Cardio, Heme, Lymph
A client with heart failure has anxiety. Which effect of anxiety makes it particularly important for the nurse to reduce the anxiety of this client? 1 Increases the cardiac workload 2 Interferes with usual respirations 3 Produces an elevation in temperature 4 Decreases the amount of oxygen used
Correct Ans: 1 Irritability and restlessness associated with anxiety increase the metabolic rate, heart rate, and blood pressure; these complicate heart failure. Anxiety does not directly interfere with respirations; an increase in cardiac workload will increase respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen used and leads to an increased respiratory rate.
A client's monitor shows a PQRST wave for each beat and indicates a rate of 120 beats/minute. The rhythm is regular. What does the nurse conclude that the client is experiencing? 1 Atrial fibrillation 2 Sinus tachycardia 3 Ventricular fibrillation 4 First-degree atrioventricular block
Correct Ans: 2 The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate greater than 100 beats per minute indicates tachycardia. Atrial fibrillation causes an irregular rhythm, and P waves are not identifiable. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.
The nurse is planning to teach a client with heart failure about the signs and symptoms of cardiac decompensation. What clinical manifestations should the nurse include? Select all that apply. 1 Weight loss 2 Extreme fatigue 3 Coughing at night 4 Excessive urination 5 Difficulty breathing
Correct Ans: 2, 3, 5 Fatigue is caused by a lack of adequate oxygenation of body cells caused by a decreased cardiac output. As the cardiac output decreases, pulmonary congestion increases, resulting in pulmonary edema; coughing, especially when lying down, and blood-tinged sputum occur. Auscultation reveals crackles and rhonchi. Dyspnea is associated with pulmonary edema that occurs as cardiac output decreases and pulmonary congestion increases. Weight gain, not loss, occurs as fluid is retained by the kidneys. Fluid retention, not diuresis, occurs because of decreased circulation to the kidneys, resulting from decreased cardiac output.
A client had a pneumonectomy. For which postoperative complication specific to this type of surgery should the nurse assess this client? 1 Brain attack 2 Renal failure 3 Internal bleeding 4 Cardiac overload
I put 3 Ans: 4 Cardiac overload can be caused by the loss of the large vascular lung or a mediastinal shift. A brain attack is not unique to a pneumonectomy. Renal failure is not unique to a pneumonectomy. Internal bleeding is not unique to a pneumonectomy.
While performing auscultation on a client's chest using the bell of the stethoscope, a nurse hears these sounds. How does the nurse document these sounds? (Could not attach sound) 1 Cardiac murmurs 2 First heart sound 3 Second heart sound 4 Fourth heart sound
The fourth heart sound (S4) is low-pitched sound, similar to a gallop; it is heard in late diastole. This is an extra heart sound that can be heard with the bell of the stethoscope. Cardiac murmurs are turbulent sounds that occur between normal heart sounds. The first heart sound (S1) is a soft, low-pitched sound heard at the lower left sternal border or the apex of the heart. The second heart sound (S2) is a short, high-pitched sound heard at the base of the heart at the end of ventricular systole. It is caused by the closure of the aortic and pulmonic valves.
A client had surgery on the shoulder, and the nurse is to obtain a brachial pulse. Use the illustration to indicate where the nurse should palpate to best obtain the brachial pulse rate. (Unable to attach image)
Correct One of the several pulse points in the body is the brachial artery; it is the main artery of the upper arm and it bifurcates into the radial and ulnar arteries. Option a is not a major artery of the arm; it is not a pulse point. Option c is the radial artery, which is where the radial pulse is palpated. Option d is the ulnar artery, which is where the ulnar pulse is palpated.
The nurse is analyzing the client's rhythm when the nurse notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. How will the nurse interpret this finding? 1 Multifocal 2 Unifocal 3 Bigeminal 4 Couplet
I put 1 Ans: 2 A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical in shape and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal) and every third beat (trigeminal). Two consecutive PVCs are called a couplet.
The nurse is caring for a client who has an occlusion of the left femoral artery and is scheduled for an arteriogram. Which clinical finding is most significant when assessing the left extremity before the arteriogram? 1 Mottling of the leg 2 Coolness of the foot 3 Absence of the pedal pulse 4 Thickening of the toenails on the foot
I put 1 Ans: 3 Absence of the left pedal pulse indicates inadequate circulatory status of the left lower extremity. Mottling of the left leg may indicate impaired circulation, but observation of both extremities for comparison is necessary. Coolness of the left foot is a less significant indication of arterial occlusive disease than the absence of a pulse. Thickening of the toenails on the left foot is not as significant as the pulse; this can occur because of inadequate circulation, aging, or fungal infection.
A client who is diagnosed as having a myocardial infarction is admitted to the coronary care unit with prescriptions for bed rest and medication for chest pain. Within an hour after admission, the nurse finds the client walking around the unit. What is the nurse's best initial response? 1 "Tell me what you are doing out of bed." 2 "It must be frustrating to be confined in bed." 3 "You need to rest. You should get back into bed." 4 "Please get back into bed immediately. The primary healthcare provider wants you to rest."
I put 4 Ans: 3 The response "You need to rest. You should get back into bed" addresses the client's behavior and explains the rationale for bed rest. "Tell me what you are doing out of bed" is a demeaning response. The response "It must be frustrating to be confined in bed" identifies feelings but does nothing to reduce the oxygen demands on the heart, which is a priority at this time. The response "Please get back into bed immediately. The primary healthcare provider wants you to rest" is an authoritarian response, which may precipitate negative feelings in the client.
A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1 Diuresis, irritability, and fever 2 Lethargy, cold skin, and hypertension 3 Thirst, cool skin, and orthostatic hypotension 4 Bounding pulse, restlessness, and slurred speech
I put 4 Ans: 3 With hypovolemic shock, extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.
A nurse is a preceptor for a new graduate nurse. The new graduate is providing care for a client who requests pain medication. The new graduate discovers that the prescribed dose is higher than the safe range listed in the hospital formulary and informs the preceptor of this discovery. The preceptor instructs the new graduate to go ahead and give the prescribed dose. Which action is best for the new graduate to take? 1 Contact the primary healthcare provider to discuss the dose. 2 Contact a hospital pharmacist to verify the dose prescribed. 3 Give the medication as prescribed to decrease the client's pain. 4 Check the dose with another nurse on the unit to see if it is correct.
Correct Ans: 1 The new nurse should discuss the dose with the primary healthcare provider who prescribed the medication. Although talking to the pharmacist may elicit additional information, this is not the best action since the new nurse will have to notify the prescribing primary healthcare provider. Giving the medication as prescribed may place the client at risk. Although checking the dose with another nurse may elicit additional information, this is not the best course of action.
A client is admitted to the hospital with reports of frequent loose, watery stools, anorexia, malaise, and weight loss during the past week. Laboratory findings indicate leukocytosis and an elevated sedimentation rate. Which condition should the nurse conclude is the probable cause of the client's presenting adaptations? 1 Long-term use of an irritant-type laxative 2 Emotional response resulting in physical symptoms 3 Inadequate dietary practices resulting in altered bowel function 4 Systemic responses of the body to a localized inflammatory process
Correct Ans: 4 With an inflammatory response, the body increases its production of white blood cells (WBCs) and fibrinogen, which increases the WBC count and blood sedimentation rate, respectively. Long-term use of an irritant-type laxative will not affect the white blood cell count or the sedimentation rate. Although emotions can cause physical responses, they will not affect the white blood cell count or the sedimentation rate. Inadequate dietary practices can contribute to malnutrition and a low white blood cell count; however, in this client's situation, the WBCs are elevated (leukocytosis).
A nurse is preparing medications. Which client's health problem motivates the nurse to question a prescription for a beta blocker? 1 Coronary artery disease 2 Essential hypertension 3 Acute heart failure 4 Sinus tachycardia
I put 4 Ans: 3 Beta blockers reduce cardiac output and must be started slowly, so they are contraindicated for clients with acute heart failure. Beta blockers are used to treat coronary artery disease because they decrease myocardial oxygen demand by reducing peripheral resistance and cardiac contractility. Beta blockers are used to treat essential hypertension because they cause vasodilation and decrease cardiac contractility. Beta blockers lower heart rate.
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client? 1 5% Dextrose and lactated Ringer solution 2 0.9% normal saline solution 3 Total parenteral nutrition 4 Whole blood products
I put 1 Ans: 4 The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive. Therefore the most appropriate parenteral fluid is whole blood.
The day after surgery a client is encouraged to ambulate. The client angrily asks the nurse, "Why am I being made to walk so soon after surgery?" How should the nurse explain the primary purpose of early ambulation? 1 To promote healing of the incision 2 To decrease the incidence of urinary tract infections 3 To use energy to help the client sleep better at night 4 To keep blood from pooling in the legs to prevent clots
I put 1 Ans: 4 The muscular action during ambulation facilitates the return of venous blood to the heart; this reduces venous stasis and minimizes the risk of postoperative thrombophlebitis. Protein and vitamin C promote wound healing. Walking is not related to the prevention of urinary tract infections. Although activity during the day may promote sleeping at night, it is not the reason for ambulating after surgery.
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply. 1 Dependent rubor 2 Warm extremities 3 Ulcers on the toes 4 Thick, hardened skin 5 Delayed capillary refill
I put 1 & 5 Ans: 1, 3, 5 Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill longer than three seconds. Warm extremities and thick, hardened skin occur in the presence of venous disease.
A child in sickle cell crisis is admitted to the pediatric unit. Which actions will the nurse take? Select all that apply. 1 Place on strict isolation 2 Administer hydroxyurea 3 Administer acetylsalicylic acid 4 Apply oxygen via nasal cannula 5 Offer age-appropriate activities 6 Administer intravenous (IV) hydration
I put 4, 5, 6 Ans: 2, 4, 5, 6 Hydroxyurea can reduce the number of sickling and pain episodes by stimulating fetal hemoglobin production. Providing oxygen via nasal cannula provides additional oxygen, which is necessary because of decreased hemoglobin, which carries oxygen. Age-appropriate activities can help alleviate boredom as the child begins to feel better. Providing intravenous hydration until the child is able to tolerate adequate by mouth fluids reduces sickle cell clotting. Strict isolation is not necessary. Aspirin should not be given to children because of risk of Reye syndrome.
The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement? 1 "Red blood cells appear normal in size and color; however, there is a decreased amount produced." 2 "The red blood cells have an increased life span with a decrease in normal functioning." 3 "Administration of vitamins B12 and folate will help to treat this type of long-term anemia." 4 "This is the mildest form of anemia and is easily corrected through administration of blood products."
Correct Ans: 1 Anemia of chronic disease results in a decrease in the production of red blood cells (RBCs) in response to chronic inflammation; the red blood cells are normal size, shape, and color. There is a decrease in the life span of the RBC, and the administration of folate or B12 will not correct the anemia, as these levels are generally within normal limits. This form of anemia can be very severe, and treatment is directed at identification and management of the underlying cause.
A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period? 1 Dysrhythmias, especially atrial fibrillation 2 Postpericardiotomy syndrome with fever and friction rub 3 Mediastinitis with boggy sternum and increased white blood cell count 4 Increased hemoglobin and hematocrit levels with a risk for embolization
Correct Ans: 1 Dysrhythmias such as atrial fibrillation, bradydysrhythmias, or heart block must be closely monitored for in the client immediately after surgery. Postpericardiotomy syndrome with fever and friction rub may occur later, not in the immediate postoperative period. Mediastinitis can occur, but it is not in the immediate postoperative period. Hemoglobin and hematocrit levels usually decrease, not increase; anemia can be a problem after this surgery.
A client's arterial blood gas report indicates that pH is 7.25, Pco2 is 60 mm Hg, and HCO3 is 26 mEq/L (26 mmol/L). Which client should the nurse consider is most likely to exhibit these blood gas results? 1 A 65-year-old with pulmonary fibrosis 2 A 24-year-old with uncontrolled type 1 diabetes 3 A 45-year-old who has been vomiting for 3 days 4 A 54-year-old who takes sodium bicarbonate for indigestion
Correct Ans: 1 The low pH and elevated Pco2 are consistent with respiratory acidosis, which can be caused by pulmonary fibrosis, which impedes the exchange of oxygen and carbon dioxide in the lung. A 24-year-old with uncontrolled type 1 diabetes most likely will experience metabolic acidosis from excess ketone bodies in the blood. A 45-year-old who has been vomiting for 3 days most likely will experience metabolic alkalosis from the loss of hydrochloric acid from vomiting. A 54-year-old who takes sodium bicarbonate for indigestion most likely will experience metabolic alkalosis from an excess of base bicarbonate.
A pt with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the pt to do? 1 Keep a record of the day's activities 2 Avoid going through laser-activated doors 3 Record the pulse and BP q 4 hrs 4 Delay taking prescribed medications until the monitor is removed
Correct Ans: 1 The purpose of monitoring is to correlate dysrhythmias with the client's reported activity. Laser-activated doors have no effect on a Holter monitor and will not affect the readings. Recording the pulse and blood pressure every 4 hours is not required for interpretation of the test. The client should take medication as prescribed and note it in the activities diary.
After a long history of recurrent thrombophlebitis with extensive varicose veins of the lower extremities, surgical intervention is suggested to the client. When asked about the procedure, what should the nurse explain that this surgery involves? 1 Removing the dilated superficial veins 2 Bypassing the varicosities with artificial veins 3 Stripping the cholesterol deposits from the veins 4 Creating fistulas between superficial and deep veins
Correct Ans: 1 The saphenous vein is ligated at its juncture with the femoral vein; injection sclerotherapy is used as the method of choice, but in chronic venous insufficiency and recurrent thrombophlebitis, surgery may be necessary. A bypass is unnecessary; the deep veins compensate for the removed saphenous vein. Cholesterol plaques are characteristic of atherosclerosis, an arterial, not venous, disease. Communicating veins normally exist between the superficial and deep veins; they are ligated to prevent further engorgement and varicosities.
A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1 72 mm Hg 2 90 mm Hg 3 100 mm Hg 4 130 mm Hg
Correct Ans: 1 When the sound disappears at 72 mm Hg, it is known as phase five of Korotkoff sounds; this reflects the diastolic pressure when the artery is no longer compressed and blood flows freely. 90 mm Hg is recorded as the diastolic pressure in adolescents and adults. The muffled sound heard at 90 mm Hg is phase four of Korotkoff sounds; the muffled sound represents the point at which the cuff pressure falls below the pressure within the arterial wall. This number is recorded as the diastolic pressure in infants and children. The tapping sound heard at 100 mm Hg is known as phase three of Korotkoff sounds; this reflects blood flow through an increasingly open artery as constriction of the cuff decreases. The swishing sound heard at 130 mm Hg is phase two of Korotkoff sounds; this is caused by blood turbulence.
A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply. 1 Crackles 2 Coughing 3 Orthopnea 4 Yellow sputum 5 Dependent edema
Correct Ans: 1, 2, 3 Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm. Yellow sputum indicates infection, not pulmonary edema. With pulmonary edema the sputum may be frothy and blood-tinged. When pulmonary pressure increases, cells in the alveoli lining are disrupted, and fluid that contains red blood cells moves into the alveoli. Pulmonary interstitial edema, not dependent edema, occurs.
How does the human body conserve heat? Select all that apply. 1 By decreasing muscle activity in the body 2 Through peripheral vasodilation in the body 3 Through peripheral vasoconstriction in body 4 By shunting blood to superficial body tissues 5 By shunting blood away from the skin surface
Correct Ans: 1, 3, 5 The human body conserves heat through peripheral vasoconstriction in the body. During peripheral vasoconstriction, the warm blood is shunted away from the skin surface to minimize heat loss from the body. Shunting blood to superficial body tissues would facilitate loss of heat. Increased muscle activity causes heat loss; the body conserves heat through decreased muscle activity. The body conserves heat through peripheral vasoconstriction; vasodilation would cause heat loss.
A client with a history of heart failure admits to the nurse that a salt-restricted diet has not been followed. The client reports increased ankle swelling and shortness of breath that is relieved by sitting up. For which other clinical indicators of fluid retention should the nurse monitor the client? Select all that apply. 1 Headache 2 Thready pulse 3 Decreased blood pressure 4 Dizziness when standing up 5 Crackles on lung auscultation
Correct Ans: 1, 5 Cerebral edema caused by hypervolemia may cause a headache. Crackles on lung auscultation indicate the presence of fluid in the alveoli (pulmonary edema). Increased fluid volume in the intravascular compartment (overhydration) will cause the pulse to feel full and bounding. The blood pressure will increase, not decrease, with hypervolemia. Dizziness when standing up occurs when pooling of blood in the peripheral vessels causes orthostatic (postural) hypotension.
During a yearly physical examination a complete blood count (CBC) is performed to determine a client's hematologic status. Which laboratory result will the nurse check? 1 Blood glucose 2 Hemoglobin (Hb) 3 C-reactive protein 4 Blood urea nitrogen (BUN)
Correct Ans: 2 A CBC includes red blood cell (RBC) count and RBC indices, white blood cell (WBC) count and WBC differential count, Hb, hematocrit (Hct), and platelet count. A blood glucose level is not part of a CBC. The C-reactive protein level is not part of a CBC. BUN is not part of a CBC.
The nurse is assessing a client with the diagnosis of chronic heart failure. Which clinical finding should the nurse expect the client to experience? 1 Dependent edema in the evening 2 Chest pain that decreases with rest 3 Palpitations in the chest when resting 4 Frequent coughing with yellow sputum
Correct Ans: 2 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.
A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion? 1 History of hypertensive disease 2 Emboli associated with atrial fibrillation 3 Developmental defect of the arterial wall 4 Inappropriate paroxysmal neural discharge
Correct Ans: 2 Emboli, occurring from atrial fibrillation, cause complete occlusion of vessels; usually middle cerebral arteries are involved. The infarct may cause hemiplegia, aphasia, or spatial perceptual deficits. Hypertension may cause spasm of the arteries, but it does not cause anatomic occlusion. A developmental defect of the arterial wall is associated with a saccular aneurysm. A seizure is caused by an inappropriate paroxysmal discharge, not a complete occlusion of the branches of the middle cerebral artery.
Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? 1 Complete blood count 2 Serum potassium level 3 X-ray film of long bones 4 Blood cultures times three
Correct Ans: 2 Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood count, x-ray film of long bones, and blood cultures times three will have no significance in the diagnosis of a potassium deficit.
A nurse is assessing a client who has had a carotid endarterectomy. Which response does the nurse consider evidence of a complication of the surgery? 1 Decreased appetite 2 Impaired swallowing 3 Change in bowel habits 4 Slight edema of the neck
Correct Ans: 2 Impaired swallowing may occur as a result of cranial nerve damage during surgery. Slight edema of the neck is expected from the trauma of surgery; it is not a complication. Decreased appetite, change in bowel habits, and slight edema of the neck are not complications of a carotid endarterectomy.
A client is in cardiogenic shock. Which explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1 An irreversible phenomenon 2 A failure of the circulatory pump 3 Usually a fleeting reaction to tissue injury 4 Generally caused by decreased blood volume
Correct Ans: 2 In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia will lead to hypovolemic shock; cardiogenic refers to the heart capabilities.
A client is diagnosed with pancytopenia caused by chemotherapy. What should a nurse teach the client about this complication? 1 Begin a program of meticulous mouth care. 2 Avoid traumatic injury and exposure to infection. 3 Increase oral fluid intake to at least 3 L/day. 4 Report unusual muscle cramps or tingling sensations in the extremities.
Correct Ans: 2 Reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase the susceptibility to infection. Beginning a program of meticulous mouth care is helpful for stomatitis, not pancytopenia; aggressive oral hygiene may precipitate bleeding from the gums. Although fluids may be increased to flush out the toxic byproducts of chemotherapy, this will have no effect on pancytopenia. Unusual muscle cramps or tingling sensations in the extremities are signs of hypocalcemia and do not apply to pancytopenia.
The client is experiencing fatigue, difficulty breathing, and dizziness. Which dysrhythmia does the nurse interpret from the cardiac monitor? (Cannot paste image) 1 Atrial flutter 2 Sinus tachycardia 3 Sinus bradycardia 4 Atrial fibrillation
Correct Ans: 2 Sinus tachycardia is regular rhythm but at a rate higher than 100 beats per min. The client may experience shortness of breath, palpitation, fatigue, and dizziness. Atrial flutter (saw-tooth waves) arises from a conduction defect in the atrium resulting in a rapid atrial rate, usually between 200 to 350 times/minute. The atrial rate is faster than the atrioventricular (AV) node can conduct so that not all atrial impulses are conducted through to the ventricle. Sinus bradycardia is a regular rhythm but at a rate lower than 60 beats per minute. Atrial fibrillation is an irregular rhythm that is a result of multiple irritable foci firing in the atria and bombarding the AV node with irregular conduction of impulses through the node.
A client who had injection sclerotherapy for varicose veins is advised to wear compression (support) stockings. What is most important for the nurse to explain to the client about compression stockings? 1 Put the stockings on at the first sign of discomfort. 2 Don the stockings before getting out of bed in the morning. 3 Ensure that the cuff of the stockings reaches the middle of the knees. 4 Substitute elastic bandages for compression stockings if they are more comfortable.
Correct Ans: 2 To prevent distention of the veins, stockings should be applied before the legs are placed in a dependent position. Stockings should be used preventively before the discomfort associated with venous pressure and edema occurs. Knee-high stockings should end 2 inches (5.1 cm) below the knee to avoid popliteal pressure, which limits venous return. Stockings apply uniform pressure. Elastic bandages may slip or develop wrinkles, creating uneven pressure and constriction; edema may result.
A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common? 1 Increased urinary output 2 Increased cardiac workload 3 Decreased oxygen saturation 4 Decreased arterial blood pressure
Correct Ans: 2 With anemia, the heart works harder to compensate for the reduced oxygen-carrying ability of the blood. With polycythemia, the heart works harder to propel more viscous blood through the circulatory system. Urinary output is not increased; it may be decreased to maintain blood volume in anemia and decrease blood viscosity in polycythemia. The percent of hemoglobin molecules saturated with oxygen is not affected. Clients with polycythemia will have increased blood pressure because of increased viscosity of the blood.
Within 4 to 6 hours after a client has a myocardial infarction, the nurse expects which blood level to increase? 1 Lactate dehydrogenase (LDH-1) 2 Creatine kinase-MB band (CK-MB) 3 Erythrocyte sedimentation rate (ESR) 4 Serum aspartate aminotransferase (AST)
Correct Ans: 2 CK-MB is an isoenzyme of creatine phosphokinase (CPK) found in cardiac muscle; it increases in 4 to 6 hours after chest pain and begins to decline in 12 to 24 hours. LDH-1 increases within 6 to 12 hours after the onset of pain. ESR is nonspecific; it indicates the presence of inflammation or infection. AST increases within the first 12 hours; it is not specific enough to provide a definitive indicator within 4 to 6 hours.
A client with a history of heart failure and hypertension is admitted with reports of syncope. Which prescribed medication should the nurse prepare to administer based on the electrocardiogram (ECG) rhythm strip image? (ECG strip shows sinus bradycardia) 1 Digoxin 2 Enalapril 3 Atropine 4 Metoprolol
Correct Ans: 3 This rhythm strip reflects sinus bradycardia. Sinus bradycardia has PQRST complexes within acceptable limits, but the rate is less than 60 beats per minute. In this strip the PR interval is 0.16, the rhythm is regular, and the rate is 40 beats per minute. Atropine, an anticholinergic that increases the heart rate, is administered when the heart rate is so slow that it causes symptoms. Digoxin is a cardiac glycoside that slows the heart rate. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that slows the heart rate. Metoprolol is a beta blocker that slows the heart rate.
A client is receiving furosemide to help treat heart failure. Which laboratory result will cause the nurse to notify the primary healthcare provider? 1 Hematocrit 46% 2 Hemoglobin 14.1 g/dL (141 mmol/L) 3 Potassium 3.0 mEq/L (3.0 mmol/L) 4 White blood cell 9200/mm3 (9.2 × 109/L)
Correct Ans: 3 A potassium level of 3.0 mEq/L (3.0 mmol/L) is indicative of hypokalemia. Normal values for an adult are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Potassium, calcium, and magnesium control the rate and force of heart contractions. Diuretics often are used to reduce fluid volume, so the heart does not work as hard. Furosemide is a potassium-losing diuretic. Hypokalemia can result in death from dysrhythmia; therefore this must be addressed. The hematocrit level of 46% is within the normal range. A hemoglobin of 14.1 (141 mmol/L) is within normal values. White blood cell level of 9200 cells/mm3is within the normal range of 4000 to 11,000 cells/mm3 (4 to 11 × 109/L).
A nurse is performing external cardiac compression. Which action should the nurse take? 1 Extend the fingers over the sternum and chest with the heels of each hand side by side. 2 Place the fingers of one hand on the sternum and the fingers of the other hand on top of them. 3 Interlock the fingers with the heel of one hand on the sternum and the heel of the other on top of it. 4 Clench the hand into a fist and place the fleshy part of a clenched fist on the lower sternum.
Correct Ans: 3 Interlocking the fingers with the heel of one hand on the sternum and the heel of the other on top of it provides the best leverage for depressing the sternum. Thus, the heart is adequately compressed, and blood is forced into the arteries. Grasping the fingers keeps them off the chest and concentrates the energy expended in the heel of the hand while minimizing the possibility of fracturing ribs. Pressure spread over two hands may inadequately compress the heart and fracture the ribs. Application of pressure by the fingers is less effective; this provides inadequate cardiac compression. Both hands must be used; pressure on the lower portion of the sternum may fracture the xiphoid process, which can injure vital underlying organs.
A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses? 1 Bladder spasms 2 Polycythemia vera 3 Hypovolemic shock 4 Pulmonary hypertension
Correct Ans: 3 These signs occur with hypovolemic shock because less blood is being circulated to vital centers in the brain. A large loss of blood may occur during and after orthopedic surgery. Urinary retention, not bladder spasms, may occur after general anesthesia. Bladder spasms are associated with intermittent suprapubic pain. Anemia and deep vein thrombosis, not an increase in the total red blood cells (polycythemia vera), tend to occur after a total hip replacement. Polycythemia vera is associated with headache, irritability, and paresthesias of the hands and feet. Atelectasis and pneumonia, not pulmonary hypertension, tend to occur after general anesthesia. Pulmonary hypertension is associated with dyspnea, substernal chest pain, and fatigue.
What is the most important teaching for a nurse to provide for a client who had sclerotherapy for varicose veins? 1 Limit activity until edema subsides. 2 Remove compression bandages when in bed. 3 Place a pillow under the knees when lying in bed. 4 Walk for several minutes every hour when awake.
Correct Ans: 4 Walking activities are encouraged to improve circulation and dilute the sclerosing agent. Limiting activity is contraindicated; inactivity contributes to venous stasis and engorgement of veins. Compression bandages should be left in place for several days to ensure external compression of veins, which enhances venous return. Placing a pillow under the knees when lying in bed is contraindicated because it will impede venous return.
A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity has a femoral angiogram. What is the priority nursing action after the angiogram? 1 Elevate the foot of the bed. 2 Encourage the client to void. 3 Maintain the high-Fowler position. 4 Assess the client's affected extremity.
Correct Ans: 4 Because of the trauma associated with insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur. The client has an arterial problem, and perfusion is promoted by keeping the legs at the level of the heart. A general anesthetic is not used; therefore, voiding usually is not a concern. Maintaining the high-Fowler position is unsafe because it increases pressure in the groin area, which may dislodge the clot at the catheter insertion site, resulting in bleeding; it also impedes arterial perfusion and venous return.
A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client? 1 Acute pain 2 Impaired mobility 3 Impaired swallowing 4 Hematoma formation
Correct Ans: 4 Because the femoral artery is large, it has the potential for hematoma formation and hemorrhage after surgery. The client should not be in pain after this procedure. Although the leg used for circulatory access must be kept extended and immobile for several hours, this is not the priority. The ability to swallow is not affected because conscious sedation, not general anesthesia, is used.
A client is admitted to the cardiac care unit with a diagnosis of myocardial infarction. The client asks the nurse, "What is causing the pain I am having?" Which explanation of the cause of the pain is the most appropriate response by the nurse? 1 Compression of the heart muscle 2 Release of myocardial isoenzymes 3 Rapid vasodilation of the coronary arteries 4 Inadequate oxygenation of the myocardium
Correct Ans: 4 Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.
A client is admitted to the intensive care unit in pulmonary edema. What should the nurse expect when performing the admission assessment? 1 Weak, rapid pulse 2 Decreased blood pressure 3 Radiating anterior chest pain 4 Crackles at the base of each lung
Correct Ans: 4 Crackles are the sound of air passing through fluid in the alveolar spaces. With pulmonary edema, fluid moves from the intravascular compartment into the alveoli. With hypervolemia, the pulse is bounding. The blood pressure is increased with hypervolemia. Radiating anterior chest pain will occur with angina or a myocardial infarction.
A client is admitted to the hospital with a large leg ulcer, and a femoral angiogram is performed. What should the nurse do after this procedure? 1 Provide passive range of motion (ROM) to all extremities 2 Elevate the foot of the bed for 36 hours 3 Assist the client to stand if unable to void 4 Apply pressure to the catheter insertion site
Correct Ans: 4 Pressure promotes coagulation and prevents the complication of bleeding. Bending the operative leg may cause decreased perfusion to the leg or bleeding at the catheter insertion site. Elevation will resist gravity flow of arterial blood, reducing oxygen to distal tissue. The client should remain in the supine position for 4 to 6 hours to prevent bleeding at the insertion site.
A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent? 1 Pulmonary edema 2 Myocardial infarction 3 Deep vein thrombosis 4 Right ventricular heart failure
Correct Ans: 4 Right ventricular heart failure causes increased pressure in the systemic venous system, which leads to a fluid shift into the interstitial spaces. Because of gravity, the lower extremities are first affected in an ambulatory client. Pulmonary edema results in severe respiratory distress and peripheral edema with pink frothy sputum. Myocardial infarction itself does not cause peripheral edema. The edema in deep vein thrombosis will be constant and not disappear at night; redness is usually present.
A client's blood pressure increases dramatically six hours after a femoral-popliteal bypass graft. Which priority concern motivates the nurse to inform the primary healthcare provider? 1 Hypertension may cause the graft to occlude. 2 Hypervolemia may be the cause of the hypertension. 3 Extremely high blood pressure may cause a brain attack. 4 Rapidly increasing blood pressure may rupture the graft.
Correct Ans: 4 The client is hypertensive, and the intraarterial pressure is increased; this increased pressure may cause the arterial suture line to rupture. Hypertension may cause the graft to occlude, but this is unlikely; however, because blood pressure is increased, the client is at risk for bleeding. Hypervolemia is an assumption; other causes, such as arterial constriction, can precipitate hypertension. Although extremely high blood pressure may cause a brain attack, the priority at this time is protecting the graft.
Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply. 1 Edema 2 Vertigo 3 Polyuria 4 Ascites 5 Palpitations
I put 1, 3, 4 Ans: 1, 4 Heart failure is the failure of the heart to pump adequately to meet the needs of the body, resulting in a backward buildup of pressure in the venous system. Clinical manifestations include edema, ascites, hepatomegaly, tachycardia, and fatigue. Dyspnea occurs in left-sided heart failure because of pulmonary congestion and inadequate delivery of oxygen to all body cells. Vertigo generally is not related to right ventricular failure. Because a diminished cardiac output decreases blood flow to the kidneys, there will be a decreased, not increased, urine output (polyuria). Palpitations may indicate dysrhythmias or anxiety.
A hospitalized client receiving a diet that limits sodium to 2 g complains about the bland food and refuses to eat dinner. What is an appropriate nursing response? 1 Asking the client about what foods are eaten at home 2 Telling the client about several brands of low-sodium spices 3 Explaining to the client that the diet eventually will have to be accepted 4 Urging the client to eat to become accustomed to the diet that must be followed at home
I put 2 Ans: 1 Asking the client what foods usually are eaten at home is an attempt to collect adequate data to plan the most appealing and appropriate diet. Low-sodium spices still contain salt and should be avoided when receiving a low-sodium diet. Explaining to the client that the diet eventually will have to be accepted will not guarantee compliance once the client goes home; the client has the right to accept or reject therapy. Urging the client to eat to become accustomed to the diet that must be eaten at home will not guarantee compliance once the client goes home; the client has the right to accept or reject therapy.
A client being treated for uncontrolled hypertension and chest pain calls out to the nurse and reports a nosebleed. Upon entry to the client's room, the nurse immediately applies pressure. Which action should the nurse take next? 1 Add humidity to the client's oxygen prescribed at 2 L/minute via nasal cannula. 2 Assess the client for further injuries indicative of a possible fall. 3 Assess the client's blood pressure. 4 Assess the client's pulse rate.
I put 2 Ans: 3 Nosebleeds in adults often are indicative of hypertension. Although oxygen can dry out the mucus membranes in the nose, and assessing the client for further injuries is plausible, the nurse's first action should be to assess blood pressure, especially because the client was admitted for uncontrolled hypertension.
A client is admitted to the hospital with atrial fibrillation. A diagnosis of mitral valve stenosis is suspected. The nurse concludes that it is most significant if the client presents with what history? 1 Cystitis as an adult 2 Pleurisy as an adult 3 Childhood strep throat 4 Childhood German measles
I put 2 Ans: 3 Streptococcal infections occurring in childhood may result in damage to heart valves, particularly the mitral valve. Group A streptococcal antigens bind to receptors on heart cells, where an autoimmune response is triggered damaging the heart. Cystitis usually is caused by Escherichia coli, which does not affect heart valves. Pleurisy usually follows pulmonary problems unrelated to streptococcal infection; it does not result in damage to heart valves. The rubella virus does affect the valves of the heart.
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. 1 Weight loss 2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea 5 Increased urinary output
I put 2, 4, 5 Ans: 2, 3, 4 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 nervous system and the renin-angiotensin-aldosterone system stimulate the retention of sodium and water in the kidneys.
A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. Which food choices by the client indicate effective learning? Select all that apply. 1 Olive oil 2 Chicken broth 3 Enriched whole milk 4 Red meats, such as beef 5 Vegetables and whole grains 6 Liver and other glandular organ meats
I put 2, 4, 6 Ans: 2, 3, 4, 6 Chicken broth is high in sodium and should be avoided to prevent fluid retention and an elevated blood pressure. Enriched whole milk is high in saturated fats and contributes to hyperlipidemia; skim milk is the healthier choice. Red meats, such as beef, are high in saturated fats and should be avoided. Liver and other glandular organ meats are high in cholesterol and should be avoided. Olive oil is an unsaturated fat, which is a healthy choice. Vegetables and whole grains are low in fat and have soluble fiber, which may reduce the risk for heart disease.
A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? 1 Allows excess tissue fluid to be excreted 2 Helps to control the volume of food intake and thus weight 3 Aids the weakened heart muscle to contract and improves cardiac output 4 Assists in reducing potassium accumulation that occurs when sodium intake is high
I put 3 Ans: 1 A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.
A client experiences crushing chest pain and is brought to the emergency department. When assessing the electrocardiogram (ECG) tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the ECG support this conclusion? 1 Irregular rhythm, abnormally shaped P wave, and normal QRS 2 Irregular rhythm, absence of a P wave, and wide and distorted QRS 3 Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS 4 Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide and distorted QRS
I put 3 Ans: 2 A PVC is a contraction originating in an ectopic focus in the ventricles; it is characterized by a premature, wide, distorted QRS complex with the P wave and PR interval buried in the distorted QRS complex resulting in an irregular rhythm. Irregular rhythm, abnormally shaped P wave, and normal QRS occur with a premature atrial complex. Regular rhythm, more than 100 beats per minute, normal P wave, and normal QRS occur with sinus tachycardia. Regular rhythm, 100 to 250 beats per minute, absent P wave, and wide and distorted QRS occur with ventricular tachycardia.
During auscultation of the heart, where does the nurse expect the first heart sound (S1) to be the loudest? 1 Base of the heart 2 Apex of the heart 3 Left lateral border 4 Right lateral border
I put 3 Ans: 2 The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apex of the heart. The base of the heart is where the second heart sound (S2) is best heard; S2 is produced by closure of the aortic and pulmonic valves. The left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. The right lateral border covers a large area; the only auscultatory area near it is the aortic area.
An 11-year-old client is admitted with enlarged supraclavicular lymph nodes, fatigue, and low-grade fever. She also has a persistent nonproductive cough. In light of these findings, the nurse knows to gear education toward preparation for which therapies? 1 Intravenous (IV) fluids and nutritional therapy 2 Bloodwork and oxygenation therapy 3 IV fluids and antibiotic therapy 4 Computed tomography (CT) and lymph node biopsy
I put 3 Ans: 4 The symptoms indicate possible Hodgkin lymphoma, so diagnostic testing will likely include CT and a lymph node biopsy. IV fluids, antibiotic therapy, oxygenation therapy, and nutritional therapy are not requirements at this point in treatment.
Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? Select all that apply. 1 Increase the client's intravenous (IV) flow rate. 2 Massage the client's extremities with lotion. 3 Place the client's legs in pneumatic sequential stockings. 4 Instruct the client to avoid crossing the legs. 5 Instruct the client to dorsiflex the feet routinely.
I put 3, 4, 5 Ans: 4, 5 Avoiding crossing the ankles and legs relieves pressure against the veins in the legs and facilitates venous return. Alternating planter flexion and dorsiflexion contracts calf muscles, facilitating venous return. Increasing IV fluids keeps the client hydrated, preventing dehydration and hypercoagulability; however, this is not an independent function of the nurse, because it requires a primary healthcare provider's prescription. Massaging the client's legs is contraindicated, because any developing clot could be dislodged. Placing the client's legs in pneumatic stockings is not an independent function of the nurse. The nurse needs a primary healthcare provider's prescription to apply pneumatic stockings.
Which anatomic changes result in thermodysregulation in elderly people? Select all that apply. 1 Increased metabolic rate 2 Increased shivering response 3 Decreased circulation of blood 4 Decreased number of sweat glands 5 Decreased vasoconstrictive response
I put 3, 5 Ans: 3, 4, 5 As aging occurs, body temperature tends to fluctuate because of the body's decreased ability to regulate its temperature. These fluctuations in temperature occur because of decreased blood circulation, decreased number and efficiency of the sweat glands, and decreased vasoconstrictive response. Increased metabolic rate and shivering response do not result in thermodysregulation; they contribute to fluctuations in the body temperature.
Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that what is the cause of the increase in the client's urinary output? 1 An expected effect of the dye used with the procedure 2 Increased cardiac output as a result of the procedure 3 An improvement of urinary functioning after the catheterization 4 A physiologic effect of the prescribed intravenous (IV) rate of 50 mL/hr
I put 4 Ans: 1 The dye used is hypertonic and has a diuretic effect. A cardiac catheterization is a diagnostic procedure, not a therapeutic one; it neither improves cardiac function nor increases cardiac output, and it does not improve urinary functioning. An IV rate of 50 mL/hr will not cause a urinary output three times the amount of intake.
The primary healthcare provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse whether it is really necessary to stay in bed so much. What would be the best reply by the nurse? 1 "Why do you want to be out of bed?" 2 "Bed rest plays a role in most therapy." 3 "Rest helps your body direct energy toward healing." 4 "Would you like me to ask your primary healthcare provider to change the prescription?"
I put 4 Ans: 3 A client's knowledge about the treatment program enhances compliance and reduces stress. The response "Why do you want to be out of bed?" does not answer the client's question and might produce frustration. The response "Bed rest plays a role in most therapy" does answer the client's question, but does not explain specifically why. The response "Would you like me to ask your primary healthcare provider to change the prescription?" does not support the treatment regimen; the client needs education.
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings? 1 Cardiogenic shock 2 Hypervolemic shock 3 Hemorrhagic shock 4 Septic shock
I put 4 Ans: 3 The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.
Mark the component of a pressure monitoring system that should be positioned while referencing. (couldn't attach image)
The transducer is positioned so that the zero reference point is at the level of the atria of the heart. This is known as referencing. To place the reference point, the phlebostatic axis is identified.
