Chapter 27 NCLEX Questions

A client with a history of acute coronary syndrome asks why she needs to take aspirin 81 mg every day. The most appropriate response by the nurse would be: "Aspirin prevents blood clotting by halting platelet production." "Aspirin will help prevent blood clotting." "It will give you a steady relief of your chest pain." "Aspirin will prevent a heart attack."

"Aspirin will help prevent blood clotting." Aspirin (i.e., acetylsalicylic acid) is the preferred antiplatelet agent for preventing platelet aggregation in persons with ACS. Aspirin, which acts by inhibiting synthesis of the prostaglandin thromboxane A2, is thought to promote reperfusion and reduce the likelihood of rethrombosis. This dose of aspirin is not appropriate for pain relief, and the final option does not demonstrate therapeutic communication.

The nurse is monitoring hourly urine output of a client diagnosed with hypovolemic shock. The nurse is most concerned if the client's output is: 60 mL/hour 80 mL/hour 40 mL/hour 20 mL/hour

20 mL/hour Urine output decreases very quickly in hypovolemic shock. Compensatory mechanisms decrease renal blood flow as a means of diverting blood flow to the heart and brain. Oliguria of 20 mL/hour or less indicates inadequate renal perfusion.

What is the most common identifiable cause of secondary cardiomyopathy? Heart transplant Heart failure Genetic abnormalities Alcohol abuse

Alcohol abuse is a cause of secondary cardiomyopathy, while the other options result in primary cardiomyopathy.

The nurse is preparing to auscultate for a mitral valve stenosis murmur. Where is the best location to place the stethoscope? Over the sternum Over the aorta At the carotid arteries At the apex of the heart

At the apex of the heart The murmur of mitral valve stenosis is heard during diastole when blood is flowing through the constricted valve; it is characteristically a low-pitched, rumbling murmur best heard at the apex of the heart. The other locations would not be effective.

A client has developed constrictive pericarditis and myocardial hypertrophy. Select the most likely cause. Diastolic dysfunction Systolic dysfunction Backward failure Frontward failure

Diastolic dysfunction The conditions that cause diastolic dysfunction are those that impede expansion of the ventricles (i.e., pericarditis), those that increase ventricular wall thickness and reduce chamber size (i.e., myocardial hypertrophy), and those that delay diastolic relaxation (i.e., aging).

Which serum biomarker is highly specific for myocardial tissue? Creatine kinase Troponin White blood cells C-reactive protein

Troponin The troponin assays have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction. Creatine kinase is specific for muscle injury but is not as focused as is troponin. White blood cells and C-reactive protein are associated with inflammation.

The health care team is developing a plan of care for a client diagnosed with congestive heart failure (CHF). The primary treatment goal would be: improving quality of life by relieving symptoms. maintaining higher oxygen levels to decrease the work of breathing. eliminating CHF through curing the disease. placing a stent for fluid drainage from the heart.

improving quality of life by relieving symptoms

A preventive measure to decrease the risk of developing rheumatic heart disease includes: prompt diagnosis of streptococcal infections with a throat culture. scheduling regular hearing examinations. blood specimen assessed for rheumatoid factor. yearly electrocardiography after the age of 50.

prompt diagnosis of streptococcal infections with a throat culture. Rheumatic heart disease is normally caused by streptococcal infections; therefore, early diagnosis of these would decrease the risk for the disease. Frequent EKG may be required after a client has a history of rheumatic heart disease. Rheumatoid factor is not related to rheumatic heart disease, and while the client may benefit from regular hearing examinations, it is not related to preventing rheumatic heart disease.

What is the most important factor in myocardial oxygen demand? Degree of anxiety Respiratory rate Hyperthermia Heart rate

Heart rate

A 75-year-old client is being evaluated for heart failure. Which questions will the nurse ask to confirm common signs and symptoms observed in older adults experiencing heart failure? Select all that apply. "Do you get up often during the night to urinate?" "Do you easily get tired?" "Are you feeling depressed?" "Do you have swelling in your ankles?" "Are you eating more than usual?"

"Do you get up often during the night to urinate?", "Do you easily get tired?", "Are you feeling depressed?", "Do you have swelling in your ankles?"

The nurse has just completed teaching a client about acyanotic congenital heart disease. The nurse determines that teaching was effective when the client states the blood is shunted to which part of the body? Right side of the heart to the left side of the heart Left lung to the right lung Right lung to the left lung Left side of the heart to the right side of the heart

Left side of the heart to the right side of the heart Defects that result in a left-to-right shunt are categorized as acyanotic disorders since they do not compromise oxygenation of blood in the pulmonary circulation.

When an acute event occurs and the circulatory system can no longer provide the body with adequate perfusion of its tissues and organs, cellular hypoxia occurs and the body goes into shock. What are the causes of shock in the human body? Select all that apply. Excessive vasoconstriction Hypervolemia Maldistribution of blood flow Obstruction of blood flow Hypovolemia

Maldistribution of blood flow, Obstruction of blood flow, Hypovolemia Shock is not a specific disease but a syndrome that can occur in the course of many life-threatening traumatic conditions or disease states. It can be caused by an alteration in cardiac function (cardiogenic shock), a decrease in blood volume (hypovolemic shock), excessive vasodilation with maldistribution of blood flow (distributive shock), or obstruction of blood flow through the circulatory system (obstructive shock). Excessive vasoconstriction and hypervolemia are not causes of shock.

The nurse is developing a plan of care for a client diagnosed with stable angina. Select the most important goal for this client. Preventing clotting disorders Assisting the client to return to previous lifestyle Myocardial infarction prevention Ensuring adequate oxygenation with continuous oxygen administration

Myocardial infarction prevention

Exudate in the pericardial cavity is a characteristic of which cardiac condition? Constrictive pericarditis Cardiac tamponade Acute pericarditis Pericardial effusion

Pericardial effusion Pericardial effusion, either acute or chronic, refers to the presence of an exudate in the pericardial cavity. Acute pericarditis is characterized by chest pain, ECG changes, and pericardial friction rub. Cardiac tamponade represents a life-threatening compression of the heart resulting from excess fluid in the pericardial sac. In constrictive pericarditis, scar tissue develops between the visceral and parietal layers of the serous pericardium. In time, the scar tissue contracts and interferes with cardiac filling.

A 62-year-old female client presents to the emergency department and is diagnosed with acute heart failure syndrome. Which assessment finding would the nurse expect? Increased urination and dry skin. Slowed breathing and dehydration. Productive cough with frothy sputum. Shortness of breath and bradycardia.

Productive cough with frothy sputum. The signs and symptoms of acute heart failure syndromes include shortness of breath and other respiratory manifestations (i.e., exertional dyspnea, orthopnea), fatigue and limited exercise tolerance, fluid retention and edema, cachexia and malnutrition, and cyanosis. Acute pulmonary edema is the most dramatic symptom of AHFS. The client would have an increased heart rate as a result of the exertional process.

In distributive shock, there are abnormalities in vascular resistance. Which types of shock display the same distributive pattern? Select all that apply. Hypovolemic Septic Neurogenic Cardiogenic Anaphylactic

Septic, Neurogenic, Anaphylactic In distributive shock, the capacity of the vascular compartment is greatly enlarged so that a normal blood volume becomes insufficient. In neurogenic shock, loss of sympathetic (adrenergic) control of blood vessels is lost and extreme vasodilation occurs. In anaphylactic shock, a severe allergic reaction, massive release of histamine induces extreme vasodilation. In septic shock, a response to severe infection, there is vascular dilation. Cardiogenic shock is a loss of ventricular contractility. Hypovolemic shock is a loss of blood volume.

The diagnosis is hypovolemic shock. The nurse knows that causes of hypovolemic shock include which of the following? Select all that apply. Excessive vasoconstriction Severe burns Myocardial infarction 15% blood volume loss Severe dehydration

Severe burns, 15% blood volume loss, Severe dehydration Hypovolemic shock is characterized by diminished blood volume with inadeaquate filling of the vascular compartment. Causes include extensive whole blood loss, severe burns with extensive loss of plasma, severe dehydration, and shifting of extracellular fluid from the circulatory system to interstitial spaces. Myocardial infarction can cause cardiogenic shock. Excessive vasoconstriction can be a compensatory mechanism in hypovolemic shock.

A client with a known history of intravenous drug abuse has been diagnosed with infective endocarditis. Select the most likely cause of infection. Staphylococcus aureus Actinobacillus actinomycetemcomitans Kingella kingae Eikenella corrodens

Staphylococcus aureus While all of these bacteria can cause infective endocarditis, Staphylococcus aureus is the major offender in injection drug abusers, whereas prosthetic heart valve infective endocarditis tends to be caused by coagulase-negative staphylococci (e.g., Staphylococcus epidermidis).

A child is suspected to have heart failure. The nurse knows that which statements regarding heart failure in children are most accurate? Select all that apply. Symptoms include tachypnea and tachycardia. Physical activity must be discouraged. Inotropic agents such as digoxin may be used in children. Congenital defects are a risk factor. The etiology of heart failure is similar in children and adults.

Symptoms include tachypnea and tachycardia., Inotropic agents such as digoxin may be used in children., Congenital defects are a risk factor.

The nurse is caring for a client with chronic heart failure. Which drug category may be pescribed for acute heart failure to improve heart performance by decreasing preload? Vasodilator drugs like nitroprusside Angiotensin-converting enzyme (ACE) inhibitors like captapril Cardiac glycosides like digitalis Beta-adrenergic receptor blocking agents like atenolol

Vasodilator drugs like nitroprusside Vasodilator drugs like nitroprusside are used in acute heart failure syndromes to improve left heart performance by decreasing the preload (through vasodilation) or reducing the afterload (through arteriolar dilation). ACE inhibitors prevent the conversion of angiotensin I to angiotensin II. Early in the course of heart failure, the renin-angiotensin-aldosterone system is activated. It results in an increase in angiotensin II, which causes vasoconstriction, ventricular remodeling, and increased aldosterone production with increased water retension by the kidneys. ACE inhibitiors limit these harmful complications. Beta blockers are used to decrease left ventricular dysfunction associated with activation of the sympathetic nervous system. Cardiac glycosides like digitalis improve cardiac function by increasing the force and strength of ventricular contractions.