AH2 Adaptive Quizzing

A nurse expects a client with right-sided heart failure will exhibit which of these signs or symptoms? a. Oliguria b. Pallor c. Cool extremities d. Distended neck veins

Answer: d - Distended neck veins a. Rationale: Veins are distended because of the systemic venous pressure and congestion that are associated with right-sided heart failure. Oliguria, pallor, and cool extremities are key features of left-sided heart failure.

Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from ventricular fibrillation? a. Treating pain b. Assessing respirations c. Initiating defibrillation d. Monitoring blood pressure

Answer C - Initiating defibrillation a. Rationale: The priority nursing action for a client who is admitted to the emergency department during cardiac arrest caused by ventricular fibrillation is initiating defibrillation. Treating pain, assessing respirations, and monitoring blood pressure will not occur until this action has been initiated.

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? a. Check for a pulse b. Start cardiac compressions c. Prepare to defibrillate the client d. Administer oxygen via an ambu bag

Answer: A - Check for a pulse a. Rationale: The treatment of ventricular tachycardia depends on the presence of a pulse. Therefore checking for a pulse is the first priority for the nurse. The nurse must rely on client assessment, not solely on the monitor. Cardiac compressions would not be initiated if there was a pulse. Administering oxygen via an ambu bag would only occur if the client was not breathing. The client is not automatically defibrillated. Cardioversion is recommended for slower ventricular tachycardia.

A client is found unconscious and unresponsive. What should the nurse do first? a. Initiate a code b. Check for a radial pulse c. Compress the lower sternum d. Give four full lung inflations

Answer: A - Initiate a code a. Rationale: Additional help and a cardiac defibrillator must be obtained immediately. The carotid, not the radial pulse is used. Compressing the mid-lower sternum is done after the nurse summons help. The ratio is two lung inflations to 30 chest compressions.

The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? a. Dependent edema in the evening b. Chest pain that decreases with rest c. Palpitations in the chest when resting d. Frequent coughing with yellow sputum

Answer: A - Dependent edema in the evening a. Rationale: Decreased cardiac output causes fluid retention, which results in dependent edema; this is often noticed in the evening after the client has been standing or sitting for prolonged periods. Chest pain is indicative of cardiac ischemia. Palpitations are indicative of cardiac dysrhythmias. Coughing with yellow sputum is indicative of an infectious process in the respiratory tract; pink, frothy sputum is associated with pulmonary edema that can result from heart failure.

1. Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include? a. Encouraging daily physical exercise b. Performing yearly physical examinations c. Providing hypertension screening programs d. Teaching a person with diabetes how to prevent complications

Answer: A - Encouraging daily physical exercise a. Rationale: Primary prevention activities are directed toward promoting a healthful lifestyle and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimal level of functioning.

1. A nurse has administered sublingual nitroglycerin. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin? a. Relief of anginal pain b. Improved cardiac output c. Decreased blood pressure d. Dilation of superficial blood vessels

Answer: A - relief of angina pain a. Rationale: Cardiac nitrates relax smooth muscles of the coronary arteries; they dilate and deliver more blood to heart muscle, relieving ischemic pain. Although cardiac output may improve because of improved oxygenation of the myocardium, improved cardiac output is not a basis for evaluating the effectiveness of sublingual nitroglycerin. Although dilation of blood vessels and a subsequent drop in blood pressure is a reason why IV nitroglycerin may be administered, decreased blood pressure is not the basis for evaluating the effectiveness of sublingual nitroglycerin, which is indicated for pain relief. Although superficial vessels dilate, lowering the blood pressure and creating a flushed appearance, dilation of superficial blood vessels is not the basis for evaluating the drug's effectiveness.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply. a. The RR intervals are relatively consistent. b. One P wave precedes each QRS complex. c. The ST segment is higher than the PR interval. d. Four to eight complexes occur in a 6-second strip. e. The QRS complex ranges from 0.12 to 0.2 seconds.

Answer: A, B (The RR intervals are relatively consistent. & One P wave precedes each QRS complex.) a. Rationale: The consistency of RR intervals indicates a regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. Elevation of ST segment is a sign of cardiac ischemia and unrelated to the rhythm. The number of complexes in a 6-second strip is multiplied by 10 to approximate the heart rate; normal sinus is 60 to 100 beats/min. Fewer than six complexes per 6 seconds equals a heart rate less than 60 beats/min. The QRS duration should be less than 0.12 seconds; the PR interval should be 0.12 to 0.2 second.

A client is diagnosed with heart failure and is admitted for medical management. Which statement made the client may indicate worsening heart failure? a. "I am unable to run a mile now." b. "I wake up at night short of breath." c. "My wife says I snore very loudly." "My shoes seem larger lately

Answer: B - "I wake up at night short of breath." a. Rationale: Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile, snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.

When an older client with heart failure is transferred from the emergency department to the medical service, what should the nurse on the unit do first? a. Interview the client for a health history. b. Assess the client's heart and lung sounds. c. Monitor the client's pulse and temperature. Obtain the client's blood specimen for electrolytes

Answer: B - Assess the client's heart and lung sounds. a. Rationale: With heart failure, the left ventricle is not functioning effectively, which is evidenced by an increased heart rate and crackles associated with pulmonary edema. The health history interview is done after vital signs and breath sounds are obtained and the client is stabilized. Although an infection would complicate heart failure, there are no signs that indicate this client has an infection. Obtaining the client's blood specimen for electrolytes is inappropriate for immediate monitoring; it should be done after vital signs and clinical assessments have been completed.

The nurse notes asystole on the cardiac monitor. Which action should the nurse take immediately? a. Defibrillate b. Assess the client's pulse c. Initiate advanced cardiac life support d. Check another lead to confirm asystole

Answer: B - Assess the client's pulse Rationale: Pulse should be immediately assessed because a lead or electrode coming off may mimic this dysrhythmia. Asystole is characterized by complete cessation of electrical activity. A flat baseline is seen, without any evidence of P, QRS, or T waveforms. A pulse is absent, and there is no cardiac output; cardiac arrest has occurred. Once confirmed, Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) protocols are initiated for asystole. Defibrillation is part of the ACLS protocol for ventricular fibrillation

1. The nurse is caring for a client with an abdominal aortic aneurysm before surgery. Which nursing care is essential preoperatively? a. Administering supplemental oxygen b. Maintaining a reduced blood pressure c. Keeping the client in a supine position d. Monitoring the peripheral vascular status

Answer: B - Maintaining a reduced blood pressure a. Rationale: Maintaining a low blood pressure reduces the risk of aortic rupture. Administering supplemental oxygen may or may not be necessary. Keeping the client in a supine position may or may not be necessary. Monitoring the peripheral vascular status will help identify whether an aneurysm has ruptured, but it will not prevent rupture.

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? a. The signs and symptoms of pericarditis b. The signs and symptoms of heart failure c. That cardiac surgery will have to be done eventually for the other valves d. That cardiac surgery will have to be done every six months to replace the valve

Answer: B - The signs and symptoms of heart failure a. Rationale: The teaching plan for this client should focus on the possibility of heart failure. Clients with a failed valve are prone to heart failure; report any signs of dyspnea, syncope, dizziness, edema, and palpitations. Infective endocarditis, not pericarditis, may occur. Endocarditis is an infection of the endothelial surface of the heart and valves. Pericarditis is an inflammation of the pericardium, the membranous sac enveloping the heart. There is no evidence of pathology of other valves. There is no schedule that valves will be replaced every six months.

The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? a. Stridor b. Crackles c. Wheezes d. Friction rubs

Answer: B - crackles a. Rationale: Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration. Stridor is not heard in heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with heart failure, but with asthma. Friction rubs are not heard with heart failure, but with pleurisy.

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply. a. Hypertension b. Pulsus paradoxus c. Muffled heart sounds d. Jugular vein distention e. Increased urine output

Answer: B, C, D Pulsus paradoxus, muffled heart sounds, jugular vein distention Rationale: Pulsus paradoxus is present in cardiac tamponade. Blood in the pericardial sac compresses the heart so the ventricles cannot fill; this leads to a rapid, thready pulse and muffled heart sounds. The increased venous pressure associated with cardiac tamponade causes jugular vein distention. Tamponade causes hypotension, not hypertension, and a narrowed pulse pressure. As the heart becomes more inefficient, there is a decrease in kidney perfusion and therefore a decrease in urine output

A client has thin, dark-red vertical lines about 1 to 3 mm long in the nails. Which diseases are associated with this physiologic alteration in the client? Select all that apply. a. Psoriasis b. Trichinosis c. Cardiac failure d. Diabetes mellitus e. Bacterial endocarditis

Answer: B, E - Trichinosis, bacterial endocarditis a. Rationale: Thin, dark-red vertical lines about 1 to 3 mm long in the nails are associated with trichinosis (parasitic disease) and bacterial endocarditis (infection of the innermost layer of the heart and heart valves). Psoriasis, diabetes mellitus, and cardiac failure are associated with yellow-brown discoloration of the nails.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? Select all that apply. Select all that apply a. Weight loss b. Unusual fatigue c. Dependent edema d. Nocturnal dyspnea e. Increased urinary output

Answer: B,C,D - Unusual fatigue, dependent edema, nocturnal dyspnea a. Rationale: Unusual fatigue is attributed to inadequate perfusion of body tissues because of decreased cardiac output in response to cardiac ischemia; women more commonly report unusual fatigue than men. Dependent edema occurs with right ventricular failure because of hypervolemia. Dyspnea at night, which usually requires the assumption of the orthopneic position, is a sign of left ventricular failure. Orthopnea, a compensatory mechanism, limits venous return, which decreases pulmonary congestion and promotes ventilation, easing the dyspnea. Weight gain, not loss, occurs because of fluid retention. Urinary output decreases, not increases, with heart failure because the sympathetic

A client is newly diagnosed with hypertension. The primary healthcare provider prescribes an antihypertensive medication to be taken once in the morning and a 2 gram sodium diet. What is most important for the nurse to teach the client about lowering the blood pressure? a. "Avoid adding salt to cooked foods." b. "Use less salt when preparing foods." c. "Take your medicine exactly as prescribed." d. "Measure your blood pressure every morning."

Answer: C - "Take your medicine exactly as prescribed." a. Rationale: The most effective way to lower blood pressure is to take the prescribed medication daily. It is not necessary to take daily blood pressure measurements unless specifically prescribed to do so by the primary healthcare provider. Restricting salt in the diet will help limit fluid retention and thus reduce the blood pressure, but it is not as effective as an antihypertensive. Salt should not be added during food preparation. The natural sodium content of foods should be calculated into a 2 gram sodium diet. Although salt should not be added, this alone will not help lower the blood pressure. The natural sodium content of foods should be calculated into a 2 gram sodium diet.

How can the nurse best describe heart failure to a client? a. A cardiac condition caused by inadequate circulating blood volume b. An acute state in which the pulmonary circulation pressure decreases c. An inability of the heart to pump blood in proportion to metabolic needs d. A chronic state in which the systolic blood pressure drops below 90 mm Hg

Answer: C - An inability of the heart to pump blood in proportion to metabolic needs a. Rationale: As the heart fails, cardiac output decreases; eventually the decrease will reach a level that prevents tissues from receiving adequate oxygen and nutrients. Heart failure is related to an increased, not decreased, circulating blood volume. The condition may be acute or chronic; the pulmonary pressure increases and capillary fluid is forced into the alveoli. The blood pressure usually does not drop.

A nurse is assessing a client with the diagnosis of primary hypertension. Which clinical finding does the nurse identify as an indicator of primary hypertension? a. Mild but persistent depression b. Transient temporary memory loss c. Occipital headache in the morning d. Cardiac palpitation during periods of stress

Answer: C - Occipital headache in the morning a. Rationale: Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect; it is not specific to hypertension.

A client with a history of heart failure on daily weights has a 2-pound weight gain and pitting edema in lower extremities bilaterally. Which action should the nurse take next? a. Check the record to ascertain the code status. b. Encourage increased intake of favorite drink. c. Perform a head-to-toe assessment, including vital signs. d. Continue to monitor daily weights and edema and to document findings

Answer: C - Perform a head-to-toe assessment, including vital signs. a. Rationale: Performing a head-to-toe assessment, including vital signs, would indicate symptoms, such as jugular vein distention with right-sided heart failure or pulmonary issues (crackles) associated with left-sided heart failure. Checking the record for code status is not a priority and should have been established and known on an elderly client. Increasing intake will make the problem of fluid retention worse. Continuing to monitor daily weights without an assessment may miss worsening symptoms.

A client with heart disease has been reading on the Internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding? a. "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." b. "Blood enters the heart from the inferior vena cava; it the flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." c. "Blood enters the heart from the aorta flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricle, and finally exits through the superior vena cava." d. "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta."

Answer: D - "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta." a. Rationale: "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricle, and exits out the aorta" correctly describes the flow of blood through the heart after birth. The ductus arteriosis is a fetal structure that is not present in the adult heart. Blood enters the right side of the heart via the inferior and superior vena cava; blood flows from the right atrium, to the right ventricle, to the lungs, and then to the left atrium. Blood exits, not enters, the heart from the aorta.

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? a. "My ankles are swollen." b. "I am tired at the end of the day." c. "When I eat a large meal, I feel bloated." d. "I have trouble breathing when I walk rapidly."

Answer: D - "I have trouble breathing when I walk rapidly." a. Rationale: Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.

A nurse is determining whether or not a client's atrial rhythm is regular when reviewing the ECG rhythm strip. Which consistency of spacing will the nurse use to determine regularity? a. P wave and the QRS complex b. QRS complexes c. QRS widths P waves

Answer: D - P waves a. Rationale: The P wave represents atrial contraction. Regularity is assessed by using electronic or physical calipers, or a piece of paper and pencil. To determine atrial regularity, identify the P wave and place one caliper point on its peak. Locate the next P wave and place the second caliper point on its peak. The second point is left stationary, and the calipers are flipped over. If the first caliper point lands exactly on the next P wave, the atrial rhythm is perfectly regular. If the point lands one small box or less away form the next P wave, the rhythm is essentially regular. If the point lands more than one small box away, the rhythm is consider irregular. The same process can be performed with a simple piece of paper. Place the paper parallel and below the rhythm line, make a hatch mark below the first and second P waves, and then move the paper over to determine if the distance between the second and third P waves is equal to the first and second. When an atrial rhythm is perfectly regular, each P wave is an equal distance from the next P wave. This process is also used to assess ventricular regularity, except that the caliper points are placed on the peak of two consecutive R waves. QRS intervals can lengthen in response to new bundle branch blocks or ventricular dysrhythmias.

A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question? a. Reduces edema b. Increases cardiac conduction c. Increases rate of ventricular contractions d. Slows and strengthens cardiac contractions

Answer: D - Slows and strengthens cardiac contractions a. Rationale: Digoxin increases the strength of myocardial contractions (positive inotropic effect) and, by altering the electrophysiological properties of the heart, slows the heart rate (negative chronotropic effect). Digoxin increases the strength of the contractions but decreases the heart rate. Although a reduction in edema may result from the increased blood supply to the kidneys, it is not the reason for administering digoxin. Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart.

1. The nurse at a health fair has taken a client's blood pressure twice, 10 minutes apart, in the same arm while the client is seated. The nurse records the two blood pressures of 172/104 mm Hg and 164/98 mm Hg. What is the appropriate nursing action in response to these readings? a. Refer the client to a nutritionist after providing health teaching about a low-sodium diet. b. Place the client in a recumbent position and call the paramedics for transport to the hospital. c. Talk with the client to assess whether there is stress in the client's life and refer to a counseling service. d. Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible.

Answer: D - Take the client's blood pressure in the other arm and then schedule a healthcare practitioner's appointment for as soon as possible. a. Rationale: According to the US Department of Health and Human Services, both of these readings indicate hypertension and thus require further evaluation by a healthcare provider; having a baseline for both arms can assist the healthcare provider with the medical diagnosis. Teaching about a low-sodium diet is an inadequate intervention. An appointment with a healthcare provider, not a nutritionist, should be scheduled as soon as possible. There is insufficient data to support this emergency intervention (calling the paramedics). The client's elevated blood pressure needs to be evaluated by a healthcare provider then medical therapy implemented. Although emotional stress can precipitate hypertension, physical causes should be ruled out first.

While assessing the skin of a client, the nurse notices edema at the dorsum of the foot and ankle. Which pre-disposing condition does the nurse anticipate in the client? a. Neurotrauma b. Hypothyroidism c. Hyperthyroidism d. Congestive heart failure

Answer: D - congestive heart failure a. Rationale: Edema at the dorsum of the foot and ankle may be due to congestive heart failure; therefore congestive heart failure is the pre-disposing condition. Neurotrauma is the condition in which there is increased temperature caused by increased blood flow to the skin. Hypothyroidism is caused due to an endocrine imbalance. Hyperthyroidism is the condition caused by an increase in moisture content.

The nurse is providing information about blood pressure to an unlicensed health care worker and recalls that the factor that has the greatest influence on diastolic blood pressure is what? a. Renal function b. Cardiac output c. Oxygen saturation d. Peripheral vascular resistance

Answer: D - peripheral vascular resistance a. Rationale: Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.

1. A nurse observes the following dysrhythmia on a client's cardiac monitor. Which rhythm does the nurse identify? a. Atrial flutter b. Atrial fibrillation c. Ventricular fibrillation d. Ventricular tachycardia

Answer: c - ventricular fibrillation a. Rationale: Ventricular fibrillation reflects a rapid, feeble twitching/quivering of the ventricles; it has irregular sawtooth configuration with unidentifiable PR intervals and QRS complexes. Atrial flutter is characterized by an atrial rate of 200-350 beats/min and a ventricular rate of approximately 150 beats/min; flutter to ventricular responses usually are 2:1, 3:1, or 4:1. Atrial fibrillation is characterized by an atrial rate of 350-600 beats/min and variable ventricular rate; the rhythm is grossly irregular. Ventricular tachycardia has a rate of 140 to 200 or even 250 beats/min; the rhythm is usually regular but may vary. P waves are unidentifiable. PR intervals are unmeasurable. QRS complexes are wide and bizarre.

A client with left ventricular heart failure is taking digoxin 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply. a. Diuresis b. Tachycardia c. Decreased edema d. Decreased pulse rate e. Reduced heart murmur f. Jugular vein distention

Answers: A, C, D - diuresis, decreased edema, decreased pulse rate a. Rationale: Digoxin increases kidney perfusion, which results in urine formation and diuresis. The urine output increases because of improved cardiac output and kidney perfusion, resulting in a reduction in edema. Because of digoxin's inotropic and chronotropic effects, the heart rate will decrease. Digoxin increases the force of contractions (inotropic effect) and decrease the heart rate (chronotropic effect). Digoxin does not affect a heart murmur. Jugular vein distention is a specific sign of right ventricular heart failure; it is treated with diuretics to reduce the intravascular volume and venous pressure.