Nokea
The nurse has instructed a client who is scheduled to have a transesophageal echocardiogram (TEE). Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will need to take antibiotics for one week following this test.
- B. This test will determine if I have any blood clots in my heart.
- C. I will receive general anesthesia for this procedure.
- D. I may feel a flushing sensation when the contrast dye is given.
Correct Answer: B
Rationale: TEE is used to detect intracardiac thrombi, such as in atrial fibrillation, making this statement correct.
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The nurse is caring for a client with congestive heart failure experiencing an exacerbation. Which of the following of the client's vital signs would indicate that the client is experiencing a complication?
- A. Decrease in blood pressure
- B. Increase in temperature
- C. Decrease in respiratory rate
- D. Increase in blood pressure
Correct Answer: A
Rationale: A decrease in blood pressure during a CHF exacerbation may indicate cardiogenic shock, a serious complication.
Which of the following interventions should the nurse include when teaching clients strategies for preventing cardiovascular disease? Select all that apply.
- A. Encouraging regular physical exercise
- B. Promoting a diet high in saturated fats
- C. Advising smoking cessation
- D. Recommend no more than 5 alcoholic drinks a day
- E. Educating about the importance of regular blood pressure monitoring
- F. Instructing on the importance of regular cholesterol screenings
Correct Answer: A,C,E,F
Rationale: Regular exercise reduces cardiovascular risk. B: Incorrect - High saturated fat diets increase cardiovascular risk. C: Correct - Smoking cessation lowers cardiovascular disease risk. D: Incorrect - Alcohol should be limited to 1-2 drinks per day for men, 1 for women. E: Correct - Blood pressure monitoring detects hypertension early. F: Correct - Cholesterol screenings identify hyperlipidemia for early intervention.
The nurse cares for a client with acute myocardial infarction (AMI). The nurse anticipates the physician will order an emergent
- A. exercise electrocardiography.
- B. computed tomography (CT) of the chest with contrast.
- C. percutaneous coronary intervention (PCI).
- D. echocardiogram.
Correct Answer: C
Rationale: PCI is the standard emergent treatment for AMI to restore coronary blood flow.
The nurse is caring for a client with cardiac tamponade. Which vital signs are expected?
- A. HR: 109 bpm; RR: 26; BP: 88/71 mmHg
- B. HR: 90 bpm; RR: 32; BP: 90/52 mmHg
- C. HR: 115 bpm; RR: 22; BP: 140/78 mmHg
- D. HR: 54 bpm; RR: 14; BP: 161/52 mmHg
Correct Answer: A
Rationale: Cardiac tamponade causes tachycardia (HR >100), increased respiratory rate, and hypotension due to restricted cardiac output.
The nurse assessed a client's cardiac rhythm strip. The nurse should plan to document this rhythm as which of the following? See the image below.
- A. Ventricular fibrillation
- B. Complete (3rd degree) heart block
- C. Sinus tachycardia
- D. Sinus bradycardia
Correct Answer: A
Rationale: Ventricular fibrillation is a chaotic, life-threatening rhythm requiring immediate defibrillation.