Med Sure 3
Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? 1- 1 to 3 minutes 2- 4 to 5 seconds 3- 30 to 45 seconds 4- 20 to 45 minutes
1- 1 to 3 minutes The onset of action of sublingual nitroglycerin tablets is rapid (1 to 3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.
A client is admitted to the coronary care unit with a tentative diagnosis of myocardial infarction. How does the nurse expect the client to describe the pain? 1- Severe, intense chest pain 2- Burning sensation of short duration 3- Mild chest pain, radiating to the fingers 4- Squeezing chest pain, relieved by nitroglycerin
1- Severe, intense chest pain Blockage of the myocardial blood supply causes accumulation of unoxidized metabolites that affect nerve endings that generally cause pain. The pain usually is crushing, severe, and of prolonged duration. The pain is unrelieved by nitroglycerin.
A client with a history of a pulmonary embolus is to receive 3 mg of warfarin daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? 1- Poached eggs 2- Spinach salad 3- Sweet potatoes 4- Cheese sandwich
2- Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.
A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1- Blood glucose is 70-100 mg/dL 2- An increased serum lactate level 3- An increased neutrophil level 4- A white blood count of 5000 cells/µL
The hallmark of sepsis is an increasing serum lactate level, a normal or low total WBC count > 12,000 cells/µL or < 4,000 cells/µL and a decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL. Blood glucose levels of 70-100 mg/dL are considered normal. STUDY TIP: Focus your study time on the common health problems that nurses most frequently encounter.
A client admitted to the hospital for chest pain is diagnosed with stable angina. Which information should the nurse include in the teaching session? 1- It is relieved by rest. 2- It is precipitated by light activity. 3- It is described as sharp or knifelike. 4- It is unaffected by the administration of vasodilators.
1- It is relieved by rest. Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload and oxygen need. Angina usually is precipitated by exertion, emotion, or a heavy meal. Anginal pain usually is described as tightness, indigestion, or heaviness. Nitroglycerin, a vasodilator and a standard treatment for angina, dilates coronary arteries, which increases oxygen to the myocardium, decreasing pain.
A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply. 1- Crackles 2- Coughing 3- Orthopnea 4- Yellow sputum 5- Dependent edema
1- Crackles 2- Coughing 3- Orthopnea Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood-tinged. When pulmonary pressure increases, cells in the alveoli lining are disrupted, and fluid that contains red blood cells moves into the alveoli. Pulmonary interstitial edema, not dependent edema, occurs.
The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. 1- Sudden chest pain 2- Flushing of the face 3- Elevation of temperature 4- Abrupt onset of shortness of breath 5- Pain rating increase from 2 to 8 in the hip
1- Sudden chest pain 4- Abrupt onset of shortness of breath Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip.
A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1- "I am unable to run a mile (1.6 kilometers) now." 2- "I wake up at night short of breath." 3- "My wife says I snore very loudly." 4- "My shoes seem larger lately."
2- "I wake up at night short of breath." Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath. STUDY TIP: In the first pass through the exam, answer what you know and skip what you do not know. Answering the questions you are sure of increases your confidence and saves time. This is buying you time to devote to the questions with which you have more difficulty.
A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol and digoxin. What outcome does the nurse anticipate when metoprolol is administered with digoxin? 1- Headaches 2- Bradycardia 3- Hypertension 4- Junctional tachycardia
2- Bradycardia Metoprolol and digoxin both exert a negative chronotropic effect, resulting in a decreased heart rate. Metoprolol reduces, not produces, headaches. These drugs may cause hypotension, not hypertension. These drugs may depress nodal conduction; therefore, junctional tachycardia would be less likely to occur.
A client presents to the emergency department with symptoms of acute myocardial infarction (MI). Which results will the nurse expect to find upon assessment? 1- Decreased breath sounds 2- Elevated serum troponin I 3- Decreased creatine kinase-MB (CK-MB) 4- Elevated brain natriuretic peptide (BNP) level
2- Elevated serum troponin I Elevations of troponin I levels are indicative and specific for cardiac muscle damage. Decreased breath sounds would indicate a pulmonary problem. An increase in CK-MB would indicate MI. Elevated BNP levels would indicate heart failure, which is a potential complication of acute myocardial infarction.
A client is experiencing a myocardial infarction. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1- Arterial spasm 2- Heart muscle ischemia 3- Blocking of the coronary veins 4- Irritation of nerve endings in the cardiac plexus
2- Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial spasm, resulting in tissue hypoxia and pain, is associated with angina pectoris. Arteries, not veins, are involved in the pathology of a myocardial infarction. Tissue injury and pain occur in the myocardium.
How can the nurse best describe heart failure to a client? 1- A cardiac condition caused by inadequate circulating blood volume 2- An acute state in which the pulmonary circulation pressure decreases 3- An inability of the heart to pump blood in proportion to metabolic needs 4- A chronic state in which the systolic blood pressure drops below 90 mm Hg
3- An inability of the heart to pump blood in proportion to metabolic needs As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.
Sublingual nitroglycerin tablets are prescribed to control periodic episodes of chest pain in the client with stable angina. Which instruction should the nurse include when teaching the client about sublingual nitroglycerin? 1- Once the tablet is dissolved, spit out the saliva. 2- Take tablets 3 minutes apart up to a maximum of five tablets. 3- Common side effects include headache and low blood pressure. 4- Once opened, the tablets should be refrigerated to prevent deterioration.
3- Common side effects include headache and low blood pressure. The primary side effects of nitroglycerin are headache and hypotension. It is not necessary to spit out saliva into which nitroglycerin has dissolved. For pain that is not relieved, additional tablets may be taken every 5 minutes up to a total of three tablets. It should be stored at room temperature.
A nurse expects that a client with right-sided heart failure will exhibit which of these signs or symptoms? 1- Oliguria 2- Pallor 3- Cool extremities 4- Distended neck veins
4- Distended neck veins Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.
A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1- Increases the cardiac workload 2- Interferes with usual respirations 3- Produces an elevation in temperature 4- Decreases the amount of oxygen used
1- Increases the cardiac workload Irritability and restlessness associated with anxiety increase the metabolic rate, heart rate, and blood pressure; these complicate heart failure. Anxiety does not directly interfere with respirations; an increase in cardiac workload will increase respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen used and leads to an increased respiratory rate.
A client is taking furosemide and digoxin for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day? 1- Maintaining potassium levels 2- Preventing increased sodium levels 3- Limiting the drugs' synergistic effects 4- Correcting the associated dehydration
1- Maintaining potassium levels Orange juice is an excellent source of potassium. Furosemide promotes excretion of potassium, which can result in hypokalemia. Digoxin toxicity can occur in the presence of hypokalemia. Neither drug increases sodium levels. Digoxin does not potentiate the action of furosemide; therefore, the client should not experience dehydration. Orange juice will not prevent an interaction between digoxin and furosemide. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.
A nurse is providing postprocedure care to a client who had a cardiac catheterization via a brachial artery. For the first hour after the procedure, what is the priority nursing intervention? 1- Monitor the vital signs every 15 minutes 2- Maintain the client in the supine position 3- Keep the client's lower extremities in extension 4- Administer the prescribed oxygen at 4 L/min via nasal cannula
1- Monitor the vital signs every 15 minutes A cardiac catheterization may cause cardiac irritability; therefore the client's vital signs should be monitored every 15 minutes for 1 hour and then every 30 minutes for the next 2 hours until stable. The vital signs may then be monitored every 4 hours. When a brachial artery is used for catheter insertion, a low-Fowler, not supine, position usually is recommended because it promotes respirations. Keeping the client's lower extremities in extension is not necessary. A brachial, not femoral, artery was used for the catheter insertion. Although administering the prescribed oxygen at 4 L/min via nasal cannula may be done, it is not the priority. The client's response to the procedure is the priority. STUDY TIP: A helpful method for decreasing test stress is to practice self-affirmation. After you have adequately studied and really know the material, start looking in the mirror each time you pass one and say to yourself—preferably out loud—"I know this material, and I will do well on the test." After several times of watching and hearing yourself reaffirm your knowledge, you will gain inner confidence and be able to perform much better during the test period. This technique really works for students who are adventurous enough to use it. It may feel silly at first, but if it works, who cares? It will work for performing skills in clinical as well, as long as you have practiced the skill sufficiently.
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. What is the pathophysiological reason for the excessive edema? 1- Shift of fluid into the interstitial spaces 2- Weakening of the cell wall 3- Increased intravascular compliance 4- Increased intracellular fluid volume
1- Shift of fluid into the interstitial spaces Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathologic reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.
What are the clinical manifestations of myocardial infarction in women? Select all that apply. 1- Anoxia 2- Indigestion 3- Unusual fatigue 4- Sleep disturbances 5- Tightness of the chest
2- Indigestion 3- Unusual fatigue 4- Sleep disturbances Indigestion, unusual fatigue, and sleep disturbances are clinical manifestations of myocardial infarction in women. Anoxia and tightness of the chest are clinical manifestations of angina pectoris, not myocardial infarction.
After a deep vein thrombosis developed in a postpartum client, an intravenous (IV) infusion of heparin therapy was instituted 2 days ago. The client's activated partial thromboplastin time (aPTT) is now 98 seconds. What should the nurse do next? 1- Increase the IV rate of heparin. 2- Interrupt the infusion and notify the primary healthcare provider of the aPTT result. 3- Document the result on the medical record and recheck the aPTT in 4 hours. 4- Call the primary healthcare provider to obtain a prescription for a low-molecular-weight heparin.
2- Interrupt the infusion and notify the primary healthcare provider of the aPTT result. The heparin should be withheld, because 98 seconds is almost three times the normal time it takes a fibrin clot to form (25 to 36 seconds), and prolonged bleeding may result; the therapeutic range for heparin is one-and-a-half to two times the normal range. The primary healthcare provider should be notified. The dosage of heparin must not be increased, because the client already has received too much. Documenting the result on the medical record and rechecking the aPTT in 4 hours is an unsafe option. Continuing the infusion could result in hemorrhage. The medication does not have to be changed; it should be stopped temporarily until the aPTT is within the therapeutic range. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.
An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to bestdecrease preload? 1- Contour 2- Orthopneic 3- Recumbent 4- Trendelenburg
2- Orthopneic The client's paroxysmal dyspnea was probably caused by sleeping in bed with the legs at the level of the heart; the orthopneic position increases venous return from dependent body areas, increasing the intravascular volume. Sitting up and leaning forward while keeping the legs dependent slows venous return and increases thoracic capacity. Although the contour position elevates the client's head, it does not place the legs in a dependent enough position to substantially decrease venous return. The recumbent position is contraindicated. Venous return increases when the lower extremities are at the level of the heart. Also, the pressure of the abdominal organs against the diaphragm decreases thoracic capacity. The Trendelenburg position is contraindicated. Venous return increases when the lower extremities are higher than the level of the heart. Also, the pressure of the abdominal organs against the diaphragm decreases thoracic capacity.
Following surgery in the inguinal area, the client reports pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. Which is the priority nursing action? 1- Auscultate the chest 2- Obtain the vital signs 3- Elevate the head of the bed 4- Position the client on the right side
3- Elevate the head of the bed Elevating the head of the bed promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. Auscultating the chest may confirm diminished breath sounds but will not facilitate breathing. Obtaining the vital signs should be done eventually, but it is not the priority. Positioning the client on the right side will impede aeration of the right lung fields.
The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response should be based on what principle about bed rest? 1- It prevents the further aggregation of platelets. 2- It enhances the peripheral circulation in the deep vessels. 3- It decreases the potential for further dislodgment of emboli. 4- It maximizes the amount of blood available to damaged tissues.
3- It decreases the potential for further dislodgment of emboli. Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation or the circulation of blood to damaged tissues
A client who is hospitalized after a myocardial infarction asks the nurse why morphine was prescribed. What will the nurse include in the reply? 1- Decreases anxiety and promotes sleep 2- Helps prevent development of atrial fibrillation 3- Relieves pain and reduces cardiac oxygen demand 4- Dilates coronary blood vessels to increase oxygen supply
3- Relieves pain and reduces cardiac oxygen demand Morphine is a specific central nervous system depressant used to relieve the pain associated with myocardial infarction; it also decreases apprehension and reduces cardiac oxygen demand by decreasing cardiac workload. Dilating coronary blood vessels is not the reason for the use of morphine. Decreasing anxiety and restlessness is not the primary reason for the use of morphine. Lidocaine is given intravenously to prevent fibrillation of the heart.
To prevent septic shock in the hospitalized client, what should the nurse do? 1- Maintain the client in a normothermic state. 2- Administer blood products to replace fluid losses. 3- Use aseptic technique during all invasive procedures. 4- Keep the critically ill client immobilized to reduce metabolic demands.
3- Use aseptic technique during all invasive procedures Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? 1- "My ankles are swollen." 2- "I am tired at the end of the day." 3- "When I eat a large meal, I feel bloated." 4- "I have trouble breathing when I walk rapidly."
4- "I have trouble breathing when I walk rapidly." Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.
An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? 1- A reduction of confusion 2- An absence of ecchymotic areas 3- A decreased viscosity of the blood 4- An activated partial thromboplastin twice the usual value
4- An activated partial thromboplastin twice the usual value Desired anticoagulant effect is achieved when the activated partial thromboplastin time is 1.5 to 2 times normal. While anticoagulants help prevent thrombi that could block cerebral circulation, they do not increase cerebral perfusion, and so will not affect existing confusion. Although absence of bleeding suggests that the drug has not reached toxic levels, it does not indicate its effectiveness. This medication does not affect the viscosity of blood. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.
A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? 1- Reduces edema 2- Increases cardiac conduction 3- Increases rate of ventricular contractions 4- Slows and strengthens cardiac contractions
4- Slows and strengthens cardiac contractions Digoxin increases the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."
A client had a total knee replacement several days ago and has been receiving warfarin sodium therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the healthcare provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. Which is the next action the nurse should take? 1- Assist with meal planning to decrease the intake of foods high in vitamin K 2- Obtain a blood specimen to have a partial thromboplastin time performed 3- Contact the healthcare provider to request the day's dosage of warfarin sodium 4- Maintain the client on bed rest until the healthcare provider reviews the laboratory results
An INR of 4.6 is higher than the desired therapeutic level of 2 to 3.5. It is prudent to maintain bed rest to prevent injury until the healthcare provider evaluates the client's INR result. Decreasing the intake of food high in vitamin K is contraindicated; vitamin K is the antidote for warfarin sodium. The client should have a consistent, limited intake of food high in vitamin K. A partial thromboplastin time is performed to evaluate a client's response to the administration of heparin. Another dose of warfarin sodium may be contraindicated in light of the client's increased INR result.
To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ? 1- Administer the injection via the Z-track technique 2- Avoid massaging the injection site after the injection 3- Use 2 mL of sterile normal saline to dilute the heparin 4- Inject the drug into the vastus lateralis muscle in the thigh
The site of the injection should not be massaged to avoid dispersion of the heparin around the site and subsequent bleeding into the area. The Z-track technique and the intramuscular route are not used with heparin; subcutaneous injection and intravenous administration are the routes appropriate for heparin administration. The drug should be injected into the subcutaneous tissue slowly, not quickly. Diluting heparin with normal saline is unnecessary. Generally heparin is provided by the pharmacy department in single-dose syringes.
