ATI Targeted Medical-Surgical 2019: Cardiovascular

C: "I took my warfarin last night according to my usually schedule." Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

D. Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

D. Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.

B. Review serum electrolyte values Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.

A. "I can't get rid of these hiccups." Rationale:

D. Valvular disease Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

b. Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

b. Weak peripheral pulses Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.

A. Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

b. Blood pressure 160/80 mm Hg Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

B. Place the patch on an area of skin away from skin folds and joints. Rationale: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.

D. Stop the heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

D Rationale: Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.

C. Urine output of 20 ml/hr Rationale: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.

C. Inquire about the presence or absence of claudication Rationale: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.

C. Elevate the head of the clients bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.

A: P wave Rationale: you observe the p wave for atrial depolarization.......so thats A.

A. Dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.

A. Slurred speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

A. Weight gain of 2 lb. in 24 hr Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A. "you may no longer be able to feel chest pain." Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.

A / B / E Rationale: Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake. Regular exercise program is correct. Clients who have hypertension should develop a regular exercise program to help reduce blood pressure. Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Tobacco cessation is correct. Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension.

D. INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.

b. A client who has diabetes mellitus Rationale: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.

d. "I smoked a cigarette this morning to calm my nerves about having this procedure." Rationale: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

b. Persistent cough Rationale: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.

b. Vagal stimulation Rationale: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.

A. Absence of adventitious breath sounds Rationale: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.

c. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl Rationale: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.

c. Creatine kinase- MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.