NSG 210 TEST 2

A client experiencing difficulty breathing and increased pulmonary congestion as a result of heart failure was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment finding indicates that the therapy has been effective? 1. The lungs are now clear upon auscultation. 2. The urine output has increased by 400 mL. 3. The blood pressure has decreased from 118/64 to 106/62 mm Hg. 4. The serum potassium has decreased from 4.7 to 4.1 mEq (4.7 to 4.1 mmol/L).

1 Furosemide is a diuretic. In this situation, it was given to decrease preload and reduce the pulmonary congestion and associated difficulty in breathing. Although all options may occur, option 1 is the reason that the furosemide was administered.

The nurse caring for a 5-year-old with a history of tetralogy of Fallot notes that the child has clubbed fingers. This finding is indicative of which associated condition? 1. Tissue hypoxia 2. Chronic hypertension 3. Delayed physical growth 4. Destruction of bone marrow

1 Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of chronic tissue hypoxia and polycythemia.

A patient with TB has been taking ethambutol for 2 months. Which adverse effects should be reported to the HCP? (select all that apply) 1. Red, orange tears 2. blurred vision 3. new numbness or tingling 4 color changes 5 Elevated liver enzymes

2 4 Ethambutol's SFX: blurred vision and color changes 1 rifampin - red, orange tears 3 INH- neuropathy numbness 5 rifampin, INH

A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted? 1. Edema present at 3+ 2. Weight loss of 5 pounds within 2 days 3. Pulse rate increased from 58 to 74 beats/min 4. Blood pressure decreased from 142/94 mm Hg to 128/82 mm Hg

4 Betaxolol is a beta-adrenergic blocking agent used to lower blood pressure, relieve angina, or eliminate dysrhythmias. Side/adverse effects include bradycardia and symptoms of heart failure, such as weight gain and increased edema.

1. A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident

A Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure. Iggy 10th Ch 32

9. A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this clients teaching? a. Take an antibiotic each day. b. Contact your provider to obtain genetic screening. c. Eat a well-balanced, nutritious diet. d. Plan to exercise for 30 minutes every day.

C CF patient is malnourished due to Vit deficiency and pancreatic malfunction maintain nutrition is essential Iggy 9th Ch 30

12. A nurse has educated a client on isoniazid. What statement by the client indicates that teaching has been effective? a. "I need to take extra vitamin C while on isoniazid." b. "I should take this medicine with milk or juice." c. "I will take this medication on an empty stomach." d. "My contact lenses will be permanently stained."

C INH needs to be taken on empty stomach, either 1 hour before or 2 hours after meals Extra Vit B6 needed Staining eye - rifampin Iggy 10th Chapter 28

A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in _________ so the results can be interpreted? A. 24-48 hours B. 12-24 hours C. 48-72 hours D. 24-72 hours

C If fail, repeat

You are assessing your newly admitted patients who are all presenting with atypical signs and symptoms of a possible lung infection. The physician suspects tuberculosis. So, therefore, the patients are being monitored and tested for the disease. Select all the risk factors below that increases a patient's risk for developing tuberculosis A. Diabetes B. Liver failure C. Long-term care resident D. Inmate E. IV drug user F. HIV G. U.S. resident

C D E F TBRISK

Your patient with a diagnosis of latent tuberculosis infection needs a bronchoscopy. During transport to endoscopy, the patient will need to wear? A. N95 mask B. Surgical mask C. No special PPE is needed D. Face mask with shield

C. No special PPE is needed

tetralogy of Fallot

VSD A rare condition caused by a combination of four heart defects that are present at birth. Right-side HF

A client diagnosed with tuberculosis (TB) is scheduled to go to the radiology department for a chest radiograph. The nurse would take which action when preparing to transport the client? 1. Apply a mask to the client. 2. Apply a mask and gown to the client. 3. Apply a mask, gown, and gloves to the client. 4. Notify the radiology department so that the personnel can be sure to wear masks when the client arrives.

1

The nurse is caring for a client with a terminal condition who is dying. Which respiratory assessment findings would indicate to the nurse that death is imminent? Select all that apply. 1. Dyspnea 2. Cyanosis 3. Tachypnea 4. Kussmaul's respiration 5. Irregular respiratory pattern 6. Adventitious bubbling lung sounds

1 2 5 6 Respiratory assessment findings that indicate death is imminent include poor gas exchange as evidenced by hypoxia, dyspnea, or cyanosis; altered patterns of respiration, such as slow, labored, irregular, or Cheyne-Stokes pattern (alternating periods of apnea and deep, rapid breathing); increased respiratory secretions and adventitious bubbling lung sounds (death rattle); and irritation of the tracheobronchial airway as evidenced by hiccups, chest pain, fatigue, or exhaustion. Kussmaul's respirations are abnormally deep, very rapid sighing respirations characteristic of diabetic ketoacidosis. Tachypnea is defined as rapid breathing. In an adult, it would indicate a respiratory rate of over 20 breaths/min.

Which statement by the patient requires further teaching? (select all that apply) 1. It is ok to have sex with lesions present while on acyclovir 2. It is normal for rifampin to cause red urine 3. It is normal for rifampin to cause yellow sclera 4. I will take vitamin B12 while on INH

1 3 4 No sex when lesions present Yellow sclera -> sign of jaundice(hepatotoxicity) Vitamin B6 for INH

A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. The nurse immediately implements which expected prescriptions for this client? Select all that apply. 1. Supplemental oxygen 2. High-Fowler's position 3. Semi-Fowler's position 4. Morphine sulfate intravenously 5. Meperidine hydrochloride intravenously 6. Two tablets of acetaminophen with codeine

1 3 4 Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. High-Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.

The nurse is ambulating a client for the first time after having abdominal surgery. What clinical manifestations would indicate to the nurse that the client may be experiencing orthostatic hypotension? Select all that apply. 1. Nausea 2. Dizziness 3. Bradycardia 4. Lightheadedness 5. Flushing of the face 6. Reports of seeing spots

1, 2, 4, 6 Rationale: Orthostatic hypotension occurs when a normotensive person develops symptoms of low blood pressure when rising to an upright position. Whenever the nurse gets a client up and out of a bed or chair, there is a risk for orthostatic hypotension. Symptoms of nausea, dizziness, lightheadedness, tachycardia, pallor, and reports of seeing spots are characteristic of orthostatic hypotension. A drop of approximately 15 mm Hg in the systolic blood pressure and 10 mm Hg in the diastolic blood pressure also occurs. Fainting can result without intervention, which includes immediately assisting the client to a lying position.

A client is brought to the emergency department reporting chest pain. Assessment shows vital signs that include a blood pressure (BP) of 150/90 mm Hg, pulse (P) 88 beats/min, and respirations (R) 20 breaths/min. The nurse administers Nitroglycerin 0.4 mg sublingually. The treatment is found to be effective when the reassessment of vital signs shows which data? 1. BP 150/90 mm Hg, P 70 beats/min, R 24 breaths/min 2. BP 100/60 mm Hg, P 96 beats/min, R 20 breaths/min 3. BP 100/60 mm Hg, P 70 beats/min, R 24 breaths/min 4. BP 160/100 mm Hg, P 120 beats/min, R 16 breaths/min

2 Nitroglycerin dilates both arteries and veins, causing blood to pool in the periphery. This causes a reduced preload and therefore a drop in cardiac output. This vasodilation causes the BP to fall. The drop in cardiac output causes the sympathetic nervous system to respond and attempt to maintain cardiac output by increasing the pulse. Beta blockers, such as propranolol, are often used in conjunction with nitroglycerin to prevent this rise in heart rate. If chest pain is reduced and cardiac workload is reduced, the client will be more comfortable; therefore, a rise in respirations should not be seen.

81. The community health nurse has reviewed information about the population of a local community and has determined that there are groups in the population that are at high risk for infection with tuberculosis (TB). The nurse targets which high-risk group for screening? 1. French Canadians 2. White, Anglo-Saxon Americans 3. Older clients in long-term-care facilities 4. Adolescents between the ages of 13 and 17years

3 Older clients, particularly those in long-term-care facilities, are at high risk for infection with TB. Other people at risk include children who are 5 years old and younger, the malnourished, the immunosuppressed, the economically disadvantaged, foreign-born persons, and persons of a minority race who formerly lived in a place where TB is common, such as Asia or the Pacific islands. Therefore, French Canadians, White Anglo-Saxon Americans, and adolescents between the ages of 13 and 17 are incorrect options.

A client diagnosed with angina pectoris appears to be very anxious and states, "So, I had a heart attack, right?" Which response would the nurse make to the client? 1. "No. That is not why you are hospitalized." 2. "No, but there could be some minimal damage to your heart." 3. "No, not this time and we will do our best to prevent a future heart attack." 4. "No, but it's necessary to monitor you and control or eliminate your pain."

4 Angina pectoris occurs as a result of an inadequate blood supply to the myocardium causing pain; managing the condition will help address the client's pain. The nurse will want to correct the client's misconception regarding a heart attack while addressing the client's concerns. Option 1 does not address the client's concerns. Option 2 is not correct because angina involves interrupted blood supply but does not result in cardiac tissue damage. Neither the nurse nor the primary health care provider can guarantee that a heart attack will not occur as option 3 appears seems to indicate.

6. A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."

A ACEs(-pril) Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the client's pulse rate. Aspirin is often prescribed in conjunction with ACE inhibitors and is not contraindicated.

11. A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide. d. Ask the client about current medications.

A Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics, and asking about current medications are important but do not take precedence over assessing respiratory status.

4. A nurse is teaching a community group of women about ways to decrease their risk of cardiovascular disease. What actions does the nurse recommend? (Select all that apply.) a. Stop smoking b. Drink 8 to 10 glasses of water daily c. Exercise on most days of the week d. Get your blood pressure checked e. Decrease the fat in your diet

ACDE Risk factor of CAD smoking, sedentary lifestyle, HTN, high fat diet Mckinney ch 32

1. A nurse learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress f. Gender

ANS: B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age and gender are not nonmodifiable risk factors.

10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse would stay with the client and ensure that the airway remains patent (especially if vomiting occurs) while another person calls the primary health care provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the primary health care provider's prescription and the client's current medications.

23. The primary health care provider requests the nurse start an infusion of milrinone on a client. How does the nurse explain the action of this drug to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."

ANS: C Milrinone, is a positive inotrope, is a medication that increases the strength of the heart's contractions. It is not a vasoconstrictor, a vasodilator, nor does it slow the heart rate.

22. A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, Will my children have cystic fibrosis? How should the nurse respond? a. Since many of your family members are carriers, your children will also be carriers of the gene. b. Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder. c. Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested. d. Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder.

C CF is autosomal recessive disorder - both gene alleles must be mutated; encourage both to be tested for the abnormal gene Iggy 9th Ch 30

2. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." c. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."

C Clients with left-sided heart failure report weakness or fatigue while performing normal activities of daily living, as well as difficulty breathing, or "catching their breath." This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to heart failure.

22. A client presents to the emergency department with acute myocardial infarction (MI) at 15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed? a. 15:30 (3:30 p.m.) b. 16:00 (4:00 p.m.) c. 16:30 (4:30 p.m.) d. 17:00 (5:00 p.m.)

C PCI would be performed within 90 minutes of diagnosis of myocardial infarction. Therefore, the client would have a PCI performed no later than 16:30 (4:30 p.m.).

12. A nurse cares for a client who is infected with Burkholderia cepacia. Which action should the nurse take first when admitting this client to a pulmonary care unit? a. Instruct the client to wash his or her hands after contact with other people. b. Implement Droplet Precautions and don a surgical mask. c. Keep the client isolated from other clients with cystic fibrosis. d. Obtain blood, sputum, and urine culture specimens.

C Burkholderia cepacia is infection thru contact b/w CF patients need to seperate Iggy 9th Ch 30

16. A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a. Community social worker for Meals on Wheels b. Occupational therapy for job retraining c. Physical therapy for homebound therapy services d. Visiting nurses for directly observed therapy

D Directed Observed Therapy(DOT) is often utilized for managing client with TB Iggy 10th Chapter 28

59. A client diagnosed with active Tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action would the nurse take when planning a bed assignment? 1. Place the client in a private, well-ventilated room. 2. Plan to transfer the client to the intensive care unit. 3. Reserve the bed furthest away from the door in a double room. 4. Assign the client to share a double room with a noninfectious client

1 According to category-specific (respiratory) isolation precautions, a client with TB requires a private room. The room needs to be well ventilated and should have at least 6 to 12 exchanges of fresh air per hour and should be ventilated to the outside if possible. Therefore, option 1 is the only correct choice.

354. The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium Tuberculosis is cultured. How would the nurse correctly analyze these results? 1. The results are positive for active tuberculosis. 2. The results indicate a less virulent strain of tuberculosis. 3. The results are inconclusive until a repeat sputum specimen is sent. 4. The results are unreliable unless the client has also had a positive tuberculin skin test (TST).

1 Culture of Mycobacterium tuberculosis from sputum or other body secretions or tissue confirms the diagnosis of active tuberculosis. Options 2 and 3 are incorrect statements. The TST test is performed to assist in diagnosing TB but does not confirm active disease.

The nurse is performing a cardiovascular assessment on a client with heart failure. Which item would the nurse assess to obtain the best information about the client's left-sided heart function? 1. The status of breath sounds 2. The presence of peripheral edema 3. The presence of hepatojugular reflux 4. The presence of jugular vein distention

1 The client with heart failure may present different symptoms depending on whether the right or the left side of the heart is failing. The assessment of breath sounds provides information about left-sided heart function. Peripheral edema, hepatojugular reflux, and jugular vein distention are all signs of right-sided heart function.

163. A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client? 1. Noting whether the client has visitors 2. Instructing all staff members to not touch the client 3. Giving the client a roommate with TB who persistently tries to talk 4. Removing the calendar and clock in the room so that the client will not obsess about time

1 The nurse should note whether the client has visitors and social contacts because the presence of others can offer positive stimulation. Touch may be important to help the client feel socially acceptable. A roommate who insists on talking could create sensory overload. In addition, the client on respiratory isolation should be in a private room. The calendar and clock are needed to promote orientation to time.

A patient is newly prescribed Isoniazid(INH) to treat their active tuberculosis(TB). What instructions are the most important to teach this patient? (select all that apply) 1. Monitor for numbness and tingling 2. Report blurred vision 3. Use additional forms of birth control 4. Avoid wine at night 5. Notify HCP if urine turns dark 6. Take B6 daily

1 4 5 6 INH I : interferes with B6 N : neuropathy numbness H : hepatotoxicity

137. The nurse determines that a tuberculin skin test is positive. Which diagnostic test would the nurse anticipate will be prescribed to confirm a diagnosis of tuberculosis (TB)? 1. Chest x-ray 2. Sputum culture 3. Complete blood cell count 4. Computed tomography scan of the chest

2 Although the findings of the chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on the basis of this examination because other diseases can mimic the appearance of TB. The demonstration of tubercle bacilli bacteriologically is essential for establishing a diagnosis. The microscopic examination of sputum for acid-fast bacilli is usually the first bacteriological evidence of the presence of tubercle bacilli. Options 3 and 4 will not diagnose TB.

A client diagnosed with valvular heart disease is at risk for developing heart failure. What would the nurse assess as the priority when monitoring for heart failure? 1. Heart rate 2. Breath sounds 3. Blood pressure 4. Activity tolerance

2 Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure.

The nurse is assessing a 39-year- old Caucasian client with a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol level of 180mg/dL (4.5 mmol/L), and a fasting blood glucose level of 90 mg/dL (5.14 mmol/L). On which risk factor for coronary artery disease would the nurse place priority? 1. Age 2. Hypertension 3. Hyperlipidemia 4. Glucose intolerance

2 Hypertension, cigarette smoking, and hyperlipidemia are major risk modifiable factors for coronary artery disease. Glucose intolerance, obesity, and response to stress are also contributing factors. An age of more than 40 years is a nonmodifiable risk factor. A cholesterol level of 180 mg/dL (4.5 mmol/L) and a blood glucose level of 90 mg/dL(5.14 mmol/L) are within the normal range. The nurse places priority on major risk factors that need modification.

A client who is being treated for acute heart failure has the following vital signs: blood pressure(BP), 85/50 mm Hg; pulse, 96 beats/min; respirations, 26 breaths/min. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs would the nurse expect? 1. BP 85/50 mm Hg, pulse 60 beats/min, respirations 26 breaths/min 2. BP 98/60 mm Hg, pulse 80 beats/min, respirations 24 breaths/min 3. BP 130/70 mm Hg, pulse 104 beats/min, respirations 20 breaths/min 4. BP 110/40 mm Hg, pulse 110 beats/min, respirations 20 breaths/min

2 The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. Options 1, 3, and 4 do not reflect the physiological changes attributed to this medication.

347. Acetylsalicylic acid (aspirin) is prescribed for a client diagnosed with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication understanding that it is prescribed for what purpose? 1. Relieve postprocedure pain. 2. Prevent thrombus formation. 3. Prevent postprocedure hyperthermia. 4. Prevent inflammation of the puncture site.

2 Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure because the aspirin inhibits platelet aggregation.

The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator(ICD). The nurse determines that there is a need for further teaching if the client makes which statement? 1. "I need to avoid doing anything where there would be rough contact with the ICD insertion site." 2. "I can perform activities and operate heavy equipment such as my lawn mower or tractor as I need to." 3. "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cut-off on the ICD." 4. "I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, as well as running motors."

2 Postdischarge instructions typically include avoiding the following: tight clothing or belts over the ICD insertion site; rough contact with the ICD insertion site; electromagnetic fields, such as those surrounding electrical transformers; radio, television, and radar transmitters; metal detectors; and the running motors of cars or boats. Clients must also alert health care providers 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 follow the specific advice of a primary health care provider regarding activities that are potentially hazardous to the self or others, such as operating heavy equipment.

279. The nurse admitting a client diagnosed with myocardial infarction (MI) to the coronary care unit (CCU) would plan care by implementing which intervention? 1. Beginning thrombolytic therapy 2. Placing the client on continuous cardiac monitoring 3. Infusing intravenous (IV) fluid at a rate of 150 mL per hour 4. Administering oxygen at a rate of 6 L per minute by nasal cannula

2 Standard interventions upon admittance to the CCU as they relate to this question include continuous cardiac monitoring. Thrombolytic therapy may or may not be prescribed by the PCP. Thrombolytic agents are most effective if administered within the first 6 hours of the coronary event. The nurse should ensure that there is an adequate IV line insertion of an intermittent lock. If an IV infusion is administered, it is maintained at a keep-vein-open rate to prevent fluid overload and heart failure. Oxygen should be administered at a rate of 2 to 4 L/min unless otherwise prescribed.

A client with active tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action would the nurse take when planning a bed assignment? 1. Tell the admitting office to send the client to the intensive care unit. 2. Place the client in a private, airborne infection isolation room (AIIR). 3. Assign the client to a room with another client because intravenous antibiotics will be administered. 4. Assign the client to a room with another client and place a "strict hand washing" sign outside the door.

2 is spread via the airborne route. Preventing the spread of infection requires the use of special air handling and ventilation in an AIIR. Therefore, option 2 is the only correct option when planning a bed assignment for this client. Remember, the nurse needs to plan and generate solutions to determine interventions for an expected outcome.

The nurse is providing discharge teaching for a client diagnosed and treated for Tuberculosis (TB). Which statement by the client indicates that teaching has been effective? (Select all that apply) 1. "All used dishes should be sterilized." 2. "My close contacts should be tested for TB." 3. "Soiled tissues should be disposed of properly." 4. "House isolation is required for at least 8 months." 5. "The mouth should always be covered when coughing."

2 3 5 TB is a communicable disease, and the nurse must teach the client measures to prevent its spread. Any close contacts with the client must be tested and treated if the results of the screening test are positive. Because it is an airborne disease, the client must properly dispose of used tissues and needs to cover the mouth when coughing. There is no evidence to suggest that sterilizing dishes would break the chain of infection with pulmonary TB. It is not necessary for the client to isolate herself or himself to the house. Once the client is treated and results of three sputum cultures are negative, the client will not spread the infection.

A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements, which dietary intervention would the nurse consult the dietitian about? 1. A low-calorie diet to prevent weight gain 2. A diet low in fluids and fiber to decrease blood volume 3. A diet adequate in fluids and fiber to decrease constipation 4. Unlimited sodium intake to increase circulating blood volume

3 Constipation can cause the client to use Valsalva's maneuver. This maneuver can cause blood to rush to the heart and overload the cardiac system. A low-calorie diet is not recommended during pregnancy. Diets low in fluid and fiber can cause a decrease in blood volume that can deprive the fetus of nutrients; it can also lead to constipation. Therefore, adequate fluid intake and high-fiber foods are important. Sodium should be restricted to some degree as prescribed by the primary health care provider because this will cause an overload to the circulating blood volume and contribute to cardiac complications.

191. The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker for a bradydysrhythmia. Which client statement indicates that an understanding of self-care is evident? 1. "I will never be able to operate a microwave oven again." 2. "I should expect occasional feelings of dizziness and fatigue." 3. "I will take my pulse in the wrist or neck daily and record it in a log." 4. "Moving my arms and shoulders vigorously helps check pacemaker functioning."

3 Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the primary health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the primary health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion.

A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction(MI). The nurse would monitor the client for which most common complication of MI? 1. Heart failure 2. Cardiogenic shock 3. Cardiac dysrhythmias 4. Recurrent myocardial infarction

3 Dysrhythmias are the most common complication and cause of death after an MI. Heart failure, Cardiogenic shock, and recurrent MI are also complications but occur less frequently.

A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response? 1. An early sign of medication tolerance 2. An allergic reaction to the nitroglycerin 3. An expected side effect of the medication 4. A warning that the medication should not be used again

3 Headache is a frequent side effect of nitroglycerin, because of the vasodilating action of the medication. It usually diminishes in frequency as the client becomes accustomed to the medication and is effectively treated with acetaminophen. The other options are incorrect.

The nurse is caring for a client scheduled to undergo a cardiac catheterization for the first time. Which information would the nurse share with the client regarding the procedure? 1. "The procedure is performed in the operating room." 2. "The initial catheter insertion is quite painful; after that, there is little or no pain." 3. "You may feel fatigue and have various aches because it is necessary to lie quietly on a stationary x-ray table for about 4 hours." 4. "You may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations."

4 Cardiac catheterization: invasive test that involves the insertion of a catheter and the injection of dye into the heart and surrounding vessels to obtain information about the structure and function of the heart chambers and valves and the coronary circulation. Access is made by the insertion of a needle in either side of the groin into an artery or vein and the catheter is advanced up to the heart through the abdomen and chest. Preprocedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so that there is little to no pain with catheter insertion. The x-ray table is hard but can be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.

A client has just been admitted to the emergency department with reports of chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis? 1. Valve disease 2. Unstable angina 3. Coronary artery disease 4. New-onset myocardial infarction (MI)

4 Creatine kinase (CK)-MB isoenzyme is a sensitive indicator of myocardial damage. Levels begin to rise 3 to 6 hours after the onset of chest pain, peak at approximately 24 hours, and return to normal in about 3 days. Troponin is a regulatory protein found in striated muscle (skeletal and myocardial). Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. Troponin I is particularly sensitive to myocardial muscle injury; therefore, the client's results are compatible with new-onset MI. Options 1, 2, and 3 all result in chest pain, these levels would not be elevated in these options.

A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action would the nurse take first? 1. Call a code. 2. Prepare for cardioversion. 3. Prepare to defibrillate the client. 4. Check the client's level of consciousness

4 Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then cardiopulmonary resuscitation is initiated.

A client diagnosed with hypertension has been taking a prescribed calcium channel blocker for approximately 2 months. The home care nurse monitoring the effects of therapy would determine that drug tolerance has developed if which is noted in the client? 1. Decrease in weight 2. Increased joint pain 3. Output greater than intake 4. Gradual rise in blood pressure

4 Drug tolerance can develop in a client taking an antihypertensive such as a calcium channel blocker, which is evident by rising blood pressure levels. The primary health care provider should be notified, who may then increase the medication dosage, change medication, or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. This would also warrant adding a diuretic to the course of therapy. Joint pain is not associated with this form of tolerance.

The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks of gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information? 1. Identify mitral valve prolapse. 2. Identify cardiac dysrhythmias. 3. Rule out the possibility of pneumonia. 4. Assess for early signs of heart failure (HF).

4 Fluid volume during pregnancy peaks between 18 and 32 weeks of gestation. During this period, it is essential to observe and record maternal data that would indicate further signs of cardiac decompensation or HF in the pregnant client with cardiac disease. By assessing lung sounds, the nurse may identify early symptoms of diminished oxygen exchange and potential HF. Options 1, 2, and 3 are not related to the data in the question.

A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication? 1. The client is afebrile. 2. The client has clear breath sounds. 3. The client reports no episodes of headache. 4. The client has a blood pressure of 118/72mm Hg.

4 Nadolol is a beta-adrenergic blocking agent that is used to treat hypertension. Therefore, a blood pressure within the normal range would indicate an effective response to the medication. Based on this information the remaining options are unrelated to the action of this medication.

The nurse is preparing to initiate an IV nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an arterial monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety? 1. Defibrillator 2. Pulse oximeter 3. Central venous pressure (CVP) tray 4. Noninvasive blood pressure monitor

4 Nitroglycerin dilates arteries and veins (vasodilator), causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside. None of the other options would monitor blood pressure. Additionally, the client should be on a cardiac monitor

The nurse cares for a client who is pale and frequently reports fatigue, weakness, and dizziness. Which serum laboratory test result is the nurse's priority for planning care? 1. Hematocrit 43% (0.43) 2. Sodium 130 mEq/L (130 mmol/L) 3. Potassium 4.8 mEq/L (4.8 mmol/L) 4. Hemoglobin of 7 g/dL (70 g/L)

4 The client's hemoglobin level(13.2) and sodium level are low; however, the nurse uses the hemoglobin results to plan care because the client's clinical indicators are consistent with anemia. The client is pale because the serum hemoglobin is low; thus, the client's tissues are perfused with blood that has a low oxygen-carrying capacity. The client is weak and dizzy because the blood does not carry enough oxygen to meet tissue oxygen demands. The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Although a client who is hyponatremic can also feel weak and dizzy, a hyponatremic client is unlikely to be pale. The hematocrit and the potassium levels are within normal limits

5. A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all clients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."

A Daily weights are needed to document fluid retention or fluid loss. 1L=2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention or loss.

21. A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the best response by the nurse? a. "I can stay if you would you like to talk more about this." b. "You are lucky to have such a devoted daughter." c. "It is normal to feel as though you are a burden." d. "Would you like to meet with the chaplain?"

A Depression can occur in clients with heart failure, especially older adults. Having the client talk about his or her feelings will help the nurse focus on the actual problem. Open-ended statements allow the client to respond safely and honestly. The other options minimize the client's concerns and do not allow the nurse to obtain more information to provide client-centered care.

15. A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a. Ask the spouse to explain the fear of visiting in further detail. b. Inform the spouse that the precautions are meant to keep other clients safe. c. Show the spouse how to follow the Isolation Precautions to avoid illness. d. Tell the spouse that he or she has already been exposed, so it's safe to visit.

A Iggy 10th Chapter 28

4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the primary health care provider immediately. d. Transfer the client to the intensive care unit.

A The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.

8. A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a. Educating the client on adherence to the treatment regimen b. Encouraging the client to eat a well-balanced diet c. Informing the client about follow-up sputum cultures d. Teaching the client ways to balance rest with activity

A Treatment 26 weeks up to 2 years Important to following entire duration of prescribed therapy Iggy 10th Chapter 28

15. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

A smoking increases pulmonary HTN, resulting in COR Pulmonale(RHF) b. inflammation - airway obstruction (wheeze) d. Left ventricular hypertrophy - LHF Iggy 9th Ch 30

8. A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

A B C F Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter, decreased activity tolerance, and decreased ejection fraction.

A patient receiving medical treatment for an active tuberculosis infection asks when she can starting going out in public again. You respond that she is no longer contagious when: A. She has 3 negative sputum cultures B. Her signs and symptoms improve C. She has completed the full medication regime D. Her chest x-ray is normal E. She has been on tuberculosis medications for about 3 weeks

A B E

1. A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night f. Jugular venous distention

A B E Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in afterload. Most of the signs will be noted in the respiratory system: crackles, confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated with pulmonary hypertension, edema, and jugular venous distention.

7. A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. "Will you be able to afford your oxygen therapy?" d. "What spiritual beliefs may impact your recovery?" e. "Are you able to accurately weigh yourself at home?"

A B E To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. The nurse would also assess the client's available social support, which may include family, friends, and home health services. The client's beliefs about and ability to adhere to medication and treatments, including daily weights, would also be reviewed. The other questions do not specifically address the client's safety upon discharge.

2. A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEq/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) e. Proteinuria f. Microalbuminuria

A B E F A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution. Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These are early warning signs of decreased compliance of the heart. The potassium level is normal and the serum creatinine level is normal.

6. A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the client regarding this drug? (Select all that apply.) a. Contact the primary health care provider if preexisting gout becomes worse. b. Report any changes in vision immediately to the health care provider. c. Avoid drinking alcoholic beverages due to the chance of liver damage. d. Do not take antacids or eat within 2 hours after taking this medication. e. You will take this medication along with some others for 8 weeks. f. Take this medicine with a full glass of water.

A B E F Preexisting gout must be reported multi-drug routine used for TB Optic neuritis for ethambutol W/ full glass of water Drinking causes severe nausea and vomiting Avoiding antacids and food is for INH Iggy 10th Chapter 28

5. A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply.) a. "Reposition the client every 2 hours." b. "Teach the client to perform deep-breathing exercises." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning." e. "Place the client on oxygen if the client becomes short of breath."

A C D The AP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The AP can also accurately record intake and output, and use the same scale to weigh the client each morning before breakfast. APs are not qualified to teach clients or assess the need for and provide oxygen therapy.

The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15 to 25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased

A C D E A normal troponin value is anticipated with unstable angina. A troponin value of 0.6ng/mL is elevated and would be indicative of a myocardial infarction. All other assessment data can accompany unstable angina

9. A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS™

A C E Management of obstructive HCM includes administering negative inotropic agents such as beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil). Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in patients with obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide imaging, and angiocardiography during cardiac catheterization are performed to diagnose and differentiate cardiomyopathies. The CardioMEMSTM device is used with clients who have heart failure. hypertrophic cardiomyopathy: heart muscle thickened

4. After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "I will drink at least 3 L of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake." f. "Salt substitutes are a good way to cut down on sodium in my diet."

A D E Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention to decrease the workload of the heart. The client would be taught to read nutritional labels on all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so although they are not strictly banned, clients would have to have their renal function and serum potassium monitored while using them. It would be safer to avoid them.

18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action would the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the client's favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement or may agitate the client further. The TV would not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

4. A nurse is caring for a client who had a myocardial infarction. The nurse is confused because the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best? a. "Continue to educate the client on possible healthy changes." b. "Emphasize complications that can occur with noncompliance." c. "Tell the client that denial is normal and will soon go away." d. "You need to make sure the client understands this illness."

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The nurse would not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

9. A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse would gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the primary health care provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. Or this client's dysrhythmias could be a consequence of the myocardial infarction. They may or may not have significant hemodynamic effects. The nurse would first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor would never be shut off. The other two actions may or may not be needed.

3. A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause f. Can be precipitated by exertion or stress

ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion or stress.

2. A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Assist the client to the chair for meals and to the commode. b. Encourage the client to use the spirometer every 4 hours. c. Ensure that the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.

ANS: A, C, E The nurse can delegate assisting the client to get up in the chair or commode (if the nurse has evaluated the client as being stable), applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer would be used every hour the day after surgery. Assessing pain using a 0-10 scale is a nursing assessment, although if the client reports pain, the AP would inform the nurse so a more detailed assessment is done.

7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse would assess the client for any bleeding associated with the arterial line. The nurse would document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

16. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best for optimal client outcomes? a. Obtain an electrocardiogram (ECG) within 20 minutes. b. Give the client a nonenteric coated aspirin. c. Notify the Rapid Response Team immediately. d. Prepare to administer thrombolytics within 30 minutes.

ANS: B Best practice recommendations for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG (within 10 minutes) is vital for best outcomes. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed depending on the type of myocardial infarction the client has.

6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends. b. Ensure that the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler position.

ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing trends are important nursing actions related to hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring.

15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. "Fish oil is contraindicated with most drugs for CAD." b. "The best source is fish, but pills have benefits too." c. "There is no evidence to support fish oil use with CAD." d. "You can reverse CAD totally with diet and supplements."

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The preferred source of omega-3 acids is from fish rich in long-chain n-3 polyunsaturated fatty acids two times a week or a daily fish oil nutritional supplement (1 to 2 g/day). The other options are not accurate. Galic + Q10

17. A nurse is caring for four clients. Which client would the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety c. Client who is post coronary artery bypass, with chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L)

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting signs and symptoms of an allergic reaction (perhaps to the contrast medium) that could progress to anaphylaxis. The nurse would assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

21. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would be reported immediately. A blood pressure drop of 20 mm Hg may not be worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

25. A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine surgery and the risk of death is very low." b. "Would you like to speak with a chaplain prior to surgery?" c. "Tell me more about your concerns about the surgery." d. "What support systems do you have to assist you?"

ANS: C The nurse would discuss the client's feelings and concerns related to the surgery. The nurse would not provide false hope or simply call the chaplain. The nurse would address support systems after addressing the client's current issue.

5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: D Normal right atrial pressures are from 0 to 8 mm Hg. This pressure is at the extreme lower end, which indicates hypovolemia, so the nurse would prepare to administer a fluid bolus. The transducer would remain leveled at the phlebostatic axis. Positioning may or may not influence readings but a reading this low is definitive for volume depletion. Diuretics would be contraindicated.

8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the client's stress levels. d. Tell the client that anxiety is common and that you can help.

ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is common and offer to help. The other actions will not reduce the client's anxiety.

13. A client has progressed to Killip class III heart failure after a myocardial infarction. What does the nurse anticipate the client's care to include? a. Diuretics b. Nitrates c. Clopidogrel d. Dobutamine

ANS: D The client in class III heart failure would benefit from a positive inotrope such as dobutamine. Clients in class I typically respond well to diuretics and nitrates so this client would already be on these medications. Clopidogrel is a platelet inhibitor that will be prescribed for anyone having acute coronary syndrome for at least 12 months.

22. A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. "Walk until you become short of breath, and then walk back home." b. "Begin walking 200 feet a day three times a week." c. "Do not lift heavy weights for 6 months." d. "Eat plenty of protein to build your strength."

B A client who has heart failure would be taught to conserve energy and given an exercise plan. The client should begin walking 200-400 feet a day at home three times a week. The client should not walk until becoming short of breath because he or she may not make it back home. The lifting restriction is specifically for clients after valve replacements. Protein does help build strength, but this direction is not specific to heart failure. Gathering all supplies needed for a chore at one time decreases the amount of energy needed. Pushing a cart takes less energy than pulling or lifting. Although walking after dinner may help the client, the nurse should teach the client to complete activities when he or she has the most energy. This is usually in the morning.

7. After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.

B ACEs(-pril) Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food. Collaboration with assistive personnel to provide hygiene is not a priority. The client would be encouraged to complete activities of daily living as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the client has renal insufficiency secondary to heart failure.

16. The nurse understands that postpartum care of the woman with cardiac disease a. is the same as that for any pregnant woman. b. includes rest and monitoring of the effect of activity. c. includes ambulating frequently, alternating with active range of motion. d. includes limiting visits with the infant to once per day.

B After delivery, the woman with cardiac disease should rest, and the nurse monitors her for the effect activity has on her cardiovascular status. Care of the woman with cardiac disease in the postpartum period is tailored to the woman's functional capacity. Although the woman may need help caring for the infant, breastfeeding and infant visits are not contraindicated. Mckinney ch 26

18. A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."

B Clients who have had heart transplants must take immunosuppressant therapy for the rest of their lives. The nurse would teach this client to avoid crowds and sick people to reduce the risk of becoming ill him- or herself. These medications do not place clients at risk for bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the denervated(loss of nerve supply) heart is generally only a problem in the immediate postoperative period.

20. A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. "Do you have trouble breathing or chest pain?" b. "Are you still able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"

B Clients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

12. A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness

B Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other signs and symptoms do not relate to the progression of mitral valve stenosis.

14. A nurse is in charge of the coronary intensive care unit. Which client would the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64 mm Hg c. Client who is 1-day post percutaneous coronary intervention, going home this morning d. Client who is 2-day post coronary artery bypass graft, who became dizzy this morning while walking

B Hypotension after coronary artery bypass graft surgery can be dangerous because it can lead to collapse of the graft. The charge nurse would see this client first. The client who became dizzy earlier would be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

13. A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need to be reported to the primary health care provider immediately? a. Albumin: 5.1 g/dL (7.4 mcmol/L) b. Alanine aminotransferase (ALT): 180 U/L c. Red blood cell (RBC) count: 5.2/million/µL (5.2 × 1012/L) d. White blood cell (WBC) count: 12,500/mm3(12.5 × 109/L)

B INH can cause liver damage ATL (7-55) Iggy 10th Chapter 28

3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."

B Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided heart failure symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing

3. A client in the emergency department is taking rifampin for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a. Blood urea nitrogen (BUN): 19 mg/dL (6.7 mmol/L) b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds d. Serum sodium: 130 mEq/L (130 mmol/L) e. White blood cell (WBC) count: 72,000/mm3(72 × 109/L)

B C Rifampin can cause liver damage(INH too) high INR and prothrombin time BUN(6-24) and WBC(5k-10k) is normal Na is not related Iggy 10th Chapter 28

Your patient is diagnosed with a latent tuberculosis infection. Select all the correct statements that reflect this condition A. "The patient will not need treatment unless it progresses to an active tuberculosis infection." B. "The patient is not contagious and will have no signs and symptoms." C. "The patient will have a positive tuberculin skin test or IGRA test. D. "The patient will have an abnormal chest x-ray." E. "The patient's sputum will test positive for mycobacterium tuberculosis."

B C only active TB: positive sputum culture and CXR

4. When caring for a pregnant woman with suspected cardiomyopathy, the nurse must be alert for signs and symptoms of cardiac decompensation, which include (Select all that apply.) a. A regular heart rate b. Hypertension c. Shortness of breath d. Weakness e. Crackles in the lung bases

B C D E Some symptoms of cardiomyopathy include shortness of breath, weakness, and crackles in the lung bases. A regular heart rate may or may not be present. Hypertension is not a typical finding. Mckinney ch 26

6. A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about energy conservation techniques. b. Ensure that the client is prescribed a beta blocker. c. Document a discussion about advanced directives. d. Confirm that a postdischarge nurse visit has been scheduled. e. Consult a social worker for additional resources. f. Care transition record transmitted to next level of care within 7 days of discharge.

B C D F Diet, Activity, Medication, weight National quality measures aim to decrease heart failure readmission by proper preparation for discharge. (1) beta blocker prescribed for left ventricular dysfunction at discharge (2) postdischarge follow-up appointment scheduled within 7 days of discharge with documentation of location, date, and time. (3) care transition record transmitted to next level of care within 7 days of discharge. (4) documentation of discussion of advance directives/advance care planning with a health care provider, (5) documentation of execution of advance directives within the medical record, and (6) postdischarge evaluation of patient for symptom assessment and treatment adherence within 72 hours of discharge (this can occur by phone, scheduled office visit, or home visit)

4. A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

B D E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

You're teaching a group of long-term care health givers about the signs and symptoms of tuberculosis. What signs and symptoms will you include in your education? A. Cough for a minimum of 6 weeks B. Night sweats C. Weight gain D. Hemoptysis E. Chills F. Fever G. Chest pain

B D E F G cough should be present for 3 weeks or more experience wt loss

Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea

B D F

17. After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. "Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures." b. "Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness." c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes." d. "While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up."

C Because the new heart is denervated, the baroreceptor and other mechanisms that compensate for blood pressure drops caused by position changes do not function. This allows orthostatic hypotension to persist in the postoperative period. The other options are false statements and do not correctly address the client's question.

14. When teaching the pregnant woman with class II heart disease, what information should the nurse provide? a. Advise her to gain at least 30 lb. b. Explain the importance of a diet high in calcium. c. Instruct her to avoid strenuous activity. d. Inform her of the need to limit fluid intake.

C activity should limited, not exceed cardiac acitivity -Weight gain should be limited -Folic acid and Iron intake for preventing anemia -Fluid intake is needed at pregnancy Mckinney ch 26

19. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. "Would you like to speak with a priest or chaplain?" b. "I will arrange for a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"

D Clients with a history of heart failure generally have negative findings, such as shortness of breath and fatigue. The nurse needs to determine whether the client's activity is the same or worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not provide data that can determine the extent of the client's heart failure.

10. A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. "Avoid drinking more than 3 quarts (3 L) of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."

D Clients with heart failure are instructed to weigh themselves daily to detect worsening heart failure early, and thus avoid complications. Other signs of worsening heart failure include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet, balance intake and output to prevent dehydration and overload, and take medications as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

9. A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."

D Gastrointestinal absorption of digoxin is erratic(unpredictable). Many medications, especially antacids, interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on digoxin absorption.

8. A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy. b. Hold the next dose. c. Instruct the client to drink water. d. Administer PRN acetaminophen.

D The vasodilating effects of nitrates frequently cause clients to have headaches during the initial period of therapy. The nurse would inform the client about this side effect and offer a mild analgesic, such as acetaminophen. The client's headache is not related to hypoxia or dehydration; therefore, applying oxygen and drinking water would not help. The client needs to take the medication as prescribed to prevent angina; the medication would not be held.

13. What form of heart disease in women of childbearing years usually has a benign effect on pregnancy? a. Cardiomyopathy b. Rheumatic heart disease c. Congenital heart disease d. Mitral valve prolapse

D Mitral valve prolapse: benign and asymptomatic cardiomyopathy -> CHF Rheumatic Heart Disease -> HF Congenital heart disease -> pumonary HTN/endocarditis Mckinney ch 26