Prepus for Exam 3
The nurse is working on a monitored unit assessing the cardiac monitor rhythms. Which waveform pattern needs attention first? A) Sustained asystole B) Superventricular tachycardia C) Atrial fibrillation D) Ventricular fibrillation
D) Ventricular fibrillation
A 1-minute electrocardiogram (ECG) tracing of a client with a regular heart rate reveals 25 small, square boxes within an RR interval. The nurse correctly identifies the client heart rate as A) 60 bpm. B) 100 bpm. C) 80 bpm. D) 70 bpm.
A) 60 bpm.
Which of the following are alterations noted in Virchow's triad? Select all that apply. A) Stasis of blood B) Vessel wall injury C) Altered coagulation D) Edema E) Tenderness
A) Stasis of blood B) Vessel wall injury C) Altered coagulation
Sudden withdrawal of which of the following may result in seizures? A) Tranquilizers B) Steroids C) Monoamine-oxidase inhibitors D) Thiazide diuretics
A) Tranquilizers
The nurse explains to a patient that the primary cause of a varicose vein is: A) Phlebothrombosis. B) An incompetent venous valve. C) Venospasm. D) Venous occlusion.
B) An incompetent venous valve.
What is the most important postoperative instruction a nurse must give to a client who has just returned from the operating room after receiving a subarachnoid block? A) "Avoid drinking liquids until the gag reflex returns." B) "Avoid eating milk products for 24 hours." C) "Notify a nurse if you experience blood in your urine." D) "Remain supine for the time specified by the physician."
D) "Remain supine for the time specified by the physician."
The following clients are in need of exercise electrocardiography. Which client would the nurse indicate as most appropriate for a drug-induced stress test? A) A 48-year-old policemen with history of knee replacement 4 years ago B) A 68-year-old housewife with history of osteoporosis C) A 72-year-old retired janitor obtaining a cardiac baseline D) A 55-year-old recovering from a fall and broken femur
D) A 55-year-old recovering from a fall and broken femur
Which aneurysm results in bleeding into the layers of the arterial wall? A) Saccular B) Dissecting C) False D) Anastomotic
B) Dissecting
A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? A) A client 4 days postoperative after mitral valve replacement B) A client with hypertrophic cardiomyopathy C) A client with a history of repaired ventricular septal defect D) A client 1 day post coronary stent placement
A) A client 4 days postoperative after mitral valve replacement
A young mother brings her 4-year-old in to the pediatric clinic with a mild fever and a red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm is abnormal. The mother states the child has been healthy until about 3 weeks ago when the child had a sore throat. The nurse suspects rheumatic carditis. What organism causes rheumatic carditis? A) Group A beta-hemolytic strep B) Staphylococcus aureus C)Streptococcus viridians D) Epstein-Barr virus
A) Group A beta-hemolytic strep
A client is administered succinylcholine and propofol for induction of anesthesia. One hour after administration, the client demonstrates muscle rigidity with a heart rate of 180. What should the nurse do first? A) Notify the surgical team. B) Document the assessment findings. C) Administer dantrolene sodium. D) Obtain cooling blankets.
A) Notify the surgical team
A patient with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this patient? A) Prepare for pericardiocentesis. B) Request STAT cardiac enzymes. C) Perform a 12-lead ECG. D) Assess the patient's heart and lung sounds.
A) Prepare for pericardiocentesis.
A 28-year-old client presents to the emergency department, stating severe restlessness and anxiety. Upon assessment, the client's heart rate is 118 bpm and regular, the client's pupils are dilated, and the client appears excitable. Which action should the nurse take next? A) Question the client about alcohol and illicit drug use. B) Instruct the client to hold the breath and bear down. C) Prepare to administer a calcium channel blocker. D) Place the client on supplemental oxygen.
A) Question the client about alcohol and illicit drug use.
As a nurse working in an ambulatory surgery center, you are admitting a client who is going to have a biopsy of a skin lesion. What is an important part of the preoperative process? A) Review preoperative instructions. B) Give postoperative instructions. C) Teach dressing changes. D) Give caregiver instructions.
A) Review preoperative instructions.
The nurse is placing electrodes for a 12-lead electrocardiogram (ECG). The nurse would be correct in placing an electrode on which area for V1? A) Right side of sternum, fourth intercostal space B) Left side of sternum, fourth intercostal space C) Midway between V2 and V4 D) Mid-clavicular line, fifth intercostal space
A) Right side of sternum, fourth intercostal space
While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate: A) Valve damage. B) pericarditis. C) cardiac tamponade. D) atrial gallop.
A) Valve damage.
Following a percutaneous transluminal coronary angioplasty, a client is monitored in the postprocedure unit. The client's heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. With regards to partial thromboplastin time (PTT), when should the nurse plan to remove the femoral sheath? A) 50 seconds or less. B) 75 seconds or less. C) 100 seconds or less. D) 125 seconds or less.
A) 50 seconds or less.
A patient with renal failure is scheduled for a surgical procedure. When would surgery be contraindicated for this patient due to laboratory results? A) A blood urea nitrogen level of 42 mg/dL B) A creatine kinase level of 120 U/L C) A serum creatinine level of 0.9 mg/dL D) A urine creatinine level of 1.2 mg/dL
A) A blood urea nitrogen level of 42 mg/dL
The nurse is assisting with a bronchoscopy at the bedside in a critical care unit. The client experiences a vasovagal response. What should the nurse do next? A) Prepare to administer intravenous fluids. B) Suction the airway. C) Check blood pressure. D) Assess pupils for reactiveness.
C) Check blood pressure.
Nursing assessment findings reveal urinary output < 30 ml/hr, tachycardia, tachypnea, decreased hemoglobin, and acute confusion. The findings are indicative of which nursing diagnosis? A) Acute pain B) Ineffective airway clearance C) Decreased cardiac output D) Urinary retention
C) Decreased cardiac output
The nurse observes bloody drainage on the surgical dressing of the client who has just arrived on the nursing unit. Which intervention should the nurse plan to do next? A) Make the client NPO and order a stat hemoglobin and hematocrit. B) Remove the dressing, assess the wound, and apply a new sterile dressing. C) Outline the drainage with a pen and record the date and time next to the drainage. D) Take the client's vital signs and call the surgeon
C) Outline the drainage with a pen and record the date and time next to the drainage.
A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be? A) Ventricular tachycardia B) Atrial fibrillation C) Third-degree heart block D) Ventricular fibrillation
D) Ventricular fibrillation
Which of the following positions would the nurse expect the client to be positioned on the operating table for renal surgery? A) Trendelenburg position B) Lithotomy position C) Supine position D) Sims position
D) Sims position
A nurse has provided discharge instructions to a client who received an implantable cardioverter defibrillator (ICD). Which statement, made by the client, indicates the need for further teaching? A) "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD." B) "I will document the date and time if my ICD fires." C) "I can play golf with my son in about 2 or 3 weeks." D) "I should tell close friends and family members that I have an ICD."
A) "I need to take a cardiopulmonary resuscitation (CPR) class now that I have an ICD."
The nurse is speaking with a client admitted with a dysrhythmia. The client asks the nurse to explain the "F waves" on the electrocardiogram. What is the nurse's best response? A) "The F waves are flutter waves representing atrial activity." B) "The F waves are flutter waves representing ventricular activity." C) "The F waves are normal parts of the heart conduction system" D) "The F waves are most likely caused by the new medication."
A) "The F waves are flutter waves representing atrial activity."
The nurse would intervene when making which of the following observations in the surgical environment? A) A staff member dressed in street clothes enters the semirestricted zone. B) A staff member is wearing scrub clothes in the semirestricted zone. C) A staff member is wearing a surgical mask and shoe covers in the restricted zone. D) A staff member fails to wear a mask in the semirestricted zone.
A) A staff member dressed in street clothes enters the semirestricted zone.
A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The nurse knows that these are symptoms of what? A) Acute pulmonary edema B) Progressive heart failure C) Pulmonary hypertension D) Cardiogenic shock
A) Acute pulmonary edema
Which aneurysm occurs as a result of infection at arterial suture or graft sites? A) Anastomotic B) False C) Dissecting D) Saccular
A) Anastomotic
Which method to induce hemostasis after sheath removal after percutaneous transluminal coronary angioplasty (PTCA) is mosteffective? A) Application of a vascular closure device such as Angio-Seal or VasoSeal B) Direct manual pressure C) Application of a pneumatic compression device (e.g., FemoStop) D) Application of a sandbag to the area
A) Application of a vascular closure device such as Angio-Seal or VasoSeal
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client? A) Assessing the client's blood pressure and heart rate frequently B) Identifying the client's code level status C) Maintaining the client's intravenous fluids D) Alerting the healthcare provider of the third-degree heart block
A) Assessing the client's blood pressure and heart rate frequently
Which of the following is a characteristic of an arterial ulcer? A) Border regular and well demarcated B) Brawny edema C) Ankle-brachial index (ABI) > 0.90 D) Edema may be severe
A) Border regular and well demarcated
A nurse is caring for a client with a chest tube connected to a dry suction water seal drainage system. The nurse notes 2cm of water and intermittent bubbling in the water seal chamber. Which action will the nurse take? A) Document the findings. B) Add water to the water seal chamber. C) Check for an air leak. D) Notify the health care provider.
A) Document the findings.
A nurse is caring for a client with end-stage cardiomyopathy and the client's spouse asks the nurse to clarify one of the last treatment options available that the health care provider mentioned earlier. What option will the nurse most likely discuss? A) Left ventricular assist device B) Chordoplasty C) Annuloplasty D) Open commissurotomy
A) Left ventricular assist device
On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? A) Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing B) Covering the well-approximated wound edges with a dry dressing C) Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive D) Cleaning the wound with soap and water, then leaving it open to the air
A) Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing
Which of the following factors may contribute to rapid and shallow respirations in a postoperative client? Select all that apply. A) Pain B) Constricting dressings C) Abdominal distention D) Obesity E) Effects of analgesics and anesthesia
A) Pain B) Constricting dressings C) Abdominal distention D) Obesity
The nurse is caring for a client with manifestations of dilated cardiomyopathy. When planning care, which consideration would the nurse make? A) Place bed in a high or semi-high Fowler's position as needed. B) Assist client to bathroom every 2 hours. C) Instruct client to avoid strenuous activity. D) Assess abdominal girth daily.
A) Place bed in a high or semi-high Fowler's position as needed.
A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant? A) The patient reports shortness of breath when walking. B) The patient has jugular vein distention and 3+ pedal edema. C) The patient reports chest pain after eating a large meal. D) The patient's has an enlarged liver and edematous abdomen.
A) The patient reports shortness of breath when walking.
The nurse is educating clients who require surgery for various ailments about the perioperative experience. What education provided by the nurse is most appropriate? A) Three phases of surgery and safety measures for each phase B) Intraoperative techniques used to perform the surgery C) Expected pain levels and narcotic medications used to treat the pain D) Risks and benefits of the surgical procedures
A) Three phases of surgery and safety measures for each phase
Which electrocardiogram (ECG) characteristic is usually seen when a client's serum potassium level is low? A) U wave B) T wave C) P wave D) QT interval
A) U wave
The nurse is caring for a patient with liver disease who had a surgical procedure. When should the nurse alert the physician? A) When the patient's blood ammonia concentration reaches 180 mg/dL B) When a lactate dehydrogenase concentration is 300 units C) When a serum albumin concentration is 5.0 g/dL D) When a serum globulin concentration reaches 2.8 g/dL
A) When the patient's blood ammonia concentration reaches 180 mg/dL
The most common site of aneurysm formation is in the: A) abdominal aorta, just below the renal arteries. B) ascending aorta, around the aortic arch. C) descending aorta, beyond the subclavian arteries. D) aortic arch, around the ascending and descending aorta
A) abdominal aorta, just below the renal arteries.
A client has a medical diagnosis of an advanced first-degree atrioventricular block and is symptomatic. What initial treatment will the nurse be prepared to complete? A) administer an IV bolus of atropine B) prepare the client for a cardioversion C) administer an IV bolus of furosemide D) prepare client for a cardiac catheterization
A) administer an IV bolus of atropine
A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms? A) atrial fibrillation B) atrial flutter C) heart block D) bundle branch block
A) atrial fibrillation
The nurse is assessing a client admitted with acute left-sided infective endocarditis. What is the best diagnostic test to confirm the diagnosis? A) blood cultures B) complete blood count C) urinalysis D) transesophageal echocardiogram
A) blood cultures
A client with CAD thinks diltiazem (Cardizem) has been causing nausea. Diltiazem (Cardizem) is categorized as which type of drug? A) calcium-channel blocker B) beta-adrenergic blocker C) nitrate D) diuretic
A) calcium-channel blocker
A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms? A) electrocardiogram B) electroencephalogram C) echocardiogram D) electrocautery
A) electrocardiogram An electrocardiogram is used to identify normal and abnormal cardiac rhythms.
Statistics show an increase in the prevalence of infective endocarditis among older adults. Which factor places older adults at risk for developing infective endocarditis? A) increased use of prosthetic valve replacements B) greater incidence of a history of repaired congenital heart defects C) increase in IV drug use D) higher rate of tuberculosis
A) increased use of prosthetic valve replacements
The nurse recognizes that the treatment for a non-ST-elevation myocardial infarction (NSTEMI) differs from that for a STEMI, in that a STEMI is more frequently treated with A) percutaneous coronary intervention (PCI). B) IV heparin. C) IV nitroglycerin. D) thrombolytics.
A) percutaneous coronary intervention (PCI).
A client develops a hemorrhage one hour post surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred: A) within the first few hours, and has darkly colored blood that flows quickly. B) during surgery, and has bright red blood that flows freely. C) at a suture site, and the blood appears intermittently in spurts. D) a few hours after surgery, and the bright red blood appears with each heartbeat.
A) within the first few hours, and has darkly colored blood that flows quickly.
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? A) Pituitary B) Adrenal C) Thyroid D) Parathyroid
B) Adrenal Clients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur in the pituitary, thyroid, or parathyroid glands.
A client asks the nurse how an inhalant general anesthetic is expelled by the body. What is the best response by the nurse? A) "The kidneys will eliminate the inhalant with urination." B) "The lungs primarily eliminate the anesthesia." C) "The skin will eliminate the anesthesia through evaporation." D) "The liver will eliminate the inhalant anesthesia."
B) "The lungs primarily eliminate the anesthesia."
The client asks the nurse to explain what is meant by a ventricular bigeminy cardiac rhythm. What is the best response by the nurse? A) "It is when the heart conduction is primarily from the atrioventricular node." B) "The rhythm has a normal beat, then a premature beat pattern." C) "The rhythm is regular but fast." D) "The heart rate is between 150 to 250 bpm."
B) "The rhythm has a normal beat, then a premature beat pattern."
The licensed practical nurse is setting up the room for a client arriving at the emergency department with ventricular arrhythmias. The nurse is most correct to place which of the following in the room for treatment? A) A suction machine B) A defibrillator C) Cardioversion equipment D) An ECG machine
B) A defibrillator
Which intervention should the nurse plan to implement to decrease the client's risk for injury during the intraoperative period? A) Allow the client to verbalize fears. B) Assess the client for allergies. C) Verify the client's preoperative vital signs. D) Keep the family informed of the client's status.
B) Assess the client for allergies.
A client in the hospital informs the nurse he "feels like his heart is racing and can't catch his breath." What does the nurse understand occurs as a result of a tachydysrhythmia? A) It causes a loss of elasticity in the myocardium. B) It reduces ventricular ejection volume. C) It increases afterload. D) It increases preload.
B) It reduces ventricular ejection volume.
The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest? A) Elevating the limb above heart level B) Lowering the limb so that it is dependent C) Massaging the limb after application of cold compresses D) Placing the limb in a plane horizontal to the body
B) Lowering the limb so that it is dependent
A client with atrial fibrillation, who does not respond to conventional treatment measures and who is not a candidate for cardioversion, would have what procedure recommended? A) Angiography B) Maze procedure C) Open heart surgery D) Heart transplantation
B) Maze procedure
A nurse reviews a client's medication history before administering a cholinergic blocking agent. Adverse effects of a cholinergic blocking agent may delay absorption of what medication? A) Amantadine B) Nitroglycerin C) Digoxin D) Diphenhydramine
B) Nitroglycerin
The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? A) Surgical debridement B) Nonselective debridement C) Enzymatic debridement D) Selective debridement
B) Nonselective debridement
An elderly client is preparing to undergo surgery. The nurse participates in preoperative care knowing that which of the following is the underlying principle that guides preoperative assessment, surgical care, and postoperative care for older adults? A) Aging processes reduce the chances that surgery will be successful for these clients. B) Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. C) Neurologic and musculoskeletal complications are the leading cause of postoperative morbidity and mortality for older adults. D) All older people face similar risks when undergoing surgeries.
B) Older adults have less physiologic reserve (or ability to regain physical equilibrium) than younger clients. The underlying principle that guides preoperative assessment, surgical care, and postoperative care is that elderly clients have less physiologic reserve (the ability of an organ to return to normal after a disturbance in its equilibrium) than younger clients. The hazards of surgery for the elderly are proportional to the number and severity of coexisting health problems and the nature and duration of the operative procedure. Respiratory and cardiac complications are the leading causes of postoperative morbidity and mortality in older adults.
A nursing instructor is reviewing the parts of an EKG strip with a group of students. One student asks about the names of all the EKG cardiac complex parts. Which of the following items are considered a part of the cardiac complex on an EKG strip? Choose all that apply. A) QRT wave B) P wave C) S-Q segment D) P-R interval E) T wave
B) P wave D) P-R interval E) T wave
A client comes into the emergency department reporting about chest pain that gets worse when taking deep breaths and lying down. After ruling out a myocardial infarction, a nurse would assess for which diagnosis? A) Rheumatic fever B) Pericarditis C) Mitral valve stenosis D) Cardiomyopathy
B) Pericarditis
The nurse is reviewing the lab work of a client diagnosed with infective endocarditis. Which diagnostic study confirms the diagnosis? A) Complete blood count B) Positive blood culture C) Serum cardiac antigens D) Immunosuppressant assay
B) Positive blood culture
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? A) Decrease the heparin infusion rate. B) Prepare to administer protamine sulfate. C) Monitor the partial thromboplastin time (PTT). D) Start an I.V. infusion of dextrose 5% in water (D5W).
B) Prepare to administer protamine sulfate.
Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? A) P wave B) QRS complex C) PR interval D) QT interval
B) QRS complex
The nursing instructor is teaching a class on thrombophlebitis. What should the nurse tell the students about the inflammatory response in thrombophlebitis? A) The inflammatory response is caused by the irritation of the clot. B) The inflammatory response is caused by accumulated waste products in the blocked vessel. C) The inflammatory response is caused by an excess for fibrin in the blocked vessel. D) The inflammatory response is caused by the irritation of blood trying to flow through the vessel.
B) The inflammatory response is caused by accumulated waste products in the blocked vessel.
The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer? A) Digoxin (Lanoxin) B) Valsartan (Diovan) C) Metolazone (Zaroxolyn) D) Carvedilol (Coreg)
B) Valsartan (Diovan)
Monitored anesthesia care differs from moderate sedation in that monitored anesthesia care: A) is used as an adjunct to spinal anesthesia. B) may result in the administration of general anesthesia. C) is a type of regional anesthesia. D) requires the introduction of an anesthetic agent into the epidural space.
B) may result in the administration of general anesthesia.
The nurse is discussing risk factors for developing CAD with a patient in the clinic. Which results would indicate that the patient is not at significant risk for the development of CAD? A) Cholesterol, 280 mg/dL B) Low density lipoprotein (LDL), 160 mg/dL C) High-density lipoprotein (HDL), 80 mg/dL D) A ratio of LDL to HDL, 4.5 to 1.0
C) High-density lipoprotein (HDL), 80 mg/dL
A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? A) Surgical debridement B) Enzymatic debridement C) Hyperbaric oxygen D) Vacuum-assisted closure device
C) Hyperbaric oxygen
The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of: A) Laryngospasm B) Hyperventilation C) Hypoxemia and hypercapnia. D) Pulmonary edema and embolism.
C) Hypoxemia and hypercapnia.
Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? A) Decreased central venous pressure B) Increase in the cardiac index C) Increased pulmonary artery diastolic pressure D) Decreased mean pulmonary artery pressure
C) Increased pulmonary artery diastolic pressure
On auscultation, the nurse suspects a diagnosis of mitral valve stenosis when which of the following is heard? A) Mitral valve click B) High-pitched blowing sound at the apex C) Low-pitched, rumbling diastolic murmur at the apex of the heart D) Diastolic murmur at the left sternal border of the heart
C) Low-pitched, rumbling diastolic murmur at the apex of the heart
Which technique is used to surgically revascularize the myocardium? A) Balloon bypass B) Peripheral bypass C) Minimally invasive direct coronary bypass D) Gastric bypass
C) Minimally invasive direct coronary bypass
Severe chest pain is reported by a client during an acute myocardial infarction. Which of the following is the most appropriate drug for the nurse to administer? A) Isosorbide mononitrate (Isordil) B) Meperidine hydrochloride (Demerol) C) Morphine sulfate (Morphine) D) Nitroglycerin transdermal patch
C) Morphine sulfate (Morphine)
A significant mortality rate exists for patients with alcoholism who experience delirium tremens postoperatively. When caring for the patient with alcoholism, the nurse should assess for symptoms of alcoholic withdrawal: A) Within the first 12 hours. B) About 24 hours postoperatively. C) On the second or third day. D) 4 days after surgery.
C) On the second or third day.
The nurse recognizes that written informed consent is required for A)Nasogastric tube. B) Urinary catheter. C) Peripherally-inserted central catheter. D) Oral airway.
C) Peripherally-inserted central catheter.
The nurse is attempting to determine the ventricular rate and rhythm of a patient's telemetry strip. What should the nurse examine to determine this part of the analysis? A) PP interval B) QT interval C) RR interval D) TP interval
C) RR interval
Which symptom occurs in the client diagnosed with mitral regurgitation when pulmonary congestion occurs? A) A loud, blowing murmur B) Hypertension C) Shortness of breath D) Tachycardia
C) Shortness of breath
Which of the following clinical manifestations increase the risk for evisceration in the postoperative client? A) Hypovolemia B) Edema C) Valsalva maneuver D) Hypoxia
C) Valsalva maneuver
When the surgeon performs an appendectomy, the nurse recognizes that the surgical category will be identified as A) clean. B) contaminated. C) clean contaminated. D) dirty.
C) clean contaminated.
A nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, what action should the nurse perform? A) administer oxygen B) have the client take deep breaths and cough C) place the client in high Fowler's position D) perform chest physiotherapy
C) place the client in high Fowler's position
The nurse is educating the client about a transvenous pacemaker. What is the best statement to explain why the client will have a transvenous pacemaker? A) "A transvenous pacemaker is used in place of a transarterial pacemaker." B) "A transvenous pacemaker is a permanent pacemaker that is asynchronous." C) "A transvenous pacemaker is used for a ventricular tachydysrhythmias." D) "A transvenous pacemaker is used to manage transient bradydysrhythmias like those that occur during acute MIs."
D) "A transvenous pacemaker is used to manage transient bradydysrhythmias like those that occur during acute MIs."
An asymptomatic client questions the nurse about the diagnosis of mitral regurgitation and inquires about continuing an exercise routine. Which is the most appropriate response by the nurse? A) "Continue the exercise routine but take ample rest after exercising." B) "Avoid any type of exercise." C) "Avoid strenuous cardiovascular exercise." D) "Continue the exercise routine unless symptoms such as shortness of breath or fatigue develop."
D) "Continue the exercise routine unless symptoms such as shortness of breath or fatigue develop."
The nurse is assessing a patient and feels a pulse with quick, sharp strokes that suddenly collapse. The nurse knows that this type of pulse is diagnostic for which disorder? A) Mitral insufficiency B) Tricuspid insufficiency C) Tricuspid stenosis D) Aortic regurgitation
D) Aortic regurgitation
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? A) Doppler ultrasound B) Magnetic resonance angiography (MRA) C) Angiography D) Computed tomography angiography (CTA)
D) Computed tomography angiography (CTA)
Which of the following actions by the nurse is appropriate? A) Touching the edges of an open sterile package B) Touching sterile items with a clean-gloved hand C) Reaching over the sterile field D) Discarding an object that comes in contact with the 1-inch border
D) Discarding an object that comes in contact with the 1-inch border
The nurse is assisting with positioning the patient on the operating table. The nurse understands that the most commonly used position is which of the following? A) Lithotomy B) Sims C) Trendelenburg D) Dorsal recumbent
D) Dorsal recumbent
The nurse is assigned a client scheduled for an outpatient colonoscopy in an ambulatory care setting. During which phase of perioperative care would the nurse document the admission vital signs in the recovery room? A) During the preoperative phase B) During the intraoperative phase C) During the transfer phase D) During the postoperative phase
D) During the postoperative phase
A nurse is caring for a client with atrial fibrillation. What procedure would the nurse educate the patient about for termination of the dysrhythmia? A) Defibrillation B) Mace procedure C) Pacemaker implantation D) Elective cardioversion
D) Elective cardioversion
The nurse assesses a client returning from the post anesthesia unit with a new onset of sinus tachycardia with a heart rate of 138 beats per minute and a blood pressure of 128/80mmHg after elevating the head of the bed. What intervention does the nurse consider? A) Assessing blood glucose level B) Decreasing intravenous fluids C) Removing anti-embolism stockings D) Evaluating laboratory values
D) Evaluating laboratory values
The client has been prescribed procainamide for a dysrhythmia. Which medication side effect will the nurse teach the client to watch for? A) Hypertension B) Tachycardia C) Change in mental status D) Feeling tired
D) Feeling tired
A patient with a history of valvular disease has just arrived in the PACU after a percutaneous balloon valvuloplasty. Which intervention should the recovery nurse implement? A) Assess the patient's chest tube output. B) Monitor the patient's chest drainage. C) Evaluate the patient's endotracheal lip line. D) Keep the patient's affected leg straight.
D) Keep the patient's affected leg straight.
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? A) Varicose veins are more common in men than in women. B) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation. C) Sclerotherapy is used to cure varicose veins. D) The severity of discomfort isn't related to the size of varicosities.
D) The severity of discomfort isn't related to the size of varicosities.
When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block? A) First degree B) Second degree, type I C) Second degree, type II D) Third degree
D) Third degree
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: A) pallor and coolness of the left foot. B) a decrease in the left pedal pulse. C) loss of hair on the lower portion of the left leg. D) left calf circumference 1" (2.5 cm) larger than the right.
D) left calf circumference 1" (2.5 cm) larger than the right.
