Nokea
The nurse provides care for a dying client following a massive myocardial infarction (MI). The nurse notes the client is experiencing dyspnea and has a barely palpable pulse. Which documentation of pulse quality by the nurse is appropriate?
- A. The client's pulse is full.
- B. The client is exhibiting a thready pulse.
- C. The client is experiencing a pulse deficit.
- D. The client's pulse indicates a regular rhythm.
Correct Answer: B
Rationale: When taking a client's pulse, the nurse notes its rate, rhythm, and quality. The pulse quality refers to its palpated volume. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. Documentation that the client's pulse is full is inaccurate. The nurse also determines any pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Documenting that the client's pulse indicates a regular rhythm is inaccurate because the documentation in this scenario focuses on the quality, not rhythm.
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The nurse caring for a client who is suspected of having cardiovascular disease has a stress test ordered. The client has a comorbidity of multiple sclerosis, so the nurse knows the stress test will be drug induced. What drug will be used to dilate the coronary arteries?
- A. Thallium
- B. Lorazepam
- C. Diazepam
- D. Dobutamine
Correct Answer: D
Rationale: Drugs such as adenosine (Adenocard), dipyridamole (Persantine), or dobutamine (Dobutrex) may be administered singularly or in combination by the IV route. The drugs dilate the coronary arteries, similar to the vasodilation that occurs when a person exercises to increase the heart muscle's blood supply. The other drugs would not dilate the coronary arteries.
The nurse is caring for a client with an elevated blood pressure and no previous history of hypertension. At 0900, the blood pressure was 158/90 mm Hg. At 0930, the blood pressure is 142/82 mm Hg. The nurse is most correct when relating the fall in blood pressure to which structure?
- A. Chemoreceptors
- B. Sympathetic nerve fibers
- C. Baroreceptors
- D. Vagus nerve
Correct Answer: C
Rationale: Baroreceptors sense pressure in nerve endings in the walls of the atria and major blood vessels. The baroreceptors respond accordingly to raise or lower the pressure. Chemoreceptors are sensitive to pH, CO2, and O2 in the blood. Sympathetic nerve fibers increase the heart rate. The vagus nerve slows the heart rate.
A client needs additional information about a heart condition. The client asks the nurse 'What is considered the pacemaker of the heart?'
- A. The AV node
- B. The bundle of HIS
- C. The Purkinje fibers
- D. The SA node
Correct Answer: D
Rationale: The SA node is called the pacemaker of the heart because it initiates the electrical impulses that cause the atria and ventricles to contract. Normally, it produces between 60 and 100 impulses per minute; the average is approximately 72 impulses per minute.
Which suggestion can the nurse provide to an older adult client to reduce the symptoms associated with sarcopenia?
- A. Maintain hydration.
- B. Avoid heavy lifting.
- C. Practice brisk walking.
- D. Limit the use of caffeine.
Correct Answer: C
Rationale: Sarcopenia refers to changes in composition of muscle tissue that can occur in aging because of deconditioning; therefore, increasing daily exercise helps to improve muscle strength, including the heart. Maintaining hydration is important for a client who requires cardiac catheterization to flush the dye used during the procedure from the system and is not an intervention supported by evidence-based practice guidelines for the client who experiences sarcopenia. Heavy lifting is discouraged following cardiac catheterization; however, avoiding lifting is not an activity that reduces symptoms associated with sarcopenia. The nurse discourages the use of caffeine for clients who experience tachycardia; however, this is not an appropriate suggestion to reduce the symptoms associated with sarcopenia.
The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test?
- A. A 48-year-old policemen with history of knee replacement 4 years ago
- B. A 68-year-old housewife with history of osteoporosis
- C. A 72-year-old retired janitor obtaining a cardiac baseline
- D. A 55-year-old recovering from a fall and broken femur
Correct Answer: D
Rationale: An exercise electrocardiography or stress test monitors the electrical activity of the heart while the client walks on a treadmill. If a client has a sedentary lifestyle or physical disability, cardiac medications may be administered to stress the heart similar to activity. Even though the client is middle aged at 55 years old, the client is recovering from a broken femur thus would be unable to have vigorous exercise. None of the other clients have a history which precludes them from exercise electrocardiography.