A nurse is assigned to care for a client with a terminal cardiovascular illness. When developing
the client's plan of care, which outcome would the nurse identify as mostrealistic for this client?
a. adaptation to living with limitations
b. maintenance of adequate comfort
c. acceptance of changes in lifestyle
d. recovery from the cardiovascular problem
➹➹➹: maintenance of adequate comfort
Rationale: The realistic outcome for a client with terminal cardiovascular disease is maintenance
of adequate comfort and acceptance of impending death.Realistic outcomes for the client with
chronic cardiovascular disease focus on helping the client to live within limitations imposed by
the disease and to improve acceptance of changesin lifestyle and self-concept. Outcomes
pertinent to the client who is admitted with an acute problem focus on recovery from the
cardiovascular problem without residual complications.
,Upon entering a client's room, the client tells the nurse, "I'm having some really strongpain in my
chest." The nurse intervenes immediately, placing the client in which position?
a. Sitting
b. Standing upright
c. Flat with legs raised 20 to 30 degrees
d. Supine
➹➹➹: Sitting
Explanation:The nurse should make the client comfortable in a sitting position. A supine position
inhibits full chest expansion and limits gas exchange in the lung, so this positionshould be
avoided. Since the heart works harder in the supine position than in the upright position, the
supine position is not recommended. The hypotensive client is positioned with legs elevated 20
to 30 degrees.
Which of the following is a noninvasive procedure assisting the nurse in cardiovascularcare?
a. Electrocardiography
b. Pulmonary artery monitoring
,c. Swan-Ganz catheterization
d. Cardiac output determination
➹➹➹: Electrocardiography
Explanation:Noninvasive heart monitoring involves electrocardiography and cardiacmonitoring.
Invasive techniques, such as pulmonary artery monitoring, Swan-Ganz catheterization, cardiac
output determination, and cardiac support via an intraaortic balloon pump (IABP), typically are
used by trained critical care personnel to provideadditional monitoring and support.
A nurse is teaching a client with heart disease about exercising and signs of overexertion. The
nurse determines that additional education is needed if the clientstates:
a. "I should wait at least an hour after eating before exercising."
b. "I need to call the doctor if it feels like my heart is racing."
c. "I need to start my routine with my warm-up exercises."
d. "I should stop exercising if my pulse is below my target zone."
➹➹➹: "I should stop exercising if my pulse is below my target zone."
, Explanation:For the client, the goal of the exercise program is to achieve the target heart rate.
The client should stop exercising if his pulse rate exceeds his target zone.
A nursing instructor is developing a class presentation about reasons people with cardiovascular
problems seek medical care. Which of the following would the instructor include as the most
common reason?
a. Lower extremity swelling
b. Persistent cough
c. Chest pain
d. Hypertension
➹➹➹: Chest pain
Explanation:Although a person with cardiovascular dysfunction may have hypertension, lower
extremity swelling, or cough, pain or discomfort in the chest is the most common reason people
with cardiovascular dysfunction seek medical care.
A nurse is preparing to administer a prescribed medication as prophylactic therapy fordeep vein
thrombosis. What would the nurse most likely give?
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