Correct Answer: C
Rationale: A weak pedal pulse post-angiography may indicate arterial obstruction or hematoma formation, which is a serious complication. The nurse should notify the provider immediately for further evaluation and intervention.