NCLEX-PN Exam Cram: Caring for the Client with Disorders of the Cardiovascular System
Date: Oct 25, 2011
Terms you'll need to understand:
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Aneurysms |
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Angina pectoris |
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Angioplasty |
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Arterosclerosis |
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Blood pressure |
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Buerger's disease |
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Cardiac catheterization |
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Cardiac tamponade |
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Cardiopulmonary resuscitation |
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Cholesterol |
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Conduction system of the heart |
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Congestive heart failure |
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Coronary artery bypass graft |
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Defribulation |
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Diastole |
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Electrocardiogram |
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Heart block |
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Hypertension |
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Implantable cardioverter |
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Myocardial infarction |
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Pacemaker |
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Raynaud's |
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Systole |
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Thrombophlebitis |
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Varicose veins |
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Ventricular fibrillation |
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Ventricular tachycardia |
Nursing skills you'll need to master:
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Performing cardiopulmonary resuscitation (CPR) |
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Monitoring central venous pressure |
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Monitoring blood pressure |
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Interpreting electrocardiography (ECG) |
The cardiovascular system is comprised of the heart and blood vessels and is responsible for the transport of oxygen and nutrients to organ systems of the body. The heart is a cone-shaped organ made up of four chambers. The right side of the heart receives deoxygenated venous blood from the periphery by way of the superior and inferior venae cavae. The left side of the heart receives blood from the lungs and pumps the oxygenated blood to the body. The blood vessels are divided into arteries and veins. Arteries transport oxygenated blood and veins transport deoxygenated blood. In this chapter, you will discover diseases that affect the cardiovascular system, the treatment of these diseases, and the effects on the client's general health status.
Hypertension
Blood pressure is the force of blood exerted on the vessel walls. Systolic pressure is the pressure during the contraction phase of the heart and is evaluated as the top number of the blood pressure reading. Diastolic pressure is the pressure during the relaxation phase of the heart and is evaluated as the lower number of the blood pressure reading. A diagnosis of hypertension is made by a blood pressure value greater than 140/90 obtained on two separate occasions with the client sitting, standing, and lying. In clients with diabetes, a reading of 130/85 or higher is considered to be hypertension.
Accuracy of the BP reading depends on the correct selection of cuff size. The bladder of the blood pressure cuff size should be sufficient to encircle the arm or thigh. According to the American Heart Association, the bladder width should be approximately 40% of the circumference or 20% wider than the diameter of the midpoint of the extremity. A blood pressure cuff that's too small yields a false high reading, whereas a blood pressure cuff that's too large yields a false low reading.
Hypertension is classified as either primary or secondary. Primary hypertension, or essential hypertension, develops without apparent cause; secondary hypertension develops as a result of another illness or condition. Symptoms associated with secondary hypertension are improved by appropriate treatment of the contributing illness. Blood pressure fluctuates with exercise, stress, changes in position, and changes in blood volume. Medications such as oral contraceptives and bronchodilators can also cause elevations in blood pressure. Often the client with hypertension will have no symptoms at all or might complain of an early morning headache and fatigue. This silent killer, if left untreated, can lead to coronary disease, renal disease, strokes, and other life-threatening illnesses.
Management of hypertension includes a program of diet and exercise. If the client's cholesterol level is elevated, a low-fat, low-cholesterol diet is ordered. The total serum cholesterol levels should be less than 200 mg/dl.
Medications Used to Treat Hypertension
Should diet and exercise prove unsuccessful in lowering the blood pressure, the doctor might decide to prescribe medications such as diuretics or antihypertensives. Table 13.1 includes drugs used to treat hypertension.
Table 13.1. Hypertension Drugs
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Drug Category |
Drug Types |
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Diuretics |
Thiazide: Chlorothiazide (Diuril), hydrochlorothiazide (Esidrix, HydroDiuril) Loop diuretics: Furosemide (Lasix), ethacrynic acid (Edecrin) Potassium-sparing diuretics: Spironolactone (Aldactone), triamterone (Dyrenium) |
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Beta blockers |
Propanolol (Inderal), atenolol (Tenormin), nadolol (Corgard), Carvedilol (Coreg) |
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Calcium channel blockers |
Nifedipine (Procardia), verapamil (Calan), diltiazem hydrochloride (Cardizem) |
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Angiotensin converting enzyme inhibitors |
Captopril (Capoten), enalpril (Vasotec), lisinopril (Zestril, Prinivil) |
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Angiotensin receptor blockers |
Candesartan (Altacand), losartan (Cozaar), telmisartan (Micardis) |
These drugs can be used alone or in conjunction with one another. Diuretics and vasodilators are often given in combination to lower blood pressure through diuresis and vasodilation. Hypertensive crisis exists when the diastolic blood pressure reaches 140. Malignant hypertension is managed with administration of IV Nitropress, nitroglycerine, Nipride, Lasix, and other potent vasodilators such as Procardia.
Heart Block
The normal conduction system of the heart is comprised of the sinoatrial (SA) node located at the junction of the right atrium and the superior vena cava. This area contains the pacing cells that initiate the contraction of the heart. The SA node is considered to be the main pacer of the heart rate. The atrioventricular (AV) node is located in the interventricular septum and receives the impulse and transmits it on to the Bundle of His, which extends down through the ventricular septum and merges with the Purkinje fibers in the lower portion of the ventricles. Figure 13.1 shows an anatomical drawing of the human heart.
Figure 13.1 Anatomical drawing of the heart.
Heart block is a condition in which the conduction system of the heart fails to conduct impulses normally. Heart block can occur as a result of structural changes in the conduction system, such as tumors, myocardial infarctions, coronary artery disease, infections of the heart, or toxic effects of drugs such as digoxin. First-degree AV block occurs when the SA node continues to function normally, but transmission of the impulse fails. Because of the conduction dysfunction and ventricular depolarization, the heart beats irregularly. These clients are usually asymptomatic and all impulses eventually reach the ventricles. Second-degree heart block is a block in which impulses reach the ventricles, but others do not. In third-degree heart block or complete heart block, none of the sinus impulses reach the ventricle. This results in erratic heart rates where the sinus node and the atrioventricular nodes are beating independently. The result of this type of heart block can be hypotension, seizures, cerebral ischemia, or cardiac arrest. Detection of a heart block is made by assessing the electrocardiogram. See Figure 13.2 for a graph depicting a normal electrocardiogram.
Figure 13.2 A normal electrocardiogram.
The P wave as shown in the graph is the SA node firing, the QRS complex is the contraction phase of the heart, and the T wave is the repolarization of the heart.
Toxicity to Medications
Toxicity to medications, such as Digoxin, can be associated with heart block. Clients taking Digitalis should be taught to check their pulse rate and to return to the physician for regular evaluation of their Digitalis level. The therapeutic level for Digoxin is 0.5–2.0 ng/ml. If the client's blood level of Digoxin exceeds 2.0 ng/ml, the client is considered to be toxic. Clients with Digoxin toxicity often complain of nausea, vomiting, and seeing halos around lights. The nurse should teach the client to check his heart rate prior to taking Digoxin. A resting pulse rate of less than 60 bpm in the adult client should alert the nurse to the possibility of toxicity. Treatment for Digoxin toxicity includes checking the potassium level because hypokalemia can contribute to Digoxin toxicity. The physician often will order potassium be given IV or orally and that the Digoxin be held until serum levels return to normal. Other medications, such as Isuprel or Atropine, and Digibind, are frequently ordered to increase the heart rate.
Malfunction of the Conduction System
Because a malfunction of the conduction system of the heart is the most common cause for heart block, a pacing mechanism is frequently implanted to facilitate conduction. Pacemakers can be permanent or temporary and categorized as demand or set. A demand pacemaker initiates an impulse if the client's heart rate fails below the prescribed beats per minute. A set pacemaker overrides the heart's own conduction system and delivers an impulse at the rate set by the physician. Frequently, pacemakers are also combined with an internal defibrillation device.
Permanent Pacemakers/Internal Defibrillators: What the Client Should Know
Clients with internal defibrillators or pacemakers should be taught to avoid direct contact with electrical equipment. Clients should be instructed to
- Wear a medic alert stating that a pacemaker/internal defibrillator is implanted. Identification will alert the healthcare worker so that alterations in care can be made.
- Take the pulse for 1 full minute and report the rate to the physician.
- Avoid applying pressure over the pacemaker/internal defibrillator. Pressure on the defibrillator or pacemaker can interfere with the electrical leads.
- Inform the dentist of the presence of a pacemaker/internal defibrillor because electrical devices are often used in dentistry.
- Avoid having a magnetic resonance imaging (MRI). Magnetic resonance interferes with the electrical impulse of the implant.
- Avoid close contact with electrical appliances, electrical or gasoline engines, transmitter towers, antitheft devices, metal detectors, and welding equipment because they can interfere with the electrical conduction of the device.
- Be careful when using microwaves. Microwaves are generally safe for use, but the client should be taught to stand approximately 5 feet away from the device while cooking.
- Report fever, redness, swelling, or soreness at the implantation site.
- If a vibration or beeping tone is noted coming from the internal defibrillator, immediately move away from any electromagnetic source. Stand clear from other people because shock can affect anyone touching the client during defibrillation.
- Report dizziness, fainting, weakness, blackouts, or a rapid pulse rate. The client will most likely be told not to drive a car for several months after the internal defibrillator is inserted to evaluate any dysrhythmias.
- Report persistent hiccupping because this can indicate misfiring of the pacemaker/internal defibrillator.
- Do not lift the left arm higher than shoulder level for approximately two weeks since this may increase the chances of displacement of the leads.
Myocardial Infarction
When there is a blockage in one or more of the coronary arteries, the client is considered to have had a myocardial infarction. Factors contributing to diminished blood flow to the heart include arteriosclerosis, emboli, thrombus, shock, and hemorrhage. If circulation is not quickly restored to the heart, the muscle becomes necrotic. Hypoxia from ischemia can lead to vasodilation of blood vessels. Acidosis associated with electrolyte imbalances often occurs, and the client can slip into cardiogenic shock. The most common site for a myocardial infarction is the left ventricle. Classic signs of a myocardial infarction include substernal pain or a feeling of heaviness in the chest. However it should be noted that women, elderly clients, and clients with diabetes may fail to report classic symptoms. Women might tell the nurse that the pain is beneath the shoulder or in the back, anxiety, or a feeling of apprehension and nausea.
The most commonly reported signs and symptoms associated with myocardial infarction include
- Substernal pain or pain over the precordium of a duration greater than 15 minutes
- Pain that is described as heavy, vise-like, and radiating down the left arm
- Pain that begins spontaneously and is not relieved by nitroglycerin or rest
- Pain that radiates to the jaw and neck
- Pain that is accompanied by shortness of breath, pallor, diaphoresis, dizziness, nausea, and vomiting
- Increased heart rate, decreased blood pressure, increased temperature, and increased respiratory rate
Diagnosis of Myocardial Infarction
The diagnosis of a myocardial infarction is made by looking at both the electrocardiogram and the cardiac enzymes. The following are the most commonly used diagnostic tools for determining the type and severity of the attack:
- Electrocardiogram (ECG), which frequently shows dysrhythmias
- Serum enzymes and isoenzymes
Other tests that are useful in providing a complete picture of the client's condition are white blood cell count (WBC), sedimentation rate, and blood urea nitrogen (BUN).
The best serum enzyme diagnostic is the creatine kinase (CK-MB) diagnostic. This enzyme is released when there is damage to the myocaridium. The Troponin T and 1 are specific to striated muscle and are often used to determine the severity of the attack. C-reactive protein (CRP) levels are used with the CK-MB to determine whether the client has had an acute MI and the severity of the attack. Lactic acid dehydrogenase (LDH) is a nonspecific enzyme that is elevated with any muscle trauma.
Management of Myocardial Infarction Clients
Management of myocardial infarction clients includes monitoring of blood pressure, oxygen levels, and pulmonary artery wedge pressures. Because the blood pressure can fall rapidly, medications such as dopamine is prescribed. Other medications are ordered to relieve pain and to vasodilate the coronary vessels—for example, morphine sulfate IV is ordered for pain. Thrombolytics, such as streptokinase, will most likely be ordered. Early diagnosis and treatment significantly improve the client's prognosis.
Clients suffering a myocardial infarction can present with dysrhythmias. Ventricular dysrhythmias such as ventricular tachycardia or fibrillation lead to standstill and death if not treated quickly.
Ventricular Tachycardia
Ventricular tachycardia is a rapid rhythm absence of a p-wave. Usually the rate exceeds 140–180 bpm. A lethal arrhythmia that leads to ventricular fibrillation and standstill, ventricular tachycardia is often associated with valvular heart disease, heart failure, hypomagnesium, hypotension, and ventricular aneurysms. Figure 13.3 shows a diagram demonstrating ventricular tachycardia.
Figure 13.3 Evidence of ventricular tachycardia.
Ventricular tachycardia is treated with oxygen and medication. Amiodarone (Cordarone), procainamide (Pronestyl), or magnesium sulfate is given to slow the rate and stabilize the rhythm. Lidocaine has long been established for the treatment of ventricular tachycardia; however, it should not be used in an acute MI client. Heparin is also ordered to prevent further thrombus formation but is not generally ordered with clients taking streptokinase.
Ventricular Fibrillation
Ventricular fibrillation (V-fib) is the primary mechanism associated with sudden cardiac arrest. This disorganized chaotic rhythm results in a lack of pumping activity of the heart. Without effective pumping, no blood is sent to the brain and other vital organs. If this condition is not corrected quickly, the client's heart stops beating and asystole is seen on the ECG. The client quickly becomes faint, loses consciousness, and becomes pulseless. Hypotension or a lack of blood pressure and heart sounds are present. Figure 13.4 shows a diagram of the chaotic rhythms typical with V-fib.
Figure 13.4 Ventricular fibrillation diagram.
Treatment of ventricular fibrillation is to defibrillate the client starting with 200 Joules. Three quick, successive shocks are delivered with the third at 360 Joules. If a defibrillator is not readily available, a precordial thump can be delivered. Oxygen is administered and antidysrhythmic medications such as epinephrine or atropine. If cardiac arrest occurs, the nurse should initiate cardiopulmonary resusicitation. (Please visit the American Heart Association guidelines for CPR).
Cardiac catheterization is used to detect blockages associated with myocardial infarctions and dysrthymias. Cardiac catheterization, as with any other dye procedure, requires a permit. This procedure can also accompany percutaneous transluminal coronary angioplasty. Prior to and following this procedure, the nurse should
- Assess for allergy to iodine or shellfish.
- Maintain the client on bed rest with the leg straight.
- Maintain pressure on the access site for at least 5 minutes or until no signs of bleeding are noted. Many cardiologists use a device called Angio Seals to prevent bleeding at the insertion site. The device creates a mechanical seal anchoring a collagen sponge to the site. The sponge absorbs in 60–90 days.
- Use pressure dressing and/or ice packs to control bleeding.
- Check distal pulses because diminished pulses can indicate a hematoma and should be reported immediately.
- Force fluids to clear dye from the body.
If the client is not a candidate for angioplasty, a coronary artery bypass graft might be performed. The family should be instructed that the client will return to the intensive care unit with several tubes and monitors. The client will have chest tubes and a mediastinal tube to drain fluid and to reinflate the lungs. If the client is bleeding and blood is not drained from the mediastinal area, fluid accumulates around the heart. This is known as cardiac tamponade. If this occurs, the myocardium becomes compressed and the accumulated fluid prevents the filling of the ventricles and decreases cardiac output.
A Swan-Ganz catheter for monitoring central venous pressure, pulmonary artery wedge pressure monitor, and radial arterial blood pressure monitor are inserted to measure vital changes in the client's condition. An ECG monitor and oxygen saturation monitor are also used. Other tubes include a nasogastric tube to decompress the stomach, a endotracheal tube to assist in ventilation, and a Foley catheter to measure hourly output.
Following a myocardial infarction, the client should be given small, frequent meals. The diet should be low in sodium, fat, and cholesterol. Adequate amounts of fluid and fiber are encouraged to prevent constipation, and stool softeners are also ordered. Post-MI teaching should stress the importance of a regular program of exercise, stress reduction, and cessation of smoking. Because caffeine causes vasoconstriction, caffeine intake should be limited. The client can resume sexual activity in 6 weeks or when he is able to climb a flight of stairs without experiencing chest pain. Medications such as Viagra are discouraged and should not be taken within 24 hours of taking a nitrate because taking these medications in combination can result in hypotension. Clients should be taught not to perform the Valsalva maneuver or bend at the waist to retrieve items from the floor. The client will probably be discharged on an anticoagulant such as enoxaparin (Lovenox) or sodium warfarin (Coumadin); however this range varies from one text to another.
Buerger's Disease
Buerger's disease (thromboangilitis obliterans) results when spasms of the arteries and veins occur primarily in the lower extremities. These spasms result in blood clot formation and eventually destruction of the vessels. Symptoms associated with Buerger's include pallor of the extremities progressing to cyanosis, pain, and paresthesia. As time progresses, tophic changes occur in the extremities. Management of the client with Buerger's involves the use of Buerger-Allen exercises, vasodilators, and oxygenation. The client should be encouraged to stop smoking because smoking makes the condition worse.
Thrombophlebitis
Thrombophlebitis occurs when there is an inflammation of a vein with formation of a clot occurs. Most thrombophlebitis occurs in the lower extremities, with the saphenous vein being the most common vein affected. Homan's sign is an assessment tool used for many years by healthcare workers to detect deep vein thrombi. It is considered positive if the client complains of pain on dorsiflexion of the foot. Homan's sign should not be performed routinely because it can cause a clot to be dislodged and lead to pulmonary emboli. If a diagnosis of thrombophlebitis is made, the client should be placed on bed rest with warm, moist compresses to the leg. An anticoagulant is ordered, and the client is monitored for complications such as cellulitis. If cellulitis is present, antibiotics are ordered.
Antithrombolitic stockings or sequential compression devices are ordered to prevent venous stasis. When antithrombolitic stockings are applied, the client should be in bed for a minimum of 30 minutes prior to applying the stockings. The circumference and length of the extremity should be measured to prevent rolling down of the stocking and a tourniquet effect.
Raynaud's Syndrome
Raynaud's syndrome occurs when there are vascular spasms brought on by exposure to cold. The most commonly effected areas are the hands, nose, and ears. Management includes preventing exposure, stopping smoking, and using vasodilators. The client should be encouraged to wear mittens when outside in cold weather.
Aneurysms
An aneurysm is a ballooning of an artery. The greatest risk for these clients is rupture and hemorrhage. Aneurysms can occur in any artery in the body and can be due to congenital malformations or arteriosclerosis or be secondary to hypertension. The following are several types of aneurysms:
- Fusiform—This aneurysm affects the entire circumference of the artery.
- Saccular—This aneurysm is an outpouching affecting only one portion of the artery.
- Dissecting—This aneurysm results in bleeding into the wall of the vessel.
Frequently, the client with an abdominal aortic aneurysm complains of feeling her heart beating in her abdomen or lower back pain. Any such complaint should be further evaluated. On auscultation of the abdomen, a bruit can be heard. Diagnosis can be made by ultrasound, arteriogram, or abdominal x-rays.
If the aneurysm is found to be 6 centimeters or more, surgery should be scheduled. During surgery the aorta is clamped above and below and a donor vessel is anastamosed in place. When the client returns from surgery, pulses distal to the site should be assessed and urinary output should be checked. Clients who are not candidates for surgery might elect to have stent placement to reinforce the weakened artery. These stents are threaded through an incision in the femoral artery, hold the artery open, and provide support for the weakened vessel. See Figure 13.5 for a diagram of an abdominal aortic aneurysm.
Figure 13.5 Abdominal aortic aneurysm.
Congestive Heart Failure
When fluid accumulation occurs and the heart is no longer able to pump in an efficient manner, blood can back up. Most heart failure occurs when the left ventricle fails. When this occurs, the fluid backs up into the lungs, causing pulmonary edema. The signs of pulmonary edema are frothy, pink-tinged sputum; shortness of breath; and orthopnea. Distended jugular veins might also be present. When right-sided congestive heart failure occurs, the blood backs up into the periphery. The nurse might also note signs of pitting edema. Pitting can be evaluated by pressing on the extremities and noting the degree of pitting, how far up the extremity the pitting occurs, and how long it takes to return to the surface. Treatment for congestive heart failure includes use of diuretics, inotropic drugs such as milrinone (Primacor), and cardiotonics such as nesiritide (Natrecor). Morphine might also be ordered.
Diagnostic Tests for Review
The following diagnostic test should be reviewed prior to taking the NCLEX exam:
- CBC—A complete blood count tells the nurse the level of oxygenation of the blood, particularly the hemoglobin and hematocrit.
- Chest x-ray—Chest x-rays and other x-rays tell the nurse whether the heart is enlarged or aneurysms are present.
- Arteriogram—Arteriography reveals the presence of blockages and abnormalities in the vascular system.
- Cardiac catheterization —A cardiac catheterization reveals blockages, turbulent flow, and arteriosclerotic heart disease.
- ECG interpretation—Indicates abnormalities in the rate and rhythm of the conductions system of the heart.
- Central venous pressure monitoring—CVP indicates fluid volume status.
- B-type natriuretic peptide (BNP)—Used to diagnose heart failure in clients with acute dyspnea. It is used to differentiate dyspnea found in those with lung disorders from those with congestive heart failure.
- Thallium or Cardiolite (sestamibi) stress—A test used to determine ischemia. A radionuclide is injected at the peak of exercise.
Pharmacology Categories for Review
The following pharmacology categories should be reviewed prior to taking the NCLEX exam:
- Diurectics
- Cardiotonics
- Antihypertensives
- Anticoagulants
- Thrombolytics
- Inotrophic
- Analgesics
Exam Prep Questions
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The client presents to the clinic with a serum cholesterol of 275 mg/dl and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?
A.
Report muscle weakness to the physician.
B.
Allow 6 months for the drug to take effect.
C.
Take the medication with fruit juice.
D.
Ask the doctor to perform a complete blood count prior to starting the medication.
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The client is admitted to the hospital with a hypertensive crisis. Diazoxide (Hyperstat) is ordered. During administration the nurse should:
A.
Utilize an infusion pump.
B.
Check the blood glucose level.
C.
Place the client in Trendelenburg position.
D.
Cover the solution with foil.
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A 6-month-old client with a ventricular septal defect is receiving Lanoxin elixir for regulation of his heart rate. Which finding should be reported to the doctor?
A.
A blood pressure of 126/80
B.
A blood glucose of 110 mg/dl
C.
A heart rate of 60 bpm
D.
A respiratory rate of 30 per minute
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The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
A.
Replenish her supply every 3 months.
B.
Take one every 15 minutes if pain occurs.
C.
Leave the medication in the brown bottle.
D.
Crush the medication and take it with water.
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A 54-year-old male is admitted to the cardiac unit with chest pain radiating to the jaw and left arm. Which enzyme would be most specific in the diagnosis of a myocardial infarction?
A.
Aspartate aminotransferase
B.
Lactic acid dehydrogenase
C.
Hydroxybutyric dehydrogenase
D.
Creatine phosphokinase
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The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
A.
Macaroni and cheese
B.
Shrimp with rice
C.
Turkey breast
D.
Spaghetti and meatballs
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The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
A.
Feet
B.
Neck
C.
Hands
D.
Sacrum
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The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:
A.
Phlebostatic axis
B.
Point of maximum impulse (PMI)
C.
Erb's point
D.
Tail of Sphence
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The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:
A.
Question the order.
B.
Administer the medications.
C.
Administer them separately.
D.
Contact the pharmacy.
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The best method of evaluating the amount of peripheral edema is:
A.
Weighing the client daily
B.
Measuring the extremity
C.
Measuring the intake and output
D.
Checking for pitting
Answer Rationales
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Answer A is correct. The client taking antilipidemics should be encouraged to report muscle weakness because this is a sign of rhabdomyositis. The medication takes effect within 1 month of beginning therapy, so answer B is incorrect. The medication should be taken with water. Fruit juice, particularly grapefruit juice, can decrease the drug's effectiveness, so answer C is incorrect. Liver function studies, not a CBC, should be checked prior to beginning the medication, so answer D is incorrect.
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Answer B is correct. Hyperstat is given IV push for hypertensive crisis. It often causes hyperglycemia. The glucose level will drop rapidly after the medication is administered. Answer A is incorrect because this medication is given IV push. The client should be placed in dorsal recumbent position, not Trendelenburg, so answer C is incorrect. Answer D is incorrect because the medication is ordered IV push.
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Answer C is correct. A heart rate of 60 in the 6-month-old receiving Lanoxin elixir (digoxin) should be reported immediately because bradycardia is associated with digoxin toxicity. The blood glucose, blood pressure, and respirations are not associated with administration of Lanoxin, so answers A, B, and D are incorrect.
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Answer C is correct. The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every 6 months, so answer A is incorrect. One tablet should be taken every 5 minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.
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Answer D is correct. CK-MB (creatine phosphokinase muscle bond isoenzyme) is the most specific for a myocardial infarction. Troponin is also extremely reliable. Answers A, B, and C are nonspecific to myocardial infarctions, so they are incorrect.
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Answer C is correct. Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.
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Answer B is correct. The neck veins should be assessed for distension in the client with congestive heart failure. Edema of the feet and hands do not indicate central circulatory overload, so answers A and C are incorrect. Edema of the sacrum is an indication of right-sided congestive heart failure, so answer D is incorrect.
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Answer A is correct. The nurse should place the zero of the manometer at the phlebostatic axis (located at the fifth intercostal space mid-axillary line) when checking the central venous pressure. Answers B, C, and D are incorrect methods for determining the central venous pressure.
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Answer B is correct. Zestril is an ACE inhibitor and is frequently given with a diuretic such as Lasix. There is no need to question the order, give the drugs separately, or contact the pharmacy, so answers A, C, and D are incorrect.
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Answer B is correct. The best method for evaluating the amount of peripheral edema is measuring the extremity. A paper tape measure should be used rather than plastic or cloth, and the area should be marked with a pen. This provides the most objective assessment. Answers A, C, and D are not the best methods for evaluating the amount of peripheral edema, therefore they are incorrect.
Suggested Reading and Resources
- Ignataviicus, Donna D., and Linda Workman. Medical-Surgical Nursing. Philadelphia: W.B. Saunders Company, 2007.
- Taber's Cyclopedic Medical Dictionary. Philadelphia: F. A. Davis, 2005.
- Vanetzian, Eleanor V. Critical Thinking: An Interactive Tool for Learning Medical-Surgical Nursing. Philadelphia: F. A. Davis, 2005.
- Rinehart, Wilda, Diann Sloan, and Clara Hurd. NCLEX Exam Cram. Indianapolis: Que Publishing, 2005.
- Deglin, Judith H., and April H. Vallerand. Davis Drug Guide for Nurses. Philadelphia: F. A. Davis, 2006.