Cardio Rationales Saunders
1. The nurse should counsel the client to keep
the total cholesterol level under 200 mg/dL.
This will aid in the prevention of
atherosclerosis, which can lead to a number of
cardiovascular disorders later in life. Options
3 and 4 are elevated values and place the
client at risk for cardiovascular disease.
Although option 1 is a low cholesterol level,
option 2 identifies the realistic value to assist
in preventing cardiovascular disease.
2. Troponin is a regulatory protein found in
striated muscle. The troponins function
together in the contractile apparatus for
striated muscle in skeletal muscle and in the
myocardium. Increased amounts of troponins
are released into the bloodstream when an
infarction causes damage to the myocardium.
A troponin T value that is higher than 0.1 to
0.2 ng/mL is consistent with a myocardial
infarction. A normal troponin I level is lower
than 0.6 ng/mL.
3. Creatine kinase (CK) is a cellular enzyme that
can be fractionated into three isoenzymes. The
MB band reflects CK from cardiac muscle.
This is the level that elevates with myocardial
infarction. The MM band reflects CK from
skeletal muscle. The BB band reflects CK
from the brain. There is no MK band.
4. The normal prothrombin time (PT) is 9.6 to
11.8 seconds (male adult) or 9.5 to 11.3
seconds (female adult). A therapeutic PT level
is 1.5 to 2.0 times higher than the normal
level. Because the value of 35 seconds is high
(and perhaps near the critical range), the nurse
should anticipate that the client would not
receive further doses at this time.
5. The normal therapeutic range for digoxin is
0.5 to 2.0 ng/mL. A level of 2.4 ng/mL
exceeds the therapeutic range and indicates
toxicity. The most important action is to notify
the physician, who may give further orders
about holding further doses of digoxin. Option
3 is incorrect because the level is not normal.
The next dose should not be administered
because the serum digoxin level exceeds the
therapeutic range. Checking the client’s last
pulse rate is not incorrect but may have
limited value in this situation. Depending on
the time that has elapsed since the last
assessment, a current assessment of the
client’s status may be more useful.
6. The normal activated partial thromboplastin
time (aPTT) varies between 20 and 36
seconds, depending on the type of activator
used in testing. The therapeutic dose of
heparin for treatment of deep vein thrombosis
is to keep the aPTT between 1.5 and 2.5 times
normal. Thus, the client’s aPTT is within the
therapeutic range, and the dose should remain
unchanged.
7. The normal serum potassium level in the adult
is 3.5 to 5.1 mEq/L. Option 1 is the only value
that falls below the therapeutic range.
Administering furosemide to a client with a
low potassium level and a history of cardiac
problems could precipitate ventricular
dysrhythmias. Options 2, 3, and 4 are within
the normal range.
8. Foods that are lower in sodium include fruits
and vegetables (option 4), because they do not
contain physiological saline. Highly processed
or refined foods (options 1 and 3) are higher in
sodium unless their food labels specifically
state “low sodium.” Saltwater fish and
shellfish are high in sodium.
9. Fruits and vegetables tend to be lower in fat
because they do not come from animal
sources. Fish is also naturally lower in fat.
Cream cheese is a high-fat food.
10. Pt with hypertension foods Smoked foods are
high in sodium. Options 1, 2, and 4 are fruits
and vegetables that are low in sodium.
11. When performing cardiopulmonary
resuscitation (CPR) on an adult client, the
sternum is depressed 1½ to 2 inches. Options
1 and 2 identify compression depths that
would be ineffective in an adult. Option 4
identifies a depth that could cause injury to the
client.
12. When performing cardiopulmonary
resuscitation (CPR) on adults, the ratio of
chest compressions to breaths is 30:2.
13. Chest pain is assessed by using the standard
pain assessment parameters (e.g.,
characteristics, location, intensity, duration,
precipitating and alleviating factors, and
1
Cardio Rationales Saunders
associated symptoms). Options 1, 2, and 4
may or may not help discriminate the origin of
pain. Pain of pleuropulmonary origin usually
worsens on inspiration.
14. Cardiogenic shock occurs with severe damage
(more than 40%) to the left ventricle. Classic
signs include hypotension, a rapid pulse that
becomes weaker, decreased urine output, and
cool, clammy skin. Respiratory rate increases
as the body develops metabolic acidosis from
shock. Cardiac tamponade is accompanied by
distant, muffled heart sounds and prominent
neck vessels. Pulmonary embolism presents
suddenly with severe dyspnea accompanying
the chest pain. Dissecting aortic aneurysms
usually are accompanied by back pain.
15. On transfer from the coronary care unit, the
client is allowed self-care activities and
bathroom privileges. Supervised ambulation in
the hall for brief distances is encouraged, with
distances gradually increased (50, 100, 200
feet).
16. Metformin (Glucophage) needs to be withheld
48 hours before and after cardiac
catheterization because of the injection of
contrast medium during the procedure. If the
contrast medium affects kidney function, with
metformin in the system, the client would be
at increased risk for lactic acidosis. The
medications in options 1, 2, and 3 do not need
to be withheld 48 hours before and after
cardiac catheterization.
17. Hypotension and dizziness are signs of
decreased cardiac output. Transcutaneous
pacing provides a temporary measure to
increase the heart rate and thus perfusion in
the symptomatic client. Digoxin will further
decrease the client’s heart rate. Defibrillation
is used for treatment of pulseless ventricular
tachycardia and ventricular fibrillation.
Continuing to monitor the client delays
necessary intervention.
18. Edema, the accumulation of excess fluid in the
interstitial spaces, can be measured by intake
greater than output and by a sudden increase
in weight. Diuretics should be given in the
morning whenever possible to avoid nocturia.
Strict sodium restrictions are reserved for
clients with severe symptoms.
19. Heart failure is precipitated or exacerbated by
physical or emotional stress, dysrhythmias,
infections, anemia, thyroid disorders,
pregnancy, Paget’s disease, nutritional
deficiencies (thiamine, alcoholism),
pulmonary disease, and hypervolemia.
20. Digoxin exerts a positive inotropic effect on
the heart while slowing the overall rate
through a variety of mechanisms. Digoxin is
the medication of choice to treat heart failure.
Diltiazem and verapamil (calcium channel
blockers) and propranolol (β-adrenergic
blocker) have a negative inotropic effect and
would worsen the failing heart.
21. Pulmonary edema is characterized by extreme
breathlessness, dyspnea, air hunger, and the
production of frothy, pink-tinged sputum.
Auscultation of the lungs reveals crackles.
Rhonchi and diminished breath sounds are not
associated with pulmonary edema. Stridor is a
crowing sound associated with laryngospasm
or edema of the upper airway.
22. Pulmonary edema causes the client to be
extremely agitated and anxious. The client
may complain of a sense of drowning,
suffocation, or smothering
23. The serum potassium level is measured in the
client receiving digoxin and furosemide.
Heightened digoxin effect leading to digoxin
toxicity can occur in the client with
hypokalemia. Hypokalemia also predisposes
the client to ventricular dysrhythmias.
24. Classic signs of cardiogenic shock as they
relate to this question include low blood
pressure and tachycardia. The central venous
pressure would rise as the backward effects of
the severe left ventricular failure became
apparent. Dysrhythmias commonly occur as a
result of decreased oxygenation and severe
damage to greater than 40% of the
myocardium.
25. Sternotomy incision sites are assessed for
signs and symptoms of infection, such as
redness, swelling, induration, and drainage.
Elevated temperature and white blood cell
2
Cardio Rationales Saunders
count after 3 to 4 days postoperatively usually
indicate infection.
26. The client who undergoes cardiac surgery is at
risk for renal injury from poor perfusion,
hemolysis, low cardiac output, or vasopressor
medication therapy. Renal insult is signaled by
decreased urine output and increased blood
urea nitrogen and creatinine levels. The client
may need medications to increase renal
perfusion and possibly could need peritoneal
dialysis or hemodialysis. No data in the
question indicate the presence of
hypovolemia, urinary tract infection, or
glomerulonephritis.
27. The nurse should encourage regular use of
pain medication for the first 48 to 72 hours
after cardiac surgery because analgesia will
promote rest, decrease myocardial oxygen
consumption resulting from pain, and allow
better participation in activities such as
coughing, deep breathing, and ambulation.
Options 2 and 4 will not help in tolerating
ambulation. Removal of telemetry equipment
is contraindicated unless prescribed.
28. Normal sinus rhythm is defined as a regular
rhythm, with an overall rate of 60 to 100
beats/min. The PR and QRS measurements are
normal, measuring 0.12 to 0.20 second and
0.04 to 0.10 second, respectively.
29. Sinus tachycardia has the characteristics of
normal sinus rhythm, including a regular PP
interval and normal width PR and QRS
intervals; however, the rate is the
differentiating factor. In sinus tachycardia, the
atrial and ventricular rates are higher than 100
beats/min.
30. Motion artifact, or “noise,” can be caused by
frequent client movement, electrode
placement on limbs, and insufficient adhesion
to the skin, such as placing electrodes over
hairy areas of the skin. Electrode placement
over bony prominences also should be
avoided. Signal interference also can occur
with electrode removal and cable
disconnection.
31. Ventricular tachycardia is characterized by the
absence of P waves, wide QRS complexes
(longer than 0.12 second), and typically a rate
between 140 and 180 impulses/min. The
rhythm is regular.
32. Ventricular tachycardia is a life-threatening
dysrhythmia that results from an irritable
ectopic focus that takes over as the pacemaker
for the heart. The low cardiac output that
results can lead quickly to cerebral and
myocardial ischemia. Clients frequently
experience a feeling of impending doom.
Ventricular tachycardia is treated with
antidysrhythmic medications, cardioversion
(client awake), or defibrillation (loss of
consciousness). Ventricular tachycardia can
deteriorate into ventricular fibrillation at any
time.
33. First-line treatment of ventricular tachycardia
in a client who is hemodynamically stable is
the use of antidysrhythmics such as
amiodarone (Cordarone), lidocaine
(Xylocaine), and procainamide (Pronestyl).
Cardioversion also may be needed to correct
the rhythm (cardioversion is recommended for
stable ventricular tachycardia). Defibrillation
is used with pulseless ventricular tachycardia.
Epinephrine would stimulate an already
excitable ventricle and is contraindicated.
34. Cough cardiopulmonary resuscitation (CPR)
sometimes is used in the client with unstable
ventricular tachycardia. The nurse tells the
client to use cough CPR, if prescribed, by
inhaling deeply and coughing forcefully every
1 to 3 seconds. Cough CPR may terminate the
dysrhythmia or sustain the cerebral and
coronary circulation for a short time until
other measures can be implemented. Options
1, 2, and 3 will not assist in terminating the
dysrhythmia.
35. The client with uncontrolled atrial fibrillation
with a ventricular rate more than 100
beats/min is at risk for low cardiac output
because of loss of atrial kick. The nurse
assesses the client for palpitations, chest pain
or discomfort, hypotension, pulse deficit,
fatigue, weakness, dizziness, syncope,
shortness of breath, and distended neck veins.
36. Atrial fibrillation is characterized by a loss of
P waves and fibrillatory waves before each
3
Cardio Rationales Saunders
QRS complex. The atria quiver, which can
lead to thrombi formation.
37. Carotid sinus massage is one maneuver used
for vagal stimulation to decrease a rapid heart
rate and possibly terminate a
tachydysrhythmia. The others include
inducing the gag reflex and asking the client
to strain or bear down. Medication therapy
often is needed as an adjunct to keep the rate
down or maintain the normal rhythm. Options
2, 3, and 4 are incorrect descriptions of this
procedure.
38. Ventricular fibrillation is characterized by
irregular chaotic undulations of varying
amplitudes. Ventricular fibrillation has no
measurable rate and no visible P waves or
QRS complexes and results from electrical
chaos in the ventricles.
39. Until the defibrillator is attached and charged,
the client is resuscitated by using
cardiopulmonary resuscitation. Once the
defibrillator has been attached, the
electrocardiogram is checked to verify that the
rhythm is ventricular fibrillation or pulseless
ventricular tachycardia. Leads also are
checked for any loose connections. A
nitroglycerin patch, if present, is removed.
The client does not have to be intubated to be
defibrillated. Lidocaine may be given
subsequently but is not required before
defibrillation. The machine is not set to the
synchronous mode because there is no
underlying rhythm with which to synchronize.
40. The client may be defibrillated up to three
times in succession. The energy levels used
are 200, 300, and 360 J for the first, second,
and third attempts, respectively.
41. After defibrillation, the client requires
continuous monitoring of electrocardiographic
rhythm, hemodynamic status, and
neurological status. Respiratory and metabolic
acidosis develops during ventricular
fibrillation because of lack of respiration and
cardiac output. These can cause cerebral and
cardiopulmonary complications. Arousable
status, adequate blood pressure, and a sinus
rhythm indicate successful response to
defibrillation.
42. The nurse or rescuer puts two large adhesive
patch electrodes on the client’s chest in the
usual defibrillator positions. The nurse stops
cardiopulmonary resuscitation and orders
anyone near the client to move away and not
touch the client. The defibrillator then
analyzes the rhythm, which may take up to 30
seconds. The machine then indicates if
defibrillation is necessary.
43. An automatic internal cardioverter-
defibrillator (AICD) detects and delivers an
electrical shock to terminate life-threatening
episodes of ventricular tachycardia and
ventricular fibrillation. These devices are
implanted in clients who are considered high
risk, including those who have survived
sudden cardiac death unrelated to myocardial
infarction, those who are refractive to
medication therapy, and those who have
syncopal episodes related to ventricular
tachycardia.
44. In the first several hours after insertion of a
permanent or a temporary pacemaker, the
most common complication is pacing
electrode dislodgement. The nurse helps
prevent this complication by limiting the
client’s activities of the arm on the side of the
insertion site.
45. Pulmonary embolism is a life-threatening
complication of deep vein thrombosis and
thrombophlebitis. Chest pain is the most
common symptom, which is sudden in onset,
and may be aggravated by breathing. Other
signs and symptoms include dyspnea, cough,
diaphoresis, and apprehension.
46. Sclerotherapy is the injection of a sclerosing
agent into a varicosity. The agent damages the
vessel and causes aseptic thrombosis, which
results in vein closure. With no blood flow
through the vessel, there is no distention. The
surgical procedure for varicose veins is vein
ligation and stripping. This procedure involves
tying off the varicose vein and large tributaries
and then removing the vein with hook and
wires via multiple small incisions in the leg.
47. Hypersensitivity or a sensation of “pins and
needles” in the surgical limb may indicate
temporary or permanent nerve injury
4
Cardio Rationales Saunders
following surgery. The saphenous vein and
saphenous nerve run close together in the
distal third of the leg. Because complications
from this surgery are relatively rare, this
symptom should be reported.
48. The mixture of arterial and venous
manifestations (claudication and phlebitis,
respectively) in the young male client suggests
thromboangiitis obliterans (Buerger’s disease).
This disorder is characterized by inflammation
and thrombosis of smaller arteries and veins.
It typically is found in young adult males who
smoke. The cause is not known precisely but
is suspected to have an autoimmune
component.
49. Raynaud’s disease responds favorably to
eliminating caffeine from the diet and
cessation of smoking. Medications may inhibit
vessel spasm and prevent symptoms. Avoiding
exposure to cold through a variety of means is
important. However, moving to a warmer
climate may not necessarily be beneficial
because the symptoms still could occur with
the use of air conditioning and during periods
of cooler weather.
50. After inferior vena cava filter insertion, the
nurse inspects the surgical site for bleeding
and signs and symptoms of infection.
Otherwise, care is the same as for any other
postoperative client.
51. An electrocardiogram taken during a chest
pain episode captures ischemic changes,
which include ST segment elevation or
depression. Tall, peaked T waves may indicate
hyperkalemia. A prolonged PR interval
indicates first-degree heart block. A widened
QRS complex indicates delay in
intraventricular conduction, such as a bundle
branch block.
52. This test is an alternative to the exercise
thallium-201 scan. Dipyridamole (Persantine)
dilates the coronary arteries as exercise would.
Before the procedure, any form of caffeine
should be withheld, as should bronchodilators
such as theophylline. Theophylline may
decrease the effects of dipyridamole. The
client does not have to avoid the items
identified in options 2, 3, and 4.
53. Blood pressure should be taken with the client
seated with the arm bared, positioned with
support and at heart level. The client should sit
with the legs on the floor, feet uncrossed, and
not speak during the recording. The client
should not have smoked tobacco or taken
caffeine in the 30 minutes preceding the
measurement. The client should rest quietly
for 5 minutes before the reading is taken. The
cuff bladder should encircle at least 80% of
the limb being measured. Finally, two or more
BP readings should be averaged
54. An expected outcome of surgery is warmth,
redness, and edema in the surgical extremity
because of increased blood flow. Therefore,
options 2, 3, and 4 are incorrect
interpretations.
55. Following pericardiocentesis, a rise in blood
pressure and a fall in central venous pressure
are expected. The client usually expresses
immediate relief. Heart sounds are no longer
muffled or distant.
56. Not all clients with abdominal aortic
aneurysm exhibit symptoms. Those who do
may describe a feeling of the “heart beating”
in the abdomen when supine or being able to
feel the mass throbbing. A pulsatile mass may
be palpated in the middle and upper abdomen.
A systolic bruit may be auscultated over the
mass. Hyperactive bowel sounds are not
related specifically to an abdominal aortic
aneurysm.
57. Following abdominal aortic aneurysm
resection or repair, the nurse monitors the
client for signs of renal failure. Renal failure
can occur because often much blood is lost
during the surgery and, depending on the
aneurysm location, the renal arteries may be
hypoperfused for a short period during
surgery. The nurse monitors hourly intake and
output and notes the results of daily blood
urea nitrogen and creatinine levels. Urine
output lower than 30 to 50 mL/hr is reported
to the physician.
58. Venous leg ulcers, also called stasis ulcers,
tend to be more superficial than arterial ulcers,
and the ulcer bed is pink. The edges of the
ulcer are uneven, and granulation tissue is
5
Cardio Rationales Saunders
evident. The skin has a brown pigmentation
from accumulation of metabolic waste
products resulting from venous stasis. The
client also exhibits peripheral edema.
59. The first signs and symptoms of digoxin
toxicity in adults include abdominal pain,
nausea, vomiting, visual disturbances (blurred,
yellow, or green vision, halos around lights),
bradycardia, and other dysrhythmias. Options
1, 2, and 3 are unrelated to digoxin therapy.
60. The first signs and symptoms of digoxin
toxicity in adults include abdominal pain,
nausea, vomiting, visual disturbances (blurred,
yellow, or green vision, halos around lights),
bradycardia, and other dysrhythmias. Options
1 Client allegoric to iodine, 2 client with DM,
and 3 client has a biological porcine valve are
unrelated to digoxin therapy.
61. Variant angina, or Prinzmetal’s angina, is
prolonged and severe and occurs at the same
time each day, most often at rest. Stable
angina is induced by exercise and relieved by
rest or nitroglycerin tablets. Unstable angina
occurs at lower and lower levels of activity or
at rest, is less predictable, and is often a
precursor of myocardial infarction.
62. The antidote to heparin is protamine sulfate; it
should be readily available for use if excessive
bleeding or hemorrhage should occur. Vitamin
K is an antidote for warfarin sodium.
Aminocaproic acid is the antidote for
thrombolytic therapy. Potassium chloride is
administered for a potassium deficit.
63. The therapeutic range for prothrombin time is
1.5 to 2 times the control for clients at high
risk for thrombus. Based on the client’s
control value, the therapeutic range for this
individual would be 16.5 to 22 seconds.
Therefore the result is within the therapeutic
range.
64. Warfarin sodium works in the liver and
inhibits synthesis of four vitamin K-dependent
clotting factors (X, IX, VII, and II), but it
takes 3 to 4 days before the therapeutic effect
of warfarin is exhibited.
65. The client is experiencing an anaphylactic
reaction to streptokinase, which is allergenic.
The infusion should be stopped, the physician
notified, and the client treated with
epinephrine, antihistamines, and
corticosteroids.
66. The antidote to warfarin sodium (Coumadin)
is vitamin K and should be readily available
for use if excessive bleeding or hemorrhage
occurs. Aminocaproic acid is the antidote for
thrombolytic agents. Protamine sulfate is the
antidote for heparin. Potassium chloride is
administered to treat potassium deficit.
67. Thrombolytic therapy is contraindicated in a
number of preexisting conditions in which
there is a risk of uncontrolled bleeding, similar
to the case in anticoagulant therapy.
Thrombolytic therapy also is contraindicated
in severe uncontrolled hypertension because
of the risk of cerebral hemorrhage. Therefore,
the nurse would report the results of the blood
pressure to the physician before initiating
therapy.
68. The ACLS nurse would place one gel pad to
the right of the sternum just below the clavicle
and the other gel pad to the left of the
precordium. The nurse would then place the
electrode paddles over the pads. Options 1, 3,
and 4 identify incorrect positions.
69. The client who has had vein ligation and
stripping should avoid standing or sitting for
prolonged periods. The client should remain
lying down unless performing a specific
activity for the first few days following the
procedure. Prolonged standing and sitting
increase the risk of edema in the legs by
decreasing blood return to the heart. The client
should avoid crossing the legs at any level for
the same reason.
70. The jaw thrust without the head tilt maneuver
is used when head and/or neck trauma is
suspected. This maneuver opens the airway
while maintaining proper head and neck
alignment, thus reducing the risk of further
damage to the neck. Option 1 is incorrect. In
situations requiring CPR, the client will be
unconscious. Option 4 is also incorrect.
Additionally, it is unlikely that the nurse will
be able to obtain these data.
71. Fruits and vegetables, except avocado, olives,
and coconut, contain minimal amounts of fat.
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Cardio Rationales Saunders
72. TSS is caused by infection and is often
associated with tampon use. Disseminated
intravascular coagulation is a complication of
TSS. Options 1, 3, and 4 are unrelated to the
etiology of TSS.
73. Assessment findings associated with cardiac
tamponade include tachycardia, distant or
muffled heart sounds, jugular vein distention,
and a falling blood pressure accompanied by
pulsus paradoxus (a drop in inspiratory BP
greater than 10 mm Hg). Bradycardia is not a
sign of cardiac tamponade.
74. Foot care instructions for the client with
peripheral arterial disease are the same
instructions as those for a client with diabetes
mellitus. The client with arterial disease,
however, should avoid raising the legs above
the level of the heart unless instructed to do so
as part of an exercise program, such as
Buerger-Allen exercises, or unless venous
stasis is also present.
75. Captopril is an antihypertensive medication
(angiotension-converting enzyme inhibitor).
Orthostatic hypotension can occur in clients
taking this medication. Clients are advised to
avoid standing in one position for long periods
of time, to change positions slowly, and to
avoid extreme warmth such as with baths,
showers, or heat from the sun in warm
weather. The client should be instructed to
monitor for signs of orthostatic hypotension
such as dizziness, lightheadedness, weakness,
and syncope. An increased intake of water
could actually aggravate the hypertension.
76. The sodium level can increase by the use of
several types of products including toothpaste
and mouthwash; over-the-counter medications
such as analgesics, antacids, laxatives, and
sedatives; and softened water, as well as some
mineral water. Clients are instructed to read
labels for sodium content. Water that is
bottled, distilled, deionized, and demineralized
may be used for drinking and cooking. Fresh
fruits and vegetables are low in sodium. The
client would avoid consuming mineral water.
77. Arterial ulcers have a pale, deep base and are
surrounded by tissue that is cool with trophic
changes such as dry, skin and loss of hair.
Arterial ulcers are caused by tissue ischemia
from inadequate arterial supply of oxygen and
nutrients. A venous stasis ulcer is one that has
a dark red base and is surrounded by brown
skin with local edema. This type of ulcer is
caused by the accumulation of waste products
of metabolism that are not cleared, as a result
of venous congestion. A stage 1 ulcer indicates
a reddened area with an intact skin surface.
78. Standard management for the client with DVT
includes bed rest for 5 to 7 days, limb
elevation, relief of discomfort with warm
moist heat, and analgesics as needed.
Ambulation is contraindicated because such
activity can cause the thrombus to dislodge
and travel to the lungs. Opioid analgesics are
not required to relieve pain, and pain normally
is relieved with acetaminophen (Tylenol).
79. Sclerotherapy is the injection of a sclerosing
agent into a varicosity. The agent damages the
vessel and causes aseptic thrombosis that
results in vein closure. With no blood flow
through the vessel, distention will not occur.
The surgical procedure for varicose veins is
vein ligation and stripping. This procedure
involves tying off the varicose vein and large
tributaries and then removal of the vein with
the use of a hook and wires applied through
multiple small incisions in the leg.
80. A sensation of pins and needles, or feeling as
though the surgical limb is falling asleep, may
indicate temporary or permanent nerve
damage after surgery. The saphenous vein and
the saphenous nerve run close together, and
damage to the nerve will produce paresthesias.
Options 1, 2, and 3 are inaccurate responses.
81. A PASG may be useful in the treatment of
hypovolemic shock associated with traumatic
injury to provide circulatory assistance. The
device is used only as a temporary measure
until definitive treatment is given because it
can compromise blood flow to the lower half
of the body. The critical nursing assessment
includes monitoring the vascular status of the
lower extremities. Although options 1, 3, and
4 may be components of the nursing
assessment, these actions are not part of the
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Cardio Rationales Saunders
critical assessment required with use of a
PASG
82. The normal LAP is 1 to 10 mm Hg. Because
the left atrium does not generate significant
pressure during atrial contraction, the atrial
pressure is recorded as an average (mean)
pressure, rather than as a systolic or diastolic
pressure. Options 2, 3, and 4 are incorrect.
83. The normal fibrinogen level is 180 to 340
mg/dL for males and 190 to 420 mg/dL for
females. A critical value is one that is less than
100 mg/dL. With DIC, the fibrinogen level
drops because fibrinogen is used up in the
clotting process. Option 2 is the only option
that identifies a normal level.
84. Raynaud’s disease is peripheral vascular
disease characterized by abnormal
vasoconstriction in the extremities. Smoking
cessation is one of the most important lifestyle
changes that the client needs to make. The
nurse should emphasize the effects of tobacco
on the blood vessels and the principles
involved in stopping smoking. The nurse
needs to provide information to the client
about smoking cessation programs available in
the community. Options 2 and 3 are incorrect.
It is not necessary to wear gloves for all
activities.
85. In the client with a venous disorder, the legs
are elevated above the level of the heart to
assist with the return of venous blood to the
heart. Option 2 specifies infrequent care
intervals, so it is not the priority intervention.
Alcohol is very irritating and drying to tissues
and should not be used in areas of skin
breakdown.
86. IABP therapy most often is used in the
treatment of cardiogenic shock and is most
effective if instituted early in the course of
treatment. Use of the IABP is contraindicated
in clients with aortic insufficiency and
thoracic and abdominal aneurysms. This
therapy is not used in the treatment of
congestive heart failure or pulmonary edema.
87. Cardiac troponin T or cardiac troponin I has
been found to be a protein marker in the
detection of myocardial infarction, and assay
for this protein is used in some institutions to
aid in the diagnosis of a myocardial infarction.
The test is not used to diagnose congestive
heart failure, ventricular tachycardia, or atrial
fibrillation.
88. The client with uncontrolled atrial fibrillation
with a ventricular rate higher than 100
beats/min is at risk for low cardiac output due
to loss of atrial kick. The nurse assesses the
client for palpitations, chest pain or
discomfort, hypotension, pulse deficit, fatigue,
weakness, dizziness, syncope, shortness of
breath, and distended neck veins.
89. The client with heart failure may present with
different symptoms depending on whether the
right or the left side of the heart is failing.
Peripheral and sacral edema, jugular vein
distention, and organomegaly all are
manifestations of problems with right-sided
heart function. Lung sounds constitute an
accurate indicator of left-sided heart function.
90. Spironolactone is a potassium-sparing
diuretic. Side effects include hyperkalemia,
dehydration, hyponatremia, and lethargy.
Although the concern with most diuretics is
hypokalemia, this medication is potassium
sparing, which means that the concern with
this medication is hyperkalemia. Additional
side effects include nausea, vomiting,
cramping, diarrhea, headache, ataxia,
drowsiness, confusion, and fever.
91. The client should be instructed to take
quinidine sulfate exactly as prescribed. The
client should not chew the sustained-release
capsules or open the capsules and mix them
with food. The client should be instructed to
wear a medical identification bracelet or tag
and to continue taking digoxin as prescribed.
Quinidine sulfate is administered for atrial
flutter or fibrillation only after the client has
been digitalized.
92. The PR interval represents the time it takes for
the cardiac impulse to spread from the atria to
the ventricles. The normal range for the PR
interval is 0.12 to 0.20 second
93. VT is associated with a significant decrease in
cardiac output. Assessing for
unresponsiveness determines whether the
client is affected by the decreased cardiac
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Cardio Rationales Saunders
output. Although options 1, 2, and 3 may be a
component of the assessment, the first action
would be to determine responsiveness of the
client.
94. Denial is a defense mechanism that allows the
client to minimize a threat that may be
manifested by refusal to discuss what has
happened. Denial is a common early reaction
associated with chest discomfort, angina, or
myocardial infarction (MI). Anxiety usually is
manifested by symptoms of sympathetic
nervous system arousal. No data are provided
in the question that would lead the nurse to
interpret the client’s behavior as boredom or
as either understanding or not understanding
the material provided at the teaching session.
95. The recommended INR range for oral
anticoagulant therapy is 2.0 to 3.0, but this
value may vary with the goals of therapy. A
recommended INR range with mechanical
prosthetic heart valve is 2.5 to 3.5, and for
survivors of acute myocardial infarction (MI),
2.5 to 3.5.
96. The heart is located in the mediastinum. Its
apex or distal end points to the left and lies at
the level of the fifth intercostal space. A
stethoscope should be placed in this area to
pick up heart sounds most clearly. The other
options are incorrect because they do not
represent the anatomical positioning of the
heart’s apex.
97. The pain associated with angina results from
ischemia of myocardial cells. The pain often is
precipitated by activity that places more
oxygen demand on heart muscle.
Supplemental oxygen will help to meet the
added demands on the heart muscle. Oxygen
does not dilate blood vessels or prevent
thrombus formation and does not directly
calm the client.
98. Pressure should be applied to the site after an
arterial blood gas specimen is drawn. The
blood pressure in the artery is higher than in
the veins, so applying pressure to the
punctured artery is necessary to control
bleeding. Covering the site with gauze may
protect the site but would not control bleeding.
Heat (by application of warm packs) causes
vasodilation, which would increase bleeding
to the site. Exercise would increase circulation
to the area.
99. The MM fraction of creatine kinase (CK-MB)
is specific in determining the presence of MI.
The CK-MM reflects injury to skeletal
muscle. The WBC count would most likely be
elevated in the client with an MI. The BUN is
unrelated to this disorder.
100.Morphine sulfate is an opioid analgesic that
may be administered to relieve pain in a client
with MI. Although monitoring mental status is
a component of the nurse’s assessment, it is
not the priority after administration of
morphine sulfate. The nurse would monitor
the client’s respirations and blood pressure.
Signs of morphine toxicity include respiratory
depression and hypotension. Urinary output is
unrelated to the administration of this
medication. Monitoring the temperature also
is not associated with the use of this
medication.
101.Nitroglycerin tablets are administered one
tablet every 5 minutes, for a total of three
tablets per episode of chest pain, so long as
the client maintains a systolic blood pressure
of 100 mm Hg or higher. Increasing the flow
rate of oxygen may be prescribed by the
physician but would not be the next nursing
action. If three nitroglycerin tablets did not
relieve the client’s chest pain, the physician
needs to be notified. It is premature to call the
client’s family.
102.After angioplasty, the client needs to be
instructed regarding the specific dietary
restrictions that must be followed. Making the
recommended dietary and lifestyle changes
will assist in preventing further
atherosclerosis. Abrupt closure of the artery
can occur if the dietary and lifestyle
recommendations are not followed. Cigarette
smoking needs to be stopped. An angioplasty
does not repair the heart.
103.A client with a diagnosis of MI should not
consume caffeinated beverages. Caffeinated
products can produce a vasoconstrictive
effect, leading to further cardiac ischemia.
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Cardio Rationales Saunders
Coffee, tea, and cola all contain caffeine and
need to be avoided in the client with MI.
104.If a client complains of chest pain, the initial
assessment question would be to ask the client
about the pain intensity, location, duration,
and quality. Although options 1, 3, and 4 all
may be components of the assessment, none
of these questions would be the initial
assessment question in this client.
105.The client with coronary artery disease should
avoid foods high in saturated fat and
cholesterol such as eggs, whole milk, and red
meat. These foods contribute to increases in
low-density lipoproteins. The use of
polyunsaturated oils is recommended to
control hypercholesterolemia. It is not
necessary to eliminate all cholesterol and fat
from the diet. It is not necessary to become a
strict vegetarian.
106.The signs and symptoms of hyperkalemia
relate to the effect of potassium on the
myocardial muscle. These include changes
noted on the electrocardiogram (ECG), such
as tall and peaked T waves, prolonged PR
interval, widening of the QRS complex,
shortening of the QT interval, and
disappearance of the P wave. Other cardiac
signs and symptoms include ventricular
dysrhythmias that may lead to cardiac arrest.
ST-segment depression is noted in
hypokalemia.
107.In the client with hypokalemia, the nurse
would note ST-segment depression on a
cardiac monitor. The client also may exhibit a
flat T wave. Options 1, 3, and 4 are cardiac
monitor findings that would be noted in the
client with hyperkalemia.
108.When a client has CHF, the goal is to reduce
fluid accumulation. One way that this is
accomplished is sodium reduction. Ham,
cheese (and most cold cuts), and potato chips
are high in sodium. Daily weighing is an
appropriate intervention to help the client
monitor fluid overload. Most fresh fruits and
vegetables are low in sodium.
109.Hypertension, cigarette smoking, and
hyperlipidemia are modifiable risk factors that
are predictors of CAD. Glucose intolerance,
obesity, and response to stress are contributing
modifiable risk factors to CAD. Age greater
than 40 is a nonmodifiable risk factor. The
nurse places priority on risk factors that can be
modified.
110.To ensure the best outcome, clients should be
able to comply with instructions related to
activity, diet, medications, and follow-up
health care on discharge from the hospital
following an MI. All of the options except
option 1 indicate that the client will be
successful in these areas.
111.Standard home care instructions for a client
with this nursing diagnosis include among
others, lifestyle changes such as decreased
alcohol intake, avoiding activities that
increase the demands on the heart, instituting
a bowel regimen to prevent straining and
constipation, and maintaining fluid and
electrolyte balance. Consuming 3000 to 3500
mL of fluid and exercising vigorously will
increase the cardiac workload
112.Each of the options indicates a positive
outcome on the part of the client. However,
option 1 would most likely indicate progress if
the client had a nursing diagnosis of
imbalanced nutrition. Option 2 would be a
satisfactory outcome for disturbed sleep
pattern. Both options 3 and 4 relate to the
nursing diagnosis of activity intolerance.
However, the question asks about progress.
Option 4 is more action-oriented and therefore
is the better choice.
113.Echocardiography is a noninvasive, risk-free,
pain-free test that involves no special
preparation. It commonly is done at the
bedside or on an outpatient basis. The client
must lie quietly for 30 to 60 minutes while the
procedure is being performed. It is important
to provide adequate information to eliminate
unnecessary worry on the part of the client.
114.The client should wear loose, comfortable
clothing for the procedure. Electrocardiogram
(ECG) lead placement is enhanced if the client
wears a shirt that buttons in the front. The
client should wear rubber-soled, supportive
shoes, such as athletic training shoes. The
client should receive nothing by mouth after
1
Cardio Rationales Saunders
bedtime, or for a minimum of 2 hours before
the test. The client should avoid smoking,
alcohol, and caffeine on the day of the test.
Inadequate or incorrect preparation can
interfere with the test, with the potential for a
false-positive result.
115.The client is taught to immediately report
chest pain or any unusual sensations. The
client is informed that a warm, flushed feeling
may accompany dye injection and is normal.
The client also is told that he or she may be
asked to cough or breathe deeply from time to
time during the procedure. Because a local
anesthetic is used, the client is expected to feel
pressure at the insertion site
116.The client can best determine fluid status at
home by weighing himself on a daily basis.
Increases of 2 to 3 pounds in a short time
period are reported to the physician. The client
should sleep with the head of the bed elevated.
During recumbent sleep, fluid (which has
seeped into the interstitium by day with the
assistance of the effects of gravity) is rapidly
reabsorbed into the systemic circulation.
Sleeping with the head of bed flat is therefore
avoided. The client does not modify
medication dosages without consulting the
physician.
117.It is common for the client to feel fatigued
after the cardiac catheterization procedure.
Other pre-procedure teaching points include
that the procedure is done in a darkened
cardiac catheterization room. A local
anesthetic is used, so little to no pain is
experienced with catheter insertion. General
anesthesia is not used. The x-ray table is hard
and may be tilted periodically, and the
procedure may take 1 to 2 hours. The client
may feel various sensations with catheter
passage and dye injection.
118.Dyspnea in the cardiac client often is
accompanied by hypoxemia. Hypoxemia can
be detected by an oxygen saturation monitor,
especially if used continuously. An oxygen
flowmeter is part of the setup for delivering
oxygen therapy. Cardiac monitors detect
dysrhythmias. An apnea monitor detects apnea
episodes, such as when the client has stopped
breathing briefly.
119.The NG tube should remain in place until the
client has bowel sounds. If bowel sounds do
not return, the client could have a paralytic
ileus, which could result in distention and
vomiting if the NG tube is discontinued. It is
normal for NG tube drainage to be Hematest
negative. The abdomen is likely to be slightly
distended after surgery, and it also is likely
that the client may be drowsy after
experiencing a stressor such as cardiac
surgery.
120.The client undergoing thoracentesis usually
sits in an upright position, with the anterior
thorax supported by pillows, or leaning over
an over-the-bed table. The client must be
placed in a position that will enlist the aid of
gravity in accessing and draining the effusion.
Any form of side-lying position will cause
fluid to accumulate under that side, which is
inaccessible to the physician. The dorsal
recumbent position also is an inaccessible
position.
121.Furosemide is a non–potassium-sparing
diuretic, and insufficient replacement of
potassium may lead to hypokalemia. Although
the glucose, sodium, and magnesium levels
may be monitored, these laboratory values are
not specific to administering furosemide.
122.Chest pain is assessed using the standard pain
assessment parameters, such as,
characteristics, location, intensity, duration,
precipitating and alleviating factors, and
associated symptoms. Pain of
pleuropulmonary (respiratory) origin usually
becomes worse on inspiration.
123.Stable angina is triggered by a predictable
amount of effort or emotion. Unstable angina
is triggered by an unpredictable amount of
exertion or emotion and may occur at night;
the attacks increase in number, duration, and
severity over time. Variant angina is triggered
by coronary artery spasm; the attacks are of
longer duration than in classic angina and tend
to occur early in the day and at rest.
Intractable angina is chronic and
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Cardio Rationales Saunders
incapacitating and is refractory to medical
therapy.
124.A prolonged PR interval indicates first-degree
heart block. A widened QRS complex
indicates a delay in intraventricular
conduction, such as bundle branch block. Tall,
peaked T waves may indicate hyperkalemia.
The development of Q waves indicates
myocardial necrosis. An ECG taken during a
pain episode is intended to capture ischemic
changes, which also includes ST-segment
elevation or depression.
125.Exercise is most effective when done at least
3 times a week for 20 to 30 minutes to reach a
target heart rate. Other healthful habits include
limiting salt and fat in the diet and using stress
management techniques. The client also
should be taught to take nitroglycerin before
any activity that previously has caused the
pain, and to take the medication at the first
sign of chest discomfort.
126.Prinzmetal’s angina results from spasm of the
coronary vessels and is treated with calcium
channel blockers. The risk factors are
unknown, and this type of angina is relatively
unresponsive to nitrates. β-Blockers are
contraindicated because they may actually
worsen the spasm. Diet therapy is not
specifically indicated.
127.Chest pain that is unrelieved by rest and three
doses of nitroglycerin administered 5 minutes
apart may not be typical anginal pain but may
signal myocardial infarction (MI). Because the
risk of sudden cardiac death is greatest in the
first 24 hours after MI, it is imperative that the
client receive emergency cardiac care. A
physician’s office is not equipped to treat MI.
Communication with the family or home care
agency delays client treatment, which is
needed immediately.
128.The pain of angina may radiate to the left
shoulder, arm, neck, or jaw. It often is
precipitated by exertion or stress, is
accompanied by few associated symptoms,
and is relieved by rest and nitroglycerin. The
pain of MI also may radiate to the left arm,
shoulder, jaw, and neck. It typically begins
spontaneously, lasts longer than 30 minutes,
and frequently is accompanied by associated
symptoms (such as nausea, vomiting, dyspnea,
diaphoresis, or anxiety). The pain of MI is not
relieved by rest and nitroglycerin and requires
opioid analgesics, such as morphine sulfate,
for relief.
129.Nitroglycerin dilates both arteries and veins,
causing peripheral blood pooling, thereby
reducing preload, afterload, and myocardial
work. This also accounts for the primary side
effect of nitroglycerin, which is hypotension.
In the absence of continuous direct arterial
pressure (intra-arterial) monitoring, the nurse
should use an automatic noninvasive blood
pressure monitor. Options 1, 3, and 4 are not
specifically associated with the administration
of intravenous nitroglycerin.
130.On transfer from CCU to an intermediate care
or general medical unit, the client is allowed
self-care activities and bathroom privileges. It
is unnecessary and possibly harmful to limit
the client to bed rest. The client should
ambulate with supervision in the hall for brief
distances, with the distances being gradually
increased to 50, 100, and 200 feet.
131.Thrombolytic agents are used to dissolve
existing thrombi, and the nurse must monitor
the client for obvious or occult signs of
bleeding. This includes assessment for
obvious bleeding within the gastrointestinal
(GI) tract, urinary system, and skin. It also
includes “hematesting” secretions for occult
blood. Option 1 is the only option that
indicates the presence of blood.
132.The risks to the cardiovascular system from
smoking are noncumulative and are not
permanent. Three to 4 years after cessation, a
client’s cardiovascular risk is similar to that of
a person who never smoked. Options 2, 3, and
4 are incorrect.
133.Clients with heart failure should immediately
report weight gain, loss of appetite, shortness
of breath with activity, edema, persistent
cough, and nocturia. An increase in urine
output during the day is expected with diuretic
therapy (Lasix). A cough due to respiratory
infection does not necessarily indicate that
heart failure is worsening.
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Cardio Rationales Saunders
134.Pulmonary edema is characterized by extreme
breathlessness, dyspnea, air hunger, and the
production of frothy, pink-tinged sputum.
Auscultation of the lungs reveals crackles
throughout the lung fields. As the client’s
condition improves, the amount of fluid in the
alveoli decreases, which may be detected by
crackles in the bases. (Clear lung sounds
would indicate full resolution of the episode.)
Wheezes and rhonchi are not associated with
pulmonary edema.
135.Morphine sulfate reduces anxiety and
dyspnea in the client with pulmonary edema.
It also promotes peripheral vasodilation and
causes blood to pool in the periphery. It
decreases pulmonary capillary pressure, which
reduces fluid migration into the alveoli. The
client receiving morphine sulfate is monitored
for signs and symptoms of respiratory
depression and extreme drops in blood
pressure, especially when it is administered
intravenously. Options 2, 3, and 4 are
unrelated to the action of morphine sulfate
136.Urine output of greater than 30 mL/hr
indicates adequate perfusion to the kidneys, so
the other organs are most likely equally
perfused. Classic cardiovascular signs of
cardiogenic shock include low blood pressure
and tachycardia. The CVP rises as the effects
of the backward blood flow of the left
ventricular failure became apparent.
Arrhythmias commonly occur as a result of
decreased oxygenation to the myocardium and
are not a favorable sign.
137.Acetazolamide is a carbonic anhydrase
inhibitor that contains sulfonamide properties.
Before administration of this medication, the
client should be assessed for an allergy to
sulfonamides because the medication is
contraindicated if an allergy exists. The client
also should be monitored during therapy for
an allergic reaction and for photosensitivity.
138.Vital signs that remain near baseline indicate
good cardiac reserve with exercise. Options 1
and 3 are incorrect because they represent
changes from normal values to abnormal ones.
Blood pressure decrease by more than 10 mm
Hg is not a sign that indicates tolerance of
activity. Only the respiratory rate remains
within the normal range. Additionally, it
reflects a minimal increase.
139.The client should alert any health care
provider about the history of infective
endocarditis before any procedure that
involves instrumentation. The provider should
place the client on prophylactic antibiotics.
Antibiotics should be taken for the full course
of therapy. The client should notify the
physician if chest pain worsens or if dyspnea
or other symptoms occur. The client should
use a soft toothbrush and floss carefully to
avoid any trauma to the gums, which could
provide a portal of entry for bacterial
infection.
140.The nurse plans postoperative measures to
prevent venous stasis. These include applying
elastic stockings or leg wraps, use of
pneumatic compression boots, discouraging
leg-crossing, avoiding use of the knee gatch
on the bed, performing passive and active
ROM exercises, and omitting placement of
pillows in the popliteal space. Covering the
legs with a light blanket during sitting
promotes warmth and vasodilation of the leg
vessels.
141.Typical discharge activity instructions for the
first six weeks include instructing the client to
lift nothing heavier than 5 pounds, to not
drive, and to avoid any activities that cause
straining. The client is taught to use the arms
for balance, but not weight support, to avoid
the effects of straining. These limitations are
to allow for sternal healing, which takes
approximately 6 weeks
142.Normal sinus rhythm is defined as a regular
rhythm with an overall rate of 60 to 100
beats/min. The PR and QRS measurements are
normal, measuring 0.12 to 0.20 second and
0.04 to 0.10 second, respectively.
143.Sinus arrhythmia has all of the characteristics
of normal sinus rhythm except for the
presence of an irregular PP interval. This
irregular rhythm occurs because of phasic
changes in the rate of firing of the sinoatrial
node, which may occur with vagal tone and
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Cardio Rationales Saunders
with respiration. Cardiac output is not
affected.
144.Ventricular fibrillation is characterized by the
absence of P waves and QRS complexes. The
rhythm is instantly recognizable by the
presence of coarse or fine fibrillatory waves
on the cardiac monitoring screen. Each of the
incorrect options has a recognizable complex
that appears on the monitoring screen.
145.Procainamide is an antiarrhythmic that may
be used to treat ventricular arrhythmias in
clients who are allergic to lidocaine. Digoxin
is a cardiac glycoside; metoprolol is a beta-
adrenergic blocking agent; verapamil is a
calcium channel–blocking agent.
146.PVCs are considered dangerous when they
are frequent (more than 6/min), occur in pairs
or couplets, are multifocal (multiform), or fall
on the T wave. In each of these instances, the
client’s cardiac rhythm is likely to degenerate
into ventricular tachycardia or ventricular
fibrillation, both of which are potentially
deadly arrhythmias.
147.Medication-specific teaching points for
quinidine sulfate include to take the
medication exactly as prescribed; not to chew
the tablets; to take with food if stomach upset
occurs; to wear a medical identification (e.g.,
Medic-Alert) bracelet or tag; and to have
periodic checks of heart rhythm and blood
counts. The client should not stop taking a
prescribed medication unless specifically
ordered by the physician.
148.Correct procedure for CPR with two rescuers
includes a compression-to-ventilation ratio of
30:2. With adults, compressions are performed
at a depth of 1.5 to 2 inches. The 30:2
compression-ventilation ratio yields an
effective rate of 12 breaths/min. With effective
compressions, carotid pulsations should be
present. At its best, CPR produces only 30%
of the normal cardiac output, so correct
technique is vital.
149.Nursing responsibilities after cardioversion
include maintenance of a patent airway,
oxygen administration, assessment of vital
signs and level of consciousness, and
arrhythmia detection. Airway, however, is
always the highest priority.
150.Clients with an ICD usually continue to
receive antiarrhythmic medications after
discharge from the hospital. The nurse should
stress the importance of continuing to take
these medications as prescribed. The nurse
should provide clear instructions about the
purposes of the medications, dosage schedule,
and side effects to report. Options 1, 3, and 4
are correct statements regarding this
implantable device.
151.If a ventricular pacemaker is functioning
properly, there will be a pacer spike followed
by a QRS complex. An atrial pacemaker spike
precedes a P wave if an atrial pacemaker is
implanted. A demand pacemaker fires only
when needed and should therefore discharge
only when no electrical activity is occurring in
the client’s own heart.
152.The client with thrombophlebitis, also known
as deep vein thrombosis, exhibits redness or
warmth of the affected leg, tenderness at the
site, possibly dilated veins (if superficial),
low-grade fever, edema distal to the
obstruction, Homans’ sign, and increased calf
circumference in the affected extremity. Pedal
pulses are unchanged from baseline because
this is a venous, not an arterial, problem.
Often, thrombophlebitis develops silently; that
is, the client does not present with any signs
and symptoms unless pulmonary embolism
occurs as a complication.
153.Standard management of the client with deep
vein thrombosis includes bed rest for possibly
5 to 7 days, limb elevation, relief of
discomfort with warm moist heat and
analgesics as needed, anticoagulant therapy,
and monitoring for signs of pulmonary
embolism. Ambulation is contraindicated,
because it increases the likelihood of
dislodgment of the tail of the thrombus, which
could travel to the lungs as a pulmonary
embolism.
154.Buerger’s disease is a vascular occlusive
disease that affects the medium and small
arteries and veins. Smoking is highly
detrimental to the client with Buerger’s
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Cardio Rationales Saunders
disease, so stopping smoking completely is
recommended. Because smoking is a form of
chemical dependency, referral to a smoking
cessation program may be helpful for many
clients. For many clients with Burger’s
disease, symptoms are relieved or alleviated
once smoking stops. Options 1, 2, and 4 are
not specifically associated with the lifestyle
changes required in this disorder.
155.Prosthetic valves require long-term
anticoagulation to prevent clots from forming
on the “foreign “ tissue implanted in the
client’s body. Anticoagulation therapy requires
clients to avoid any trauma or potential means
of causing bleeding, such as use of straight
razors. Options 2, 3, and 4 are not specifically
related to postoperative care after prosthetic
valve replacement. Option 2 relates to a client
taking a diuretic. Option 3 relates to a client
with a pacemaker. Option 4 is necessary in the
immediate postoperative period.
156.Long-term management of peripheral arterial
disease consists of measures that increase
peripheral circulation (exercise), promote
vasodilation (warmth), relieve pain, and
maintain tissue integrity (foot care and
nutrition). Application of a heating pad
directly to the extremity is contraindicated.
The affected extremity may have decreased
sensitivity and is at risk for burns. Also, the
affected tissue does not obtain adequate
circulation at rest. Direct application of heat
raises oxygen and nutritional requirements of
the tissue even further.
157.The client recovering from cardiogenic shock
secondary to a myocardial infarction will
require a progressive rehabilitation related to
physical activity. The heart requires several
months to heal from an uncomplicated
myocardial infarction. The complication of
cardiogenic shock will increase recovery
period for healing. Paced activities with
planned rest periods will decrease the chance
of experiencing angina or delayed healing.
Options 1, 3, and 4 are not related to the
instructions needed after this diagnosis.
158.Exercise is an integral part of the
rehabilitation program. It is necessary for
optimal physiological functioning and
psychological well-being. Postoperative
physical rehabilitation must be progressive
with planned periods of rest. Exercise
tolerance is judged by the client’s response,
such as heart rate and endurance. Options 1, 2,
and 3 identify appropriate client activities.
Option 4 lacks planned periods of rest, and the
client has grouped too many activities in a
brief period of time, which will decrease
endurance. Also, exercise after meals can
decrease the client’s tolerance because of
shunting of blood to the gastrointestinal tract
for digestion.
159.The normal cardiac output is 4 to 7 L/min.
With cardiogenic shock, the CO falls below
normal because of failure of the heart as a
pump. The PCWP, however, rises because it is
a reflection of the left ventricular end-diastolic
pressure, which rises with pump failure.
160.The nursing interventions for the client with
an intra-aortic balloon pump are the same as
for any client who has had cardiovascular
surgery. The peripheral circulation to the
affected limb is monitored for signs of
occlusion, such as coolness, mottling, pain,
tingling, and decreased or absent distal pulse.
Adverse changes are reported immediately.
161.Hypertension increases the workload of the
left ventricle, because the ventricle has to
pump the stroke volume against increased
resistance (afterload) in the major blood
vessels. Over time, this causes the left
ventricle to fail, leading to signs and
symptoms of heart failure. Left-sided heart
failure is characterized by pulmonary signs
and symptoms, because the lungs lie behind
the left side of the heart from the perspective
of circulation.
162.The myocardial layer of the heart is damaged
when the client experiences a myocardial
infarction. This is the middle layer that
contains the striated muscle fibers responsible
for the contractile force of the heart. The
endocardium is the thin inner layer of cardiac
tissue. The parietal pericardium and visceral
pericardium are outer layers that protect the
heart from injury and infection.
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Cardio Rationales Saunders
163.The mitral valve separates the left atrium
from the left ventricle. Options 2, 3, and 4
describe the aortic, tricuspid, and pulmonic
valves, respectively.
164.The aortic valve separates the aorta from the
left ventricle. Options 1, 3, and 4 describe the
mitral, tricuspid, and pulmonic valves,
respectively
165.The primary effect of a decreased blood
pressure is reduced blood flow to the
myocardium. This in turn decreases the
oxygenation to cardiac tissue. Cardiac tissue is
likely to become more excitable or irritable in
the presence of hypoxia. Correspondingly, the
heart rate is likely to increase in response to
this change, not decrease. The effects of tissue
ischemia will lead to decreased contractility
over time.
166.The normal calcium level is 8.6 to 10 mg/dL.
A low calcium level could lead to severe
ventricular dysrhythmias, prolonged QT
interval, and ultimately cardiac arrest.
Calcium is needed by the heart for
contraction. Calcium ions move across cell
membranes into cardiac cells during
depolarization, and move back during
repolarization. Depolarization is responsible
for cardiac contraction. Options 1 and 2 are
unrelated to calcium levels. Elevated calcium
levels can lead to urinary stone formation.
167.The SA node is responsible for initiating
electrical impulses that are conducted through
the heart. The impulse leaves the SA node,
travels down through internodal and interatrial
pathways to the AV node. From there,
impulses travel through the bundle of His to
the right and left bundle branches, and then to
the Purkinje fibers. This group of specialized
cardiac cells is referred to as the cardiac
conduction system. The ability of this
specialized tissue to generate its own impulses
is called automaticity.
168.The left coronary artery divides into the
anterior descending artery and the circumflex
artery, providing blood for the left atrium and
left ventricle. The right coronary artery
supplies the right atrium and right ventricle.
Options 1, 2, and 3 are correct.
169.The cardiac cycle consists of contraction and
relaxation of the heart muscle. The heart
normally sends out about 5 L of blood every
minute to the body.
170.The cardiac output is determined by the
volume of the circulating blood, the pumping
action of the heart, and the tone of the
vascular bed. Early decreases in fluid volume
are compensated for by an increase in the
pulse rate. Options 3 and 4 indicate an
increase in fluid volume. Although the BP will
decrease, it is not the earliest indicator.
171.The diaphragm of the stethoscope is placed
over the skin at the mitral area to listen to the
apical pulse. S1 (lub) and S2 (dub) should be
distinguished. The pulse should be counted for
a full minute.
172.Applying pressure to both carotid arteries at
the same time is contraindicated. Excess
pressure to the baroreceptors in the carotid
vessels could cause the heart rate and blood
pressure to reflexively drop. In addition, the
manual pressure could interfere with the flow
of blood to the brain, causing possible
dizziness and syncope.
173.Found in the peripheral arteries and veins, α1-
adrenergic receptors cause a powerful
vasoconstriction when stimulated. Options 1,
2, and 4 describe β1-, β2-, and α2-adrenergic
receptors, respectively.
174.The normal cardiac output for the adult can
range from 4 to 8 L/min and varies greatly
with body size. The heart normally pumps 5 L
of blood every minute.
175.The normal heart rate is 60 to 100 beats/min
in an adult. On auscultating a heart rate that is
less than 60 beats/min, the nurse would not
administer the digoxin and would report the
finding to the physician. Options 1, 2, and 3
are incorrect because the heart rate of 52
beats/min is not normal.
176.The client’s symptoms are the direct result of
the body’s attempt to meet the metabolic
demands of the body during exercise. An
adequate cardiac output is needed to maintain
perfusion to the vital organs of the body. With
exercise, these demands increase, and the
heart must beat faster (increased heart rate)
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and harder (increased stroke volume) to
achieve this. Cardiac index is an artificial
number used to determine the adequacy of the
cardiac output for a given individual. It is
calculated by adjusting the cardiac output by
body surface area.
177.The LAD bifurcates from the left main
coronary artery to supply the anterior wall of
the left ventricle and a few other structures.
The RCA supplies the right side of the heart,
including the atrium and ventricles. The
circumflex coronary artery bifurcates from the
left coronary artery, and supplies the left
atrium and the lateral wall of the left ventricle.
The PDA supplies the posterior wall of the
heart.
178.Hypothermia decreases the heart rate and
blood pressure because the metabolic needs of
the body are reduced in this condition. With
fewer metabolic needs, the workload of the
heart decreases, with drops in both the heart
rate and the blood pressure.
179.Bearing down as if straining to have a bowel
movement can stimulate a vagal reflex.
Stimulation of the vagus nerve causes a
decrease in heart rate and cardiac contractility.
The sympathetic nervous system stimulation
has the opposite effect. These two branches of
the autonomic nervous system oppose each
other to maintain homeostasis.
180.Dopaminergic receptors are found in the renal
blood vessels and in the nerves. When these
are stimulated, they dilate renal arteries and
help modulate release of this neurotransmitter.
Renal artery dilation helps to improve urine
output by increasing blood flow through the
kidneys. Epinephrine and norepinephrine
affect the α and β receptors in the body.
Serotonin is a local hormone that is released
from platelets after an injury. It constricts
arterioles but dilates capillaries.
181.With ventricular tachycardia in a stable client,
the nurse assesses airway, breathing, and
circulation; administers oxygen; and confirms
the rhythm via a 12-lead ECG. The physician
is contacted and antiarrhythmics may be
prescribed. With pulseless ventricular
tachycardia, the physician or a specially
trained nurse must immediately defibrillate the
client or initiate CPR followed by
defibrillation as soon as possible.
182.The first heart sound (S1) is heard loudest at
the lower left sternal border or the apex of the
heart. The apex is located at the fifth
intercostal space at the left midclavicular line.
Therefore, options 1, 2, and 3 are incorrect.
183.Hyperkalemia can cause tall peaked or tented
T waves on the ECG. Levels of potassium of
5.1 mEq/L or greater indicate hyperkalemia.
Options 1, 2, and 4 are normal levels.
184.In atrial fibrillation, the P waves may be
absent. There is no PR interval, and the QRS
duration usually is normal and constant. In
NSR, a P wave precedes each QRS complex,
the rhythm is essentially regular, the PR
interval is 0.12 to 0.20 second in duration, and
the QRS interval is 0.06 to 0.10 second in
duration. Bradycardia is a slowed heart rate,
and tachycardia is a fast heart rate.
185.This cardiac rhythm identifies a coarse
ventricular fibrillation (VF). The goals of
treatment are to terminate VF promptly and to
convert it to an organized rhythm. The
physician or an advanced cardiac life support
(ACLS)-qualified nurse or other health care
provider must immediately defibrillate the
client. If a defibrillator is not readily available,
CPR is initiated until the defibrillator arrives.
Options 1, 3, and 4 are incorrect actions and
delay life-saving treatment.
186.This cardiac rhythm is normal sinus rhythm
with unifocal premature ventricular complexes
(PVCs). PVCs may be insignificant or may
occur with myocardial ischemia or MI;
congestive heart failure; hypokalemia;
hypomagnesemia; medications; stress;
nicotine, caffeine, or alcohol intake; infection;
trauma; or surgery. This client is receiving
furosemide, which is a diuretic that causes the
excretion of potassium. The most likely cause
of the PVCs in this client is hypokalemia.
Option 1 is an incorrect interpretation. The
question presents no data indicating that this
client has a pacemaker or has signs and
symptoms of MI.
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187.In VT, it usually is not possible to determine
the atrial rhythm. The ventricular rhythm
usually is regular or nearly regular. The P
waves usually are not visible and are obscured
in the QRS complexes. VT occurs with
repetitive firing of an irritable ventricular
ectopic focus, usually at a rate of 140 to 180
beats/min or more.
188.Edema is accumulation of fluid in the
intercellular spaces and is not normally
present. To check for edema, the nurse would
imprint his or her thumbs firmly against the
ankle malleolus or the tibia. Normally, the
skin surface stays smooth. If the pressure
leaves a dent in the skin, “pitting” edema is
present. Its presence is graded on the
following 4-point scale: 1+, mild pitting,
slight indentation, no perceptible swelling of
the leg; 2+, moderate pitting, indentation
subsides rapidly; 3+, deep pitting, indentation
remains for a short time, leg looks swollen;
4+, very deep pitting, indentation lasts a long
time, leg is very swollen.
189.Ferrous sulfate is an iron preparation and the
client is instructed to take the medication with
orange juice or another vitamin C–containing
product, to increase the absorption of the iron.
Milk and eggs inhibit the absorption of the
iron. Tomato juice is highest in vitamin C
from the options presented.
190.MUGA is a radionuclide study used to detect
myocardial infarction, decreased myocardial
blood flow, and left ventricular function. A
radioisotope is injected intravenously.
Therefore, a signed informed consent is
necessary. The procedure does not use
radiopaque dye. Therefore, allergies to iodine
and shellfish are not a concern. A Foley
catheter and CVP line are not required.
191.Orthostatic changes can occur in the client
with cardiomyopathy as a result of venous
return obstruction. Sudden changes in blood
pressure may lead to falls. Vasodilators
normally are not prescribed for the client with
cardiomyopathy. Options 1 and 2, although
important, are not directly related to the issue
of safety.
192.Sinus tachycardia often is caused by fever,
physical and emotional stress, heart failure,
hypovolemia, certain medications, nicotine,
caffeine, and exercise. Exercise and fluid
restriction will not alleviate tachycardia.
Option 2 will not decrease the heart rate.
Additionally, the pulse should be taken more
frequently than each shift.
193.Digoxin may be withheld for up to 48 hours
before cardioversion because it increases
ventricular irritability and may cause
ventricular arrhythmias after the countershock.
The client typically receives a dose of an
intravenous sedative or antianxiety agent. The
defibrillator is switched to synchronizer mode
to time the delivery of the electrical impulse to
coincide with the QRS and avoid the T wave,
which could cause ventricular fibrillation.
Energy level typically is set at 50 to 100 J.
During the procedure, any oxygen is removed
temporarily, because oxygen supports
combustion, and a fire could result from
electrical arcing.
194.For cardioversion procedures, the defibrillator
is charged to the energy level ordered by the
physician. Countershock usually is started at
50 to 100 joules. Options 2, 3, and 4 are
incorrect.
195.The client with uncontrolled atrial fibrillation
with a ventricular rate over 100 beats/min is at
risk for low cardiac output due to loss of atrial
kick. The nurse assesses the client for
palpitations, chest pain or discomfort,
hypotension, pulse deficit, fatigue, weakness,
dizziness, syncope, shortness of breath, and
distended neck veins.
196.Postdischarge instructions typically include
avoiding tight clothing or belts over AICD
insertion sites, rough contact with the AICD
insertion site, electromagnetic fields such as
with electrical transformers, radio/TV/radar
transmitters, metal detectors, and running
motors of cars or boats. Clients also must alert
physicians or dentists to the presence of the
device, because certain procedures such as
diathermy, electrocautery, and magnetic
resonance imaging may need to be avoided to
prevent device malfunction. Clients should
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follow the specific advice of a physician
regarding activities that are potentially
hazardous to self or others, such as swimming,
driving, or operating heavy equipment.
197.Triamterene is a potassium-sparing diuretic,
so the client should avoid foods high in
potassium. Fruits that are naturally higher in
potassium include avocadoes, bananas, fresh
oranges, mangoes, nectarines, papayas, and
prunes.
198.The client with deep vein thrombosis requires
bedrest to prevent embolization of the
thrombus due to skeletal muscle action,
anticoagulation to prevent thrombus extension
and allow for thrombus autodigestion, fluids
for hemodilution and to decrease blood
viscosity, and compression stockings to reduce
peripheral edema and promote venous return.
While the client is on bedrest, the nurse
prevents complications of immobility by
encouraging coughing and deep breathing.
Venous return is important to maintain
because it is a contributing factor in DVT, so
the nurse maintains venous return from the
lower extremities by avoiding hip flexion,
which occurs with Fowler’s position. The
nurse avoids providing foods rich in vitamin K
such as dark green leafy vegetables because
this vitamin can interfere with anticoagulation,
thereby increasing the risk of additional
thrombi and emboli. The nurse also would not
include use of sequential compression boots
for an existing thrombus. They are used to
prevent DVT only, because they mimic
skeletal muscle action and can disrupt an
existing thrombus, leading to pulmonary
embolism.
199.Spironolactone is a potassium-sparing
diuretic, and the client should avoid foods
high in potassium. If the client does not avoid
foods high in potassium, hyperkalemia could
develop. The client does not need to avoid
foods that contain calcium, magnesium, or
phosphorus while taking this medication.
200.The particular isoenzymes that are affected
after acute myocardial infarction are LDH1
and LDH2. The LDH level begins to elevate
about 24 hours after myocardial infarction and
peaks in 48 to 72 hours. Thereafter, it returns
to normal, usually within 7 to 14 days.
201.Chicken breast has 70 mg of sodium,
compared with 457 for cottage cheese, 700 mg
for grilled cheese, and 800 mg for beef
bouillon.
202.The sound that the nurse hears is the first
heart sound, S1. The first heart sound (S1) is
created by the closure of the mitral and
triscupid valves (atrioventricular [AV] valves).
It marks the onset of systole (ventricular
contraction). When auscultated, the first heart
sound (S1) is softer and longer than the
second heart sound (S2). S1 is low in pitch
and is best heard at the left lower sternal
border or the apex of the heart. Disease and
stiffened AV valves (as in rheumatic heart
disease) may augment S1; rhythms of
asynchrony between the atria and ventricles
(as in atrial fibrillation and with AV block)
cause variable intensity of S1. Phonetically, if
a typical heartbeat, composed of the heart
sounds S1 and S2, is auscultated as “lub-dup,”
S1 is the “lub.” To assess S1, the nurse should
assist the client to a supine position (the head
of the bed may be elevated slightly if
necessary). The second heart sound (S2) is
related to closure of the pulmonic and aortic
(semilunar) valves and is heard best with the
diaphragm at the aortic area. Phonetically, it is
the “dup” of the “lub-dup” of a typical
heartbeat (the first heart sound, S1, is the
“lub”). It signifies the end of systole and the
onset of diastole (ventricular filling). S2 is
characteristically shorter and higher pitched
than the first heart sound (S1). Diastolic
filling sounds or gallops (S3, the third heart
sound, and S4, the fourth heart sound) are
produced when compliance of either or both
ventricles is decreased. S3 is termed
ventricular gallop and S4 is referred to as
atrial gallop. The S3 heart sound (a gallop
sound) occurs in early diastole, during
passive, rapid filling of the ventricles. The S4
sound occurs in the later stage of diastole,
during atrial contraction and active filling of
the ventricles. It is a soft, low-pitched sound
and is heard immediately before S1.
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203.PVCs are abnormal ectopic beats originating oxygenation. This increases cardiac workload.
in the ventricles. They are characterized by an Seasonings may be high in sodium.
absence of P waves, presence of wide and 209.Raynaud’s disease produces closure of the
bizarre QRS complexes, and a compensatory small arteries in the distal extremities in
pause that follows the ectopy response to cold, vibration, or external stimuli.
204.The client undergoing pericardiocentesis is Palpation for diminished or absent peripheral
positioned supine with the head of bed raised pulses checks for interruption of circulation.
to a 45- to 60-degree angle. This places the The nails grow slowly, become brittle or
heart in close proximity to the chest wall for deformed, and heal poorly around the nail
easier insertion of the needle into the beds when infected. Skin changes include hair
pericardial sac. Options 1, 2, and 4 are loss, thinning or tightening of the skin, and
incorrect. delayed healing of cuts or injuries. Although
205.Assessment findings with cardiac tamponade palpation of peripheral pulses is correct, a
include tachycardia, distant or muffled heart rapid or irregular pulse would not be noted.
sounds, jugular vein distention, and a falling Peripheral pulses may be normal, absent, or
blood pressure (BP), accompanied by pulsus diminished.
paradoxus (a drop in inspiratory BP by greater
than 10 mm Hg).
206.The number of cigarettes smoked daily and
the duration of the habit are used to calculate
the number of pack-years, which is the
standard method of documenting smoking
history. The brand of cigarettes may give a
general indication of tar and nicotine levels,
but the information is of no immediate clinical
use. Desire to quit and number of past
attempts to quit smoking may be useful when
the nurse develops a smoking cessation plan
with the client.
207.The client is hypertensive, which is a known
major modifiable risk factor for coronary
artery disease (CAD). The other major
modifiable risk factors not exhibited by this
client include smoking and
hypercholesterolemia. The client is
overweight, which is a contributing risk factor.
The client’s nonmodifiable risk factors are age
and gender. Because the client presents with
several risk factors, the nurse places priority
of attention on the client’s major modifiable
risk factors.
208.Using a bedside commode decreases the work
of getting to the bathroom or struggling to use
the bedpan. Elevating the client’s legs
increases venous return to the heart, increasing
cardiac workload. The supine position
increases respiratory effort and decreases