Practice Questions for MS 2 Exam 2
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?"
"Are you still able to walk upstairs without fatigue?"
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."
"Avoid large crowds and people who are sick."
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."
"Avoid using salt substitutes."
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."
"Begin walking 200 feet a day three times a week."
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."
"Continue to educate the client on possible healthy changes."
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."
"Do not take this medication within 1 hour of taking an antacid."
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?"
"Do you have any concerns about sexuality?"
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?"
"I can stay if you would you like to talk more about this."
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."
"I must stop halfway up the stairs to catch my breath."
The primary health care provider requests the nurse start an infusion of an milrinone on a client. How does the nurse explain the action of these drugs 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."
"It increases the force of the heart's contractions."
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."
"My shoes fit really tight lately."
A nurse prepares a client for coronary artery bypass graft surgery. The client states, "I'm 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?"
"Tell me more about your concerns about the surgery."
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 reverese CAD totally with diet and supplements."
"The best source is fish, but pills have benefits too."
A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occuring as the t-PA wears off."
"The heparin keeps that artery from getting blocked again."
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."
"Weigh yourself daily while wearing the same amount of clothing."
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 you are 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."
"Weight is the best indication that you are gaining or losing fluid."
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?"
"Would you like information about advance directives?"
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."
"Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)
1630 (4:30 PM)
A nurse assesses patients 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 36 year old woman with aortic stenosis
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
Administer PRN acetaminophen
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 2L/min b. Allow continued bathroom privileges. c. Obtain a bedide commode d. Suggest the client use a bedpan
Allow continued bathroom privileges.
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 should 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.
Allow family members to remain at the bedside.
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
Assess for any hemodynamic effects of the rhythm.
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.
Assess for symptoms of left-sided heart failure.
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. Medicare the client for pain.
Assess the client for bleeding.
A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the client's blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.
Assess the client's blood pressure and level of consciousness.
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.
Assess the client's respiratory status.
A client is receiving an infusion of tissue plasminogen activator (tPA). the nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary response. b. Request a neurologic consultation. c. Call the primary health care provider immediately. d. Take and document a full set of vital signs
Call the primary health care provider immediately.
A nurse is caring for four client s. 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)
Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety
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 percutaneous coronary intervention, going home this morning. d. Client who is 2-day post coronary artery bypass graft, wh became dizzy this morning while walking.
Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64 mm Hg
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
Dyspnea on exertion
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. Maintainn the client in a semi-Fowler position.
Ensure that the balloon does not remain wedged.
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Gather central line supplies b. Mark the client's pedal pulses c. Monitor the client's vital signs. d. Ensure an accurate weight is charted
Gather central line supples
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 ECG within 20 mins b. Give the client a nonenteric coated aspirin. c. Notify the Rapid Response Team immediately d. Prepare to administer thrombolytics within 30 mins
Give the client a nonenteric coated aspirin.
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.
Instruct the client to ask for assistance when rising from bed.
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
Maintain airway patency
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.
Notify the provider immediately.
The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs b. Don a mask and gown c. Gather needed supplies d. Perform hand hygiene
Perform hand hygiene
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
Poor peripheral pulses and cool skin
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
Prepare to administer a fluid bolus.
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.
Tell the client that anxiety is common and that you can help
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. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" d. "What spiritual beliefs may impact your recovery?"
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. "I'll read the nutritional labels on food items for salt content." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."
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. "Reposition the client every 2 hours." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning."
A nurse student 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
a. Accompanied by shortness of breath b. Feelings of fear or anxiety d. No relief from taking nitroglycerin e. Pain occurs without known cause
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. Administering beta blockers c. Preparing for a cardiac catheterization e. Instructing the client to avoid strenuous exercise
A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (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 the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol
a. Assist the client to the chair for meals and to the bathroom. c. Ensure the client wears TED hose or sequential compression devices. e. Take and record a full set of vital signs per hospital protocol
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. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) e. Proteinuria f. Microalbuminuria
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. Pulmonary crackles b. Confusion e. Cough that worsens at night
A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (SATA) a. Right atrial pressure 12 mm. Hg: right ventricular failure b. Right atrial pressure 4 mm Hg: Hypovolemia c. Pulmonary artery pressure 20/10 mm Hg: normal finding d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction
a. Right atrial pressure 12 mm. Hg: right ventricular failure c. Pulmonary artery pressure 20/10 mm Hg: normal finding d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction
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. Shortness of breath b. Abdominal bloating c. New-onset bradycardia f. Fatigue
Prior to discharge, a client who had an acute myocardial infarction and coronary artery bypass graft asks the nurse about sexual activity. What information does the nurse provide? (SATA) a. "You will need to wait at least 6 weeks before intercourse." b. "Your usual sexual activity is not likely to damage your heart." c. "Start having sex when you are most rested, like in the morning." d. "When you can climb four flights of stairs, you can tolerate sex." e. "Don't eat for 3 hours before engaging in sexual activity." f. "Use a comfortable position that doesn't stress your incision."
b. "Your usual sexual activity is not likely to damage your heart." c. "Start having sex when you are most rested, like in the morning." f. "Use a comfortable position that doesn't stress your incision."
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. Assist the client into a position of comfort in bed. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.
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. 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. f. Care transition record transmitted to next level of care within 7 days of discharge.
A nursing 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
b. Hypertension c. Obesity d. Smoking e. Stress
