Med Surg exam 1

13. A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer?

0.25 ml

40. The post-cardiac catheterization patient has a NSR with several runs of non-sustained runs of ventricular tachycardia (VT). His blood pressure is 105/60. The MD prescribes a continuous infusion of the antidyshythmic Amiodarone (Cordarone) 1mg/minute. The drug concentration of Amiodarone is 900mg in 500ml of DSW. The nurse should set the IV pump at how many mL/hour?

33.3 ml/hr

12. A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units per hour is the client receiving?

500 units/ hour

1. A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond? A. "Weight is the best indication that you are gaining or losing fluid." B. "Daily weights will help us make sure that you're eating properly." C. "The hospital requires that all inpatients be weighed daily." D. "You need to lose weight to decrease the incidence of heart failure."

A

10. The nurse understands that patients with which dysrhythmia constitute the largest group of those hospitalized with dysrhythmias? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular fibrillation

A

11. A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." How should the nurse respond? A. "Would you like to talk more about this?" B. "You are lucky to have such a devoted daughter." C. "It is normal to feel as though you are a burden." D. "Would you like to meet with the chaplain?"

A

11. A patient is started on etanercept (Enbrel). What teaching by the nurse is most appropriate? A. Giving subcutaneous injections B. Having a chest x-ray once a year C. Taking the medication with food D. Using heat on the injection site

A

13. A nurse is care for a patient who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The patient develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurse's best action? A. Check for abdominal distention and check pulses. B. Raise the head of the bed to 90 degrees C. Assess urine output D. Auscultate the abdomen

A

13. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? A. Assess for any hemodynamic effects of the rhythm. B. Prepare to administer antidysrhythmic medication. C. Notify the provider or call the Rapid Response Team. D. Turn the alarms off on the cardiac monitor.

A

14. A nurse is assessing a patient with peripheral artery disease (PAD). The patient states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? A. "Could you walk further than that a few months ago?" B. "Do you walk mostly uphill, downhill, or on flat surfaces?" C. "Have you ever considered swimming instead of walking?" D. "How much pain medication do you take each day?"

A

14. A patient in the orthopedic clinic has a self-reported history of osteoarthritis. The patient reports a low-grade fever that started when the weather changed and several joints started "acting up," especially both hips and knees. What action by the nurse is best? A. Assess the patient for the presence of subcutaneous nodules or Baker's cysts. B. Inspect the patient's feet and hands for podagra and tophi on fingers and toes. C. Prepare to teach the patient about an acetaminophen (Tylenol) regimen. D. Reassure the patient that the problems will fade as the weather changes again.

A

15. A patient is taking warfarin (Coumadin) and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? A. "No, it may interfere with the warfarin." B. "There isn't any information about that." C. "Why would you want to take that?" D. "Yes, it is a good supplement for you."

A

18. A patient had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? A. Appropriate hand hygiene before giving care B. Assessing the patient's temperature every 4 hours C. Clean technique when changing dressings D. Monitoring the patient's daily white blood cell count

A

19. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? A. "Minimize or abstain from caffeine." B. "Lie on your side until the attack subsides." C. "Use your oxygen when you experience PACs." D. "Take amiodarone (Cordarone) daily to prevent PACs."

A

19. A patient is getting out of bed into the chair for the first time after an uncemented hip replacement. What action by the nurse is most important? A. Have adequate help to transfer the patient. B. Provide socks so the patient can slide easier. C. Tell the patient full weight bearing is allowed. D. Use a footstool to elevate the patient's leg.

A

2. A nurse in the family clinic is teaching a patient newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching? A. Acetaminophen (Tylenol) B. Cyclobenzaprine hydrochloride (Flexeril) C. Hyaluronate (Hyalgan) D. Ibuprofen (Motrin)

A

2. The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action? A. Administer both heparin and warfarin as prescribed. B. Turn off the heparin before administering the warfarin. C. Clarify the warfarin order with the nursing supervisor. D. Hold the warfarin dose until the heparin is discontinued

A

2. The normal values for the ECG waves and complexes are: A. PR interval 0.12-0.20 seconds B. QRS duration greater than 0.12 seconds C. QT interval variable and greater than or equal to have the distance between consecutive QRS complexes D. T wave denoted as a negative deflection from the isoelectric line

A

20. A patient has been diagnosed with rheumatoid arthritis. The patient has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best? A. Assess the patient's culture more thoroughly. B. Discuss options for performing duties. C. See if the patient will call a community meeting. D. Suggest the patient give up the role of elder.

A

20. A patient has peripheral arterial disease (PAD). What statement by the patient indicates misunderstanding about self-management activities? A. "I can use a heating pad on my legs if it's set on low." B. "I should not cross my legs when sitting or lying down." C. "I will go out and buy some warm, heavy socks to wear." D. "It's going to be really hard but I will stop smoking."

A

21. Which of the following characteristics is typical of the pain associated with DVT? A. Dull ache B. No pain C. Tingling

A

22. A patient comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the patient for Heberden's nodules. What assessment technique is correct? A. Inspect the patient's distal finger joints. B. Palpate the patient's abdomen for tenderness. C. Palpate the patient's upper body lymph nodes. D. Perform range of motion on the patient's wrists.

A

23. A patient takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The patient also requests the celecoxib in addition to the morphine. What action by the nurse is best? A. Consult with the health care provider about administering both drugs to the patient. B. Inform the patient that the celecoxib will be started when he or she goes home. C. Teach the patient that, since morphine is stronger, celecoxib is not needed. D. Tell the patient he or she should not take both drugs at the same time.

A

26. The nurse evaluates diagnostic results for a client who has chest pain. Which laboratory test is specific for acute coronary syndromes? A. Troponin I & T markers B. Serum lactate dehydrogenase (LDH) C. Serum myoglobin D. BNP

A

28. A patient is receiving digoxin therapy for heart failure. What assessment does the nurse perform before administering the medication? A. Auscultate the apical pulse rate and heart rhythm B. Assess for nausea and abdominal distension C. Auscultate the lungs for crackles D. Check for increased urine output

A

30. The dose of warfarin (Coumadin) is based on what laboratory parameter? A. INR B. Partial thromboplastin time C. Platelet count D. Template bleeding time

A

32. The nurse is teaching a patient about the treatment regimen for heart failure. Which statement by the patient indicates a need for further instruction? A. "I must weigh myself once a month and watch for fluid retention." B. "If my heart feels like it is racing, I should call my doctor." C. "I'll need to consider my activities for the day and rest as needed." D. "I'll need periods of rest and activity, and I should avoid activity after meals."

A

36. A patient with chest pain arrives in the emergency department and orders are written. Which intervention is the first priority for the nurse to complete? A. Administer aspirin 325 mg PO B. Administer morphine 2 mg IV C. Administer beta blocker slow IV D. Place the patient in a supine position

A

4. The nurse is recovering a patient with peripheral arterial disease who has just undergone percutaneous transluminal angioplasty. What complication does the nurse monitor for in the immediate postprocedure period? A. Bleeding B. Aspiration C. Hypertensive crisis D. Chest pain

A

4. To determine whether a patient is "tolerating" a rhythm, the following should be assessed: A. Blood pressure and level of consciousness B. Exercise capacity C. Blood sugar D. Body mass index (BMI)

A

4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? A. Assess for symptoms of left-sided heart failure. B. Document this as a normal finding. C. Call the health care provider immediately. D. Transfer the client to the intensive care unit.

A

40. During the first 15 minutes of the blood administration the nurse stays with the patient obtaining baseline vital signs and vital signs after 15 minutes. The nurse notes that the patient's temperature has increased from 37.0C to 38.2C, the blood pressure has decreased from 120/80 to 90/40, and the patient complains of itching, and shortness of breath. What is the nurse's priority action? A. Stop the packed red blood cells and start Normal saline to keep vein open B. Call the blood bank C. Give Tylenol D. Find the charge nurse to double check the primary nurse's findings

A

41. A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? A. Atropine (Atropine) B. Digoxin (Lanoxin) C. Lidocaine (Xylocaine) D. Metoprolol (Lopressor)

A

41. A splint is prescribed for nighttime use by a patient with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A. Prevention of deformities B. Avoidance of joint trauma C. Relief of joint inflammation D. Improvement in joint strength

A

41. Which of the following findings in the postoperative cardiac patient (20 hours postop) should be reported to the surgeon immediately? A. A decrease in BP with muffled heart sounds and jugular venous distension. B. Chest pain that is localized to the sternum, achy, and intensified with coughing. C. Chest tube drainage of 50-75 ml/hour. D. Serum potassium 4.2 with hourly urine output of 40 ml.

A

42. Ms. Jones is a 35 yo female with a new diagnosis of rheumatoid arthritis. Ms. Jones reports severe pain and swelling of the hands and feet. Before administering methotrexate which question should you ask her? A. Does she consume alcohol? B. Is she a smoker? C. Any history of falls? D. Any history of nose bleeds?

A

44. Which of symptoms is most characteristic of RA? A. Bilateral pain and swelling in the joints and fingers closest to the hands B. Anemia, fatigue, and lymph node involvement C. Unilateral pain and swelling concentrated in the cervical spine D. Decreased eye tearing and photosensitivity

A

5. Sinus bradycardia is associate with: A. Heart rate less than 60 bpm B. Inverted P waves C. A prolonged PR interval D. All of the above

A

5. The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? A. Elevate the head of the bed and apply oxygen. B. Listen to the client's lung sounds. C. Pull the call bell out of the wall socket. D. Assess the client's pulse oximetry.

A

5. The nurse is monitoring a patient who has returned to the unit after arterial revascularization. The patient reports pain in the affected limb that is similar to the pain experienced before the procedure. What is the nurse's best action? a. Assess the peripheral pulses in the limb. b. Elevate the affected extremity on pillows. c. Administer pain medication as prescribed. d. Place a warm blanket on the operative limb.

A

6. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? A. Monitor the client's oxygenation and monitor for bleeding. B. Teach the client about potential side effects. C. Monitor the IV insertion site. D. Teach the patient to avoid green, leafy vegetables

A

6. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a patient having a total joint replacement? A. Administer preoperative antibiotic as ordered. B. Assess the patient's white blood cell count. C. Instruct the patient to shower the night before. D. Monitor the patient's temperature postoperatively.

A

7. The nurse on the postoperative inpatient unit assesses a patient after a total hip replacement. The patient's surgical leg is visibly shorter than the other one and the patient reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best? A. Assess neurovascular status in both legs. B. Elevate the affected leg and apply ice. C. Prepare to administer pain medication. D. Try to place the affected leg in abduction.

A

9. A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? A. Assess the client's respiratory status. B. Draw blood to assess the client's serum electrolytes. C. Administer intravenous furosemide (Lasix). D. Ask the client about current medications.

A

A patient with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of bradycardia, the nurse assesses the patient's medication record. Which medication is most likely the cause of the bradycardia? A. Propanolol (Inderal) B. Captopril (Capoten) C. Furosemide (Lasix) D. Dobutamine (Dobutrex)

A

5. A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching? A. "Avoid using salt substitutes." B. "Take your medication with food." C. "Avoid using aspirin-containing products." D. "Check your pulse daily."

A (its an ACE inhibitor)

31. A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) A. Assess vital signs more often. B. Hold other IV fluids running. C. Premedicate to prevent reactions. D. Transfuse smaller bags of blood. E. Transfuse each unit over 8 hours.

A, B

29. A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) A. Hanging the blood product using normal saline and a filtered tubing set B. Taking a full set of vital signs prior to starting the blood transfusion C. Telling the patient someone will remain at the bedside for the first 5 minutes D. Using gloves to start the patient's IV if needed and to handle the blood product E. Verifying the patient's identity, and checking blood compatibility and expiration time

A, B, C, D

23. A nurse is caring for a patient on IV infusion of heparin. What actions does this nurse include in the patient's plan of care? (Select all that apply.) A. Assess the patient for bleeding. B. Monitor the daily activated partial thromboplastin time (aPTT) results. C. Stop the IV for aPTT above baseline. D. Use an IV pump for the infusion. E. Weigh the patient daily on the same scale.

A, B, D

27. A patient has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the patient to maintain independence in activities of daily living (ADLs)? (Select all that apply.) A. Grab bars to reach high items B. Long-handled bath scrub brush C. Soft rocker-recliner chair D. Toothbrush with built-up handle E. Wheelchair cushion for comfort

A, B, D

25. A nurse is teaching a female patient with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.) A. "Avoid acetaminophen in over-the-counter medications." B. "It may take several weeks to become effective on pain." C. "Pregnancy and breast-feeding are not affected by MTX." D. "Stay away from large crowds and people who are ill." E. "You may find that folic acid, a B vitamin, reduces side effects."

A, B, D, E

28. A home health care nurse is visiting a patient discharged home after a hip replacement. The patient is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the patient? (Select all that apply.) A. Buy and install an elevated toilet seat. B. Install grab bars in the shower and by the toilet. C. Step into the bathtub with the affected leg first. D. Remove all throw rugs throughout the house. E. Use a shower chair while taking a shower.

A, B, D, E

24. A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) A. "Until your incision is healed, do not submerge your pacemaker. Only take showers." B. "Report any pulse rates lower than your pacemaker settings." C. "If you feel weak, apply pressure over your generator." D. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." E. "Do not lift your left arm above the level of your shoulder for 8 weeks."

A, B, E

24. A patient is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) A. Dietary restrictions B. Driving restrictions C. Follow-up laboratory monitoring D. Possible drug-drug interactions E. Reason to take medication

A, C, D, E

25. A nurse reviews a patient's laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) A. Total cholesterol: 280 mg/dL B. High-density lipoprotein cholesterol: 50 mg/dL C. Triglycerides: 200 mg/dL D. Serum albumin: 4 g/dL E. Low-density lipoprotein cholesterol: 160 mg/dL

A, C, E

26. An older patient returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Apply an abduction pillow to the patient's legs. B. Assess the skin under the abduction pillow straps. C. Place pillows under the heels to keep them off the bed. D. Monitor cognition to determine when the patient can get up. E. Take and record vital signs per unit/facility policy.

A, C, E

11. The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) A. Use antiembolism stockings. B. Massage calf muscles per client request. C. Maintain supine position with the legs flat. D. Turn every 2 hours if client is in bed. E. Refrain from active range-of-motion exercises.

A, D

30. A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) A. Donor blood type A can donate to recipient blood type AB. B. Donor blood type B can donate to recipient blood type O. C. Donor blood type AB can donate to anyone. D. Donor blood type O can donate to anyone. E. Donor blood type A can donate to recipient blood type B.

A, D

1. The following is characteristic of the sinoatrial (SA) node: A. Intrinsic rate of 40-60 bpm B. Is capable of spontaneously generating an electrical impulse C. Located near the interatrial septum or junction D. Serves as a gatekeeper, delaying impulses to allow time for the ventricles to fill

B

11. Mr. Booth is a 49-year-old male who suffers from intermittent claudication. He smokes 1 pack per day of cigarettes and has hypertension that is medically controlled. Mr. Booth is fearful of undergoing amputation in the future. Your knowledge of the general progression of peripheral arterial disease allows you to instruct him that: A. If he follows a home walking program, his chances of needing surgery should be minimal. B. Smoking causes vasoconstriction and therefore smoking cessation would be a great goal. C. The majority of individuals with intermittent claudication do have amputations. D. The vasodilator he has been prescribed to take has been proven to reverse the progression of the disease.

B

12. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? A. "Make certain that your bath water is warm." B. "Avoid straining while having a bowel movement." C. "Limit your intake of caffeinated drinks to one a day." D. "Avoid strenuous exercise such as running."

B

13. A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? A. A 45-year-old who takes an aspirin daily B. A 50-year-old who is post coronary artery bypass graft surgery C. A 78-year-old who had a carotid endarterectomy D. An 80-year-old with chronic obstructive pulmonary disease

B

13. A patient with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply? A. Heating pad B. Ice packs C. Splints D. Wax dip

B

14. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commission's Core Measures outcomes? A. Obtain an electrocardiogram (ECG) now and in the morning. B. Give the client an aspirin. C. Notify the Rapid Response Team. D. Prepare to administer thrombolytics.

B

14. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? A. Sinus tachycardia B. Speech alterations C. Fatigue D. Dyspnea with activity

B

14. Mrs. Jane and her new husband just returned from their honeymoon on a 9 hour flight from Hawaii two days ago. She presents to the ED complaining of a severe burning pain and warmth in the right leg. The client reported this began 24-48 hours prior and had increasingly worsened to the point where she knew she had to come in. Mrs. Jane takes an oral contraceptive and smokes ½ pack of cigarettes each day. The nurse identifies that Mrs. Jane has which risk factors? A) Pregnancy B) Travel, Smoking, oral contraceptive use C) Smoking and travel

B

15. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? A. Sotalol (Betapace) B. Warfarin (Coumadin) C. Atropine (Sal-Tropine) D. Lidocaine (Xylocaine)

B

15. On assessment you note redness to the area of the leg that Mrs. Jane points to and a DVT was suspected immediately. What diagnostic testing would you anticipate preparing your patient for? A. CBC and CT Scan B. D-Dimer and Duplex Ultrasound C. Chest X-Ray and D-Dimer D. CBC and V/Q scan

B

16. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? A. Administer intravenous diltiazem (Cardizem). B. Assess vital signs and level of consciousness. C. Administer sublingual nitroglycerin. D. Assess capillary refill and temperature.

B

16. A patient had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this patient has been met? A. Pain rated as 2/10 after medication B. Distal pulse on affected extremity 2+/4+ C. Remains on bedrest as directed D. Verbalizes understanding of procedure

B

16. What is a potential complication of deep vein thrombosis? A. Hemorrhagic stroke B. Pulmonary embolus C. Septic shock D. Increased ejection fraction

B

17. A patient is 4 hours postoperative after a femoropopliteal bypass. The patient reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? A. Administer pain medication as ordered. B. Assess distal pulses and skin color. C. Document the findings in the patient's chart. D. Notify the surgeon immediately

B

17. A patient is scheduled to have a hip replacement. Preoperatively, the patient is found to be mildly anemic and the surgeon states the patient may need a blood transfusion during or after the surgery. What action by the preoperative nurse is most important? A. Administer preoperative medications as prescribed. B. Ensure that a consent for transfusion is on the chart. C. Explain to the patient how anemia affects healing. D. Teach the patient about foods high in protein and iron.

B

18. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? A. "I should wear a snug-fitting shirt over the ICD." B. "I will avoid sources of strong electromagnetic fields." C. "I should participate in a strenuous exercise program." D. "Now I can discontinue my antidysrhythmic medication."

B

19. A patient is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The patient begins to mumble and is disoriented. What action by the nurse takes priority? A. Assess the patient's neurologic status. B. Notify the Rapid Response Team. C. Prepare to administer vitamin K. D. Turn down the infusion rate.

B

20. A patient is receiving heparin therapy and warfarin sodium (coumadin). The patient asks the nurse why both medications are being administered. The nurse understands that Warfarin: A. Stimulates the breakdown of specific clotting factors by the liver, and it several days for this is exhibit an anticoagulant effect. B. Inhibits synthesis of specific clotting factors in the liver, and it takes several days for this medication to exert an anticoagulation effect. C. Stimulates production of the body's own thrombolytic substances, but it takes several days for it to begin. D. Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic.

B

23. Central venous catheters can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

B

25. A nurse is providing preoperative teaching for a patient who will undergo percutaneous insertion of an inferior vena cava filter. The nurse explains to the patient that the vena cava filter is placed because: A. "This will catch the PE that you have before it goes to your heart." B. "This is recommended therapy for patients who do not have therapeutic results for anticoagulation, or anticoagulation is contraindicated." C. "This is an experimental procedure to see if it works better than anticoagulation."

B

26. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? A. Schedule an electrocardiogram just before the MRI. B. Notify the health care provider before scheduling the MRI. C. Call the physician and request a laboratory draw for cardiac enzymes. D. Instruct the client to increase fluid intake the day before the MRI.

B

28. The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, "The pain has not gotten any better." What kind of angina does the patient have? A. Stable Angina B. Unstable Angina C. Neither. This is normal for the patient.

B

29. An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion? A. Calf pain on exertion which stops when standing in one place. B. Pain in the calf upon exertion and dull ache in the ball of the foot C. Pain upon arising in the morning which is relieved after some stretching and exercise.

B

29. The nurse identifies a priority problem of fatigue and weakness for the patient with heart failure. After ambulating 200 feet down the hall, the patient's blood pressure change is more than 20 mmHg. How does the nurse interpret this data? A. The patient is building endurance. B. The activity is too stressful. C. The patient could walk farther. D. The activity is appropriate.

B

3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? A. "I sleep with four pillows at night." B. "My shoes fit really tight lately." C. "I wake up coughing every night." D. "I have trouble catching my breath."

B

3. The clinic nurse assesses a patient with diabetes during a checkup. The patient also has osteoarthritis (OA). The nurse notes the patient's blood glucose readings have been elevated. What question by the nurse is most appropriate? A. "Are you compliant with following the diabetic diet?" B. "Have you been taking glucosamine supplements?" C. "How much exercise do you really get each week?" D. "You're still taking your diabetic medication, right?"

B

3. The nurse is assessing a patient who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the patient's right foot. What condition do these findings correlate with? A. Diabetic foot ulceration B. Peripheral arterial disease C. Peripheral venous disease D. Deep vein thrombosis

B

30. The nurse is assessing a client who is 6 hours postoperative from coronary artery bypass graft surgery. The client's mediastinal tubes are not draining. Which action does the nurse implement at this time? A. Replace the drainage tubing. B. Check for kinks in the tubing. C. Irrigate the tubing with normal saline. D. Document the finding.

B

31. The FDA has issued a black box warning for many anticoagulants. The warning indicates that these agents should be: A. Continued throughout orthopedic surgical procedures to prevent DVT B. Discontinued for a few days before any spinal procedure C. Continued throughout spinal procedures D. Continued in patients undergoing neurosurgery procedures

B

33. After assessing the patient, you document the following: Jugular venous distention 2+ edema in feet and ankles Swollen hands and fingers Distended abdomen Bibasilar crackles on auscultation Productive cough with pink-tinged sputum What is your most likely interpretation of these findings? A. Biventricular failure B. Class IV heart failure C. Left-sided heart failure D. Right-sided heart failure

B

33. The nurse is working with a patient experiencing palpitations, lightheadedness, and fatigue. Diagnostic tests reveal atrial fibrillation at a rate of 130. The patient has had unsuccessful cardioversions in the past. After seeing a cardiologist, the patient is scheduled for radiofrequency catheter ablation. What is an important teaching point to include at discharge for this patient? A. The importance of taking antibiotics B. The need to report the recurrence of palpitations, lightheadedness, or fatigue C. The recommendation to avoid all contact sports activities for six months D. The importance of a heart healthy diet to maintain his heart's rhythm

B

33. The nurse understands that all of the following are risk factors for DVT except: A. Tobacco use B. Running 2 miles every day C. Recent abdominal surgery D. Cancer E. Heart Failure

B

34. A 51-year-old man came to the hospital 2 days ago for recurrent exacerbation of heart failure. He weighs 237 lbs and is 5' 8" tall. He has IV access in his left forearm and is on oxygen at 2 L per nasal cannula. When you assess the patient, he is sitting on the side of the bed and appears to be short of breath. He tells you that he has just returned from the bathroom. He is sweating and his nasal cannula is laying on the bedside table. Which action should you take first? A. Take his vital signs. B. Replace the nasal cannula. C. Sit him up in a bedside chair. D. Call the Rapid Response Team.

B

34. The nurse recognizes that the appropriate pain management method on post-op day #2 for a patient who has under gone a hip arthroplasty is which of the following? A. IV PCA pump with morphine B. Oxycodone oral route C. An epidural catheter with hydromorphone D. Tylenol

B

34. The patient with stable angina is to undergo a stress test with radioactive imaging. The patient tells the nurse that he does not understand what the point of this test is. The nurse responds that the test will: A. Determine if a clot-busting fibrinolytic drug or a stent would be best for managing the patient's angina. B. Show portions of the heart muscle that might not receive an adequate blood flow. C. Show the actual anatomical location and degree of coronary blockages D. Try to reproduce heart rhythms, such as atrial fibrillation, that might be harmful outside of the hospital setting,

B

35. A client returns to the clinic following discharge from the hospital. He is taking warfarin sodium (Coumadin) 2mg PO daily. Which of the following statements by the patient to the nurse indicates that further teaching is necessary? a. "I have been taking an antihistamine before bed." b. "I take an aspirin when I have a headache." c. "I use sunscreen when I go outside." d. "I take Mylanta if my stomach gets upset."

B

35. A nurse plans a discharge teaching session with a client who has received a permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. Avoid using cell phones B. Avoid working over open motors C. Carry nitroglycerin with you at all times D. Have your blood drawn to check your bleeding times

B

35. The nurse anticipates a patient who has undergone a hip arthroplasty procedure will require which of the following strategies to aid elimination on post-op day #2? A. Use of a urinary catheter to gravity drain B. Use of a bedside commode C. Use of an anti-diarrheal D. Fluid intake of 500 ml

B

35. When caring for a patient after a cardiac catheterization, it is most important that the nurse: A. Administer oxygen until the patient is permitted to ambulate B. Be alert to changes in blood pressure which could indicate bleeding C. Check the 12 lead electrocardiogram (ECG) every 30 minutes for ST changes D. Medicate the patient with prn aspirin for back pain related to the procedure and bedrest

B

36. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? A. Assess the client's lung sounds. B. Notify the Rapid Response Team. C. Provide reassurance to the client. D. Take a full set of vital signs.

B

36. The nurse notes a change in the patient's cardiac rhythm. The patient is second day post-MI. The rhythm strip changed from normal sinus rhythm to sinus rhythm with short runs of ventricular tachycardia. The nurse assesses the patient, whose blood pressure is now 100/54, pulse is palpable 188 bpm. She is lethargic, but arousable. Which intervention should the nurse initiate first? A) Place the crash cart in close proximity to the room. B) Administer amiodarone (cordarone) IV. C) Hang an IV infusion of dopamine (Intropin). D) Charge the defibrillator to 200 joules.

B

37. A patient had two stents placed in the left anterior descending (LAD) artery after having an ST elevated myocardial infarction (STEMI). As the nurse, you are reviewing the discharge instructions with the patient. Which of the following statements is NOT correct related to this patient's discharge medications? A. The atorvastatin should be taken at night. The goal is a low density lipoprotein (LDL) of less than 70. B. You should not need to carry nitroglycerin since you now have the stents C. You should use acetaminophen (Tylenol), not aspirin, to relieve pain at the catheter insertion site D. You will need to take both clopidogrel (Plavix) and aspirin until the doctor tells you otherwise

B

37. A patient who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? A. Give 20 mEq of potassium chloride B. Initiate continuous cardiac monitoring C. Teach about the side effects of diuretics D. Arrange a consultation with the dietician.

B

38. The patient returning from a stent tells the nurse: "I think I had another heart attack when they put that stent in, but nobody will listen to me. It felt just like it did when I came in." The nurse's best response is: A. If you said you have pain, I believe you. I know you must be glad it is over. B. It is common to have pain when the balloon is inflated, so the physician carefully watches your electrocardiogram to make sure you are safe during the procedure. C. Since you were sedated during the procedure, they probably thought it was nothing to worry about. D. I will let your physician team know, and they will explain it.

B

39. A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? A. Decrease the heparin rate. B. Increase the heparin rate. C. No change to the heparin rate. D. Stop heparin; start warfarin (Coumadin).

B

39. Which of the following is NOT an appropriate nursing intervention for the patient who has a post-operative fever 24-48 hours after cardiac surgery? A. Ambulate with assistance B. Maintain patient on complete bedrest. C. Deep breath and cough D. Use incentive spirometer 5-10 times/hr

B

4. A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? A. Oxygen saturation of 92% B. Dyspnea on exertion C. Muted systolic murmur D. Upper extremity weakness

B

40. Which of the following statements is true about decreased cardiac output in the postop coronary artery bypass graft patient? A. Decreased cardiac output usually does not manifest until the patient is ambulatory B. A change in mentation could be an indicator of decreased cardiac output. C. Only hemodynamic monitoring would indicate decreased cardiac output. D. The nurse would anticipate administering beta blockers for the patient with decreased cardiac output.

B

43. A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurse's priority intervention while waiting for the defibrillator to arrive? A. Perform a pericardial thump. B. Initiate cardiopulmonary resuscitation. C. Start an 18-gauge IV in the antecubital. D. Ask the client's family about code status.

B

43. The patient with rheumatoid arthritis may present with a positive rheumatoid factor and what other laboratory value? A. Elevate Cardiac enzymes B. Elevated Erythrocyte sedimentation rate (ESR) C. Decreased antinuclear antibody (ANA) D. Elevated potassium levels

B

46. Which drug is given within 1-2 hours of an MI when the patient is hemodynamically stable, to help the heart to perform more work without ischemia? A. SL nitroglycerin B. Beta blockers C. Antiplatelet agents D. Calcium channel blockers

B

5. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? A. "The prosthetic valve places you at greater risk for a heart attack." B. "Blood clots form more easily in artificial replacement valves." C. "The vein taken from your leg reduces circulation in the leg." D. "The surgery left a lot of small clots in your heart and lungs."

B

6. After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? A. Provide food to decrease nausea and aid in absorption. B. Instruct the client to ask for assistance when rising from bed. C. Collaborate with unlicensed assistive personnel to bathe the client. D. Monitor potassium levels and check for symptoms of hypokalemia.

B

6. After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? A. "I'll be able to carry heavy loads after 6 months of rest." B. "I will have my teeth cleaned by my dentist in 2 weeks." C. "I must avoid eating foods high in vitamin K, like spinach." D. "I must use an electric razor instead of a straight razor to shave."

B

7. A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? A. Heart rate that speeds up and slows down B. Friction rub at the left lower sternal border C. Presence of a regular gallop rhythm D. Coarse crackles in bilateral lung bases

B

8. The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? A. Respiratory rate of 28 breaths/min B. Urinary output of 10 mL/hr C. Heart rate of 100 beats/min D. Dry cough

B

9. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? A. Premature ventricular contractions B. Atrial fibrillation C. Symptomatic bradycardia D. Sinus tachycardia

B

9. A nurse works in the rheumatology clinic and sees patients with rheumatoid arthritis (RA). Which patient should the nurse see first? A. Patient who reports jaw pain when eating B. Patient with a red, hot, swollen right wrist C. Patient who has a puffy-looking area behind the knee D. Patient with a worse joint deformity since the last visit

B

6. Which of the following is NOT an appropriate teaching point for patients with Stage 2 (Claudication) Peripheral Arterial Disease? A. Always wear well-insulated, soft shoes, along with cotton socks. B. Avoid cold. Keep your legs warm with blankets or heating pads when needed. C. If you have pain when walking, rest but then try to walk just a little further. D. Don't cross your legs. Try to keep them in a dangling position to relieve pain.

B All of the instructions are appropriate except the use of heating pads. Individuals with PAD should not be encouraged to use heating pads, as they may not accurately perceive the temperature, hence risking a burn injury.

9. Which of the following nursing diagnoses has the highest priority for a newly admitted patient with acute femoral artery occlusion? A. Activity intolerance B. Altered tissue perfusion C. Risk for infection D. Risk for bleeding

B Highest priority is circulation. "Risk for" diagnoses are not often priorities, although the nurse will of course do every intervention possible to keep the actual problem from occurring.

1. Mrs. George is a 65-year-old female with a past medical history of hypertension. She has been having increasing intermittent claudication and is being seen for diagnostic evaluation. You are asked by the physician to measure an ankle-brachial index (ABI). The following findings would be consistent with arterial insufficiency: A. Brachial pressure of 60; ankle pressure 120 B. Brachial pressure of 100; ankle pressure 90 C. Brachial pressure of 140; ankle pressure of 140

B ankle/brachial PAD if </=0.9

18. An older patient is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate? A. Instruct the patient to avoid large crowds. B. Prepare to administer epoetin alfa (Epogen). C. Teach the patient about foods high in iron. D. Tell the patient that all laboratory results are normal

B epotein is a drug to treat anemia, so it will help with low iron counts

The older patient with CAD is more likely to have what symptoms if experienceing cardiac ischemia? a. syncope b. dyspnea c. chest pain d. depression

B . dyspnea

24. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.) A. It affects single joints only. B. Antibodies lead to inflammation. C. It consists of an autoimmune process. D. Morning stiffness is rare. E. Permanent damage is inevitable.

B, C

28. A 67-year-old woman who lives alone is admitted after tripping on a rug in her home and fractures her hip. A hip fracture can cause changes in what component of Virchow's triad? Select all that apply A. Blood coagulability B. Vessel walls C. Blood flow

B, C think trauma

19. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) A. Age B. Hypertension C. Obesity D. Smoking E. Stress

B, C, D, E

10. Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) A. Middle-aged client awaiting surgery B. Older adult with a 20-pack-year history of smoking C. Client who has been on bedrest for 3 weeks D. Obese client who has elevated platelets E. Middle-aged client with diabetes mellitus type 1 F. Older adult who has just had abdominal surgery

B, C, D, F

35. During the evening shift, the patient has a bedside echocardiogram, which reveals an ejection fraction of 30%. Based on this finding, which medications might the provider order? (Select all that apply.) A. Multivitamin 1 PO each day B. Lisinopril (Zestril) 5 mg PO daily C. Digoxin (Lanoxin) 0.25 mg PO daily D. Ibuprofen (Advil) 200 PO mg twice daily E. Furosemide (Lasix) 20

B, C, E

4. An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) A. Hypertension B. Fatigue despite adequate rest C. Indigestion D. Abdominal pain E. Shortness of breath

B, C, E

9. Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) A. Wheezes throughout lung fields B. Hemoptysis C. Sharp chest pain D. Flattened neck veins E. Hypotension F. Pitting edema

B, C, E

3. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) A. Administer pain medication. B. Assess distal pulses every 10 minutes. C. Have the client sign a surgical consent. D. Notify the Rapid Response Team. E. Take vital signs every 10 minutes.

B, D, E

40. A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) A. Client who had a reaction to contrast dye yesterday B. Client with a new spinal cord injury on a rotating bed C. Middle-aged man with an exacerbation of asthma D. Older client who is 1-day post hip replacement surgery E. Young obese client with a fractured femur

B, D, E

1. The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time? A. 15 seconds B. 30 seconds C. 60 seconds D. 150 seconds

C

12. The nurse is providing discharge education to a patient after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include? A. "No restrictions are necessary." B. "Avoid sleeping on your left side for 6 weeks." C. "Avoid heavy lifting for about 3 months." D. "You will have a distended abdomen for 2 weeks."

C

16. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? A. Blood pressure that is 20 mm Hg below baseline B. Oxygen saturation of 94% on room air C. Poor peripheral pulses and cool skin D. Urine output of 1.2 mL/kg/hr for 4 hours

C

16. A nurse is discharging a patient after a total hip replacement. What statement by the patient indicates good potential for self-management? A. "I can bend down to pick something up." B. "I no longer need to do my exercises." C. "I will not sit with my legs crossed." D. "I won't wash my incision to keep it dry."

C

17. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed? A. 1530 (3:30 PM) B. 1600 (4:00 PM) C. 1630 (4:30 PM) D. 1700 (5:00 PM)

C

17. A doppler ultrasound study revealed abnormalities at the level of the tibial veins, superficial thrombophlebitis in the greater saphenous vein from the distal thigh to the knee level for a distance of eight centimeters, and a calf vein thrombosis. The client was, at this point, admitting to the hospital for coagulation therapy due to a family history of Factor V Leiden deficiency. Mrs. Jane is started on a heparin infusion for her DVT. The nurse understands that which lab value will be followed closely? A. INR every 4 hours B. PT every 2 hours C. aPTT every 6 hours D. D-Dimer every day

C

18. When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: A. At least 6 hours B. The first 24 hours C. 2-3 days D. 1 week

C

19. The nurse receives orders to begin a heparin infusion (FULL Bolus nomogram) for a patient with a DVT and PE. While implementing this order, a nurse ensures that which of the following antidote medications is available? A. Amicar B. Potassium chloride C. Protamine sulfate D. Fresh frozen plasma E. Vitamin K

C

2. A patient with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse's best response? A. "Injury to the arteries causes them to spasm, reducing blood flow to the extremities." B. "Excess fats in your diet are stored in the lining of your arteries, causing them to constrict." C. "A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow." D. "Excess sodium causes injury to the arteries, reducing blood flow and eventually causing obstruction."

C

20. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? A. "Substance abuse puts clients at risk for many health issues." B. "The hospital requires that I ask you about cocaine use." C. "Clients who use cocaine are at risk for fatal dysrhythmias." D. "We can provide services for cessation of substance abuse."

C

20. The nurse should be correct in withholding a dose of digoxin in a patient with heart failure without specific instruction from the healthcare provider if the patient's A. Serum digoxin level is 1.5 B. Blood pressure is 104/68 C. Serum potassium level is 3. D. Apical pulse is 68bpm

C

21. A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The patient's history indicates the infarction occurred ten hours ago. Which laboratory test result should the nurse expect the patient to exhibit? A. Elevated LDH B. Elevated serum amylase C. Elevated CK-MB D. Elevated hematocrit

C

22. A lung tumor can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

C

22. Which definition best describes left-sided heart failure? A. Increased volume and pressure develop and result in peripheral edema B. Can occur when cardiac output remains normal or above normal. C. Decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in the pulmonary vessels D. Percentage of blood ejected from the heart during systole

C

23. Which instruction should the nurse include when teaching about the use of sublingual nitroglycerin? A. Put 1 tablet under the tongue each morning to help prevent angina attacks. B. Obtain a fresh supply of tablets if tingling occurs when the tablet is placed under the tongue. C. Place a tablet under the tongue every 5 minutes until the pain is relieved, up to 3 tablets. D. Store the container of nitroglycerin tablets in the refrigerator to maintain freshness.

C

25. A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min she is stable with no signs or symptoms of decreased perfusion. Which action should the nurse take first? A. Document the finding in the chart. B. Initiate external pacing. C. Assess the client's medications. D. Administer 1 mg of atropine.

C

26. A female client taking oral contraceptives calls the internal medicine clinic and tells the nurse that she is experiencing calf pain. What action should the nurse implement? A. Determine if the client has also experienced breast tenderness and weight gain. B. Encourage the client to begin a regular, daily program of walking and exercise. C. Advise the client to present to the ED for immediate medical attention. D. Tell the client to stop taking the medication for a week to see if symptoms subside

C

3. The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client? A. "You must have your aPTT checked every 2 weeks." B. "Massage the injection site after the heparin is injected." C. "Notify your health care provider if your stools appear tarry." D. "An IV catheter will be placed to administer your heparin."

C

30. Why does the nurse document the precise location of crackles auscultated in the lungs of a patient with heart failure? A. Crackles will eventually change to wheezes as the pulmonary edema worsens B. The level of the fluid spreads laterally as the pulmonary edema worsens C. The level of fluid ascends as the pulmonary edema worsens D. Crackles will eventually diminish as the pulmonary edema worsens.

C

32. A patient who has been receiving heparin subcutaneously for 10 days has all of the following laboratory blood test values. Which value does the nurse report to the physician immediately? A. Prothrombin time (PT) 1.5 B. International normalized ration (INR) 1.7 C. Platelets 20,000/mm2

C

32. The nurse is caring for a patient post-cataract surgery in the post-anesthesia care unit. The patient complains of chest pain. An electrocardiogram is obtained and shows ST elevation. The nurse proactively prepares for what intervention? A. Admission to the step-down unit for further monitoring B. Fibrinolytic therapy C. Left heart catheterization and possible percutaneous intervention (PCI) D. Right heart catheterization

C

32. The nurse recognizes that a patient's level of activity post-op day 2 after hip arthroplasty should consist of which of the following? A. Bedrest B. Climbing stairs C. Ambulating in the hallway D. Run on the treadmill

C

34. The nurse is preparing to discharge a 82-year-old patient on warfarin (Coumadin) therapy for pulmonary embolism. The nurse's discharge instructions should include with of the following instructions? a. Follow a healthy diet by increasing ingestion of green, leafy vegetables. b. Take herbal remedies to manage cold symptoms. c. Avoid alcohol due to enhanced coagulation effect. d. Take Coumadin only on an empty stomach.

C

37. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? A. Encourage the client to walk 5 minutes each hour. B. Refer the client to smoking cessation classes. C. Teach the client about factor V Leiden testing. D. Tell the client that sometimes no cause for disease is found.

C

38. A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the client has respiratory distress syndrome." C. "The blood clot interferes with perfusion in the lungs." D. "The client needs immediate intubation and mechanical ventilation."

C

4. The nurse working in the orthopedic clinic knows that a patient with which factor has an absolute contraindication for having a total joint replacement? A. Needs multiple dental fillings B. Over age 85 C. Severe osteoporosis D. Urinary tract infection

C

42. The nurse is caring for a client admitted for myocardial infarction. The client's monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for? A. Sinus tachycardia B. Rapid atrial flutter C. Ventricular tachycardia D. Atrioventricular junctional rhythm

C

46. The post anesthesia recovery unit (PACU) nurse is giving hand off report to the 6 East nurse for an 82 year old patient who had a total hip replacement 2 hours ago. For which reported information about the patient or surgery does the receiving nurse ask the reporting team more details? A. Estimated blood loss 150ml B. The patient reported an allergy to codeine C. The total intraoperative urine output is 25 ml

C

6. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? A. Urinary output less than intake B. Bruising at the insertion site C. Slurred speech and confusion D. Discomfort in the left leg

C

7. The nurse is caring for a patient recovering from a stent to the tibial artery. The pedal pulse was palpable at the beginning of the shift and now 4 hours later, the Doppler is unable located a pulse. The nurse's priority action at this point is to: A. Call the physician B. Give a prn dose of cilostazol (Pletal) C. Assess capillary refill, temperature, color, and sensation of the extremity D. Obtain a 12 lead electrocardiogram (ECG)

C

8. The nurse is caring for a patient 6 hours after an aorto-bi-femoral bypass surgery. Which of the following findings would be significant to report to the physician post-operatively? A. 2+ pedal pulses bilaterally (pre-op pedal pulses 1+ bilaterally) B. 2 out of 10 pain on a 10 point scale and 1+ edema at the incision site C. A decreasing urine output D. A blood pressure reading of 138/74 (pre-op 144/78)

C

9. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? A. Assess the client's pupillary responses. B. Request a neurologic consultation. C. Stop the infusion and call the provider. D. Take and document a full set of vital signs.

C

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? A. "I have been drinking more water than usual." B. "I am awakened by the need to urinate at night." C. "I must stop halfway up the stairs to catch my breath." D. "I have experienced blurred vision on several occasions."

C

21. A patient has rheumatoid arthritis that especially affects the hands. The patient wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best? A. "Let's ask the provider about increasing your pain pills." B. "Hold ice bags against your hands before quilting." C. "Try a paraffin wax dip 20 minutes before you quilt." D. "You need to stop quilting before it destroys your fingers."

C Paraffin wax can be applied to the hands to heat up the joints and relieve pain

41. When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) A. Avoid drinking alcohol. B. Eat more omega-3 fatty acids. C. Exercise on a regular basis. D. Maintain a healthy weight. E. Stop smoking cigarettes.

C, D, E

10. A patient with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The patient reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? A. Assist the patient to change positions. B. Document the findings in the patient's chart. C. Encourage range of motion of the neck. D. Notify the provider immediately.

D

11. On a telemetry monitor, the nurse observes that a patient's heart rhythm is sustained ventricular tachycardia (VT). Upon assessment, the patient is alert and oriented with no reports of chest pain, but expresses feeling slightly short of breath. His blood pressure is 108/70. What is the nurse's first action? A. Synchronized cardioversion B. CPR and immediate defibrillation C. Administration of IV amiodarone (Cordarone) and dextrose D. Administration of oxygen and observation of the heart rhythm

D

12. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? A. Assessing blood pressure in both upper extremities B. Auscultating the carotid arteries for any bruits C. Classifying capillary refill of 4 seconds as normal D. Palpating both carotid arteries at the same time

D

12. The nurse in the rheumatology clinic is assessing patients with rheumatoid arthritis (RA). Which patient should the nurse see first? A. Patient taking celecoxib (Celebrex) and ranitidine (Zantac) B. Patient taking etanercept (Enbrel) with a red injection site C. Patient with a blood glucose of 190 mg/dL who is taking steroids D. Patient with a fever and cough who is taking tofacitinib (Xeljanz)

D

13. The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning? A. Cholesterol: 126 mg/dL B. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL C. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL D. Triglycerides: 198 mg/dL

D

15. A nurse is caring for a patient after joint replacement surgery. What action by the nurse is most important to prevent wound infection? A. Assess the patient's white blood cell count. B. Culture any drainage from the wound. C. Monitor the patient's temperature every 4 hours. D. Use aseptic technique for dressing changes.

D

17. A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? A. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg B. Respiratory rate decreased from 25 breaths/min to 14 breaths/min C. Oxygen saturation increased from 88% to 96% D. Pulse decreased from 100 beats/min to 80 beats/min

D

17. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? A. Make sure the defibrillator is set to the synchronous mode. B. Administer 1 mg of intravenous epinephrine. C. Test the equipment by delivering a smaller shock at 100 joules. D. Ensure that everyone is clear of contact with the client and the bed.

D

19. A patient taking furosemide (Lasix) reports difficulty sleeping. What question is most important for the nurse to ask the patient? A. What dose of the medication are you taking? B. Are you eating foods rich in potassium? C. Have you lost weight recently? D. At what time do you take the medication?

D

2. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? A. Assesses the client for back pain B. Auscultates over abdominal bruit C. Measures the abdominal girth D. Palpates the abdomen abdominal mass

D

21. A 77 year-old female patient is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 bpm. Which question is a priority for the nurse to ask this patient or her family on admission? "Does the patient A. Have her own teeth or dentures?" B. Take aspirin and if so, how much?" C. Take nitroglycerin?" D. Take digitalis?"

D

22. Dysrhythmias are a concern for any patient. However, the presence of a dysrhythmia is more serious in an elderly person because A. Elderly persons usually live alone and cannot summon help when symptoms appear B. Elderly persons are more likely to eat high-fat diets which make them susceptible to heart disease C. Cardiac symptoms, such as confusion, are more difficult to recognize in the elderly. D. Elderly persons are intolerant of decreased cardiac output which may result in dizziness and falls.

D

24. Which technique is considered the gold standard for diagnosing DVT? A. CT Scan B. Venography C. MRI D. Doppler flow ultrasound study

D

27. The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, "The pain has not gotten any better." What does the nurse do next? A. Place the client in a semi-Fowler's position. B. Administer intravenous nitroglycerin. C. Begin supplemental oxygen at 2 L/min. D. Notify the health care provider.

D

27. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? i. Apply sequential compression devices (SCDs) bilaterally. ii. Assess for a positive Homan's sign in each leg. iii. Pad all bony prominences on the affected leg. iv. Advise the client to keep the leg elevated when in bed.

D

29. The nurse is assessing a client who had percutaneous transluminal coronary angioplasty (PTCA) 1 hour ago. Which complication does the nurse monitor for? A. Hypertensive crisis B. Hyperkalemia C. Infection D. Bleeding

D

31. Which of the following patients is most likely to present with a myocardial infarction (MI) without chest pain? A. A 35 year old man with hypothyroidism B. A 43 year old man with allergy to contrast dye C. A 50 year old woman with hyperthyroidism D. A 65 year old woman with diabetes mellitus

D

32. The nurse is working with a 62 year-old woman admitted with a heart rate of 160. After receiving intravenous (IV)metoprolol (Lopressor), her heart rate decreases to 130 but she develops crackles and her oxygen saturation drops to 89%. The physician decides to urgently cardiovert the patient. What diagnostic test would the nurse likely prepare the patient for prior to the cardioversion? A. Cardiac catheterization B. Electrophysiology studies C. Holter monitoring D. Transesophageal echocardiogram

D

33. The nurse assesses a patient in the emergency room with complaints of nausea, fatigue, and dull chest pain after exercise. Which test provides the earliest sign that the patient might have cardiac muscle injury? A. Myoglobin B. Erythrocyte sedimentation rate (ESR) C. Lactate dehydrogenase (LDH) D. Troponin T

D

33. The nurse should assess the following in order to ensure that the patient receives safe and effective analgesia post hip arthroplasty procedure. A. Age B. Pre-operative use of opioids C. Mental status D. All of the above

D

34. Which of the following nursing interventions should be included in the care of a patient who has just returned from a permanent pacemaker insertion? A. Give the patient's morning medications upon return to the unit, including aspirin and other anticoagulants, if ordered B. Maintain the patient NPO until the electrocardiogram (ECG) shows normal sinus rhythm C. Maintain the patient on strict bedrest for at least 24 hours after placement of the pacemaker D. Restrict movement of the affected arm and shoulder for at least 6 hours

D

39. Signs and symptoms of a moderate to severe systemic and inflammatory blood transfusion reaction includes all of the following except: A. Itching and hives B. Bronchospasm and dyspnea C. Hypotension D. Hypertension

D

42. Which client should the nurse assess first? A) A patient post-PTCA, whose pulse distal to the insertion site is +3, with capillary refill of 2 seconds. B) A client with stable angina who is complaining of chest discomfort that has been relieved by one nitroglycerin tablet sublingually (SL). C) A client 5 days post-MI who is complaining that he is constipated and demands that his healthcare provider be called. D) A client recently started on a fibrinolytic for reocclusion after a PCI.

D

44. The nurse is working with a 62 year-old woman admitted with a heart rate of 160. After receiving intravenous (IV) metoprolol (Lopressor), her heart rate decreases to 130 but she develops crackles and her oxygen saturation drops to 89%. The physician decides to urgently cardiovert the patient. What diagnostic test would the nurse likely prepare the patient for prior to the cardioversion? A. Cardiac catheterization B. Electrophysiology studies C. Holter monitoring D. Transesophageal echocardiogram

D

45. The nurse is caring for a patient less than 24 hours post-op. In report the nurse learns that he rings his call light frequently, is anxious, and has had pain medications as ordered. Which of the following nondrug interventions should the nurse include when caring for this patient? A. Assure that patient his anxiety is understandable, because the pain medications need time to take effect. B. Assess other patients first, giving the patient time to relax. C. Call the MD to increase the amount or frequency of pain medications ordered. D. Provide a quiet environment, offer repositioning, straighten the bed linens, offer fluids, and assess the pain level.

D

5. An older patient has returned to the surgical unit after a total hip replacement. The patient is confused and restless. What intervention by the nurse is most important to prevent injury? A. Administer mild sedation. B. Keep all four siderails up. C. Restrain the patient's hands. D. Use an abduction pillow.

D

7. A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? A. Irrigate the Foley. B. Administer an antibiotic. C. Clamp the Foley. D. Notify the health care provider.

D

7. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? A. Client's level of anxiety B. Ability to turn self in bed C. Cardiac rhythm and heart rate D. Allergies to iodine-based agents

D

7. A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching? A. "Avoid taking aspirin or aspirin-containing products." B. "Increase your intake of foods that are high in potassium." C. "Hold this medication if your pulse rate is below 80 beats/min." D. "Do not take this medication within 1 hour of taking an antacid."

D

8. A nurse is discharging a patient to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important? A. Administering pain medication before transport B. Answering any last-minute questions by the patient C. Ensuring the family has directions to the facility D. Providing a verbal hand-off report to the facility

D

A patient has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The patient will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the patient?" A. Facial flushing B. Fever C. Pounding headache D. Feelings of dizziness

D

4. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.5. What is the nurse's best action? A. Increase the heparin dose. B. Increase the warfarin dose. C. Continue the current therapy. D. Discontinue the heparin.

D (The patient has reached a therapeutic INR with the Coumadin, so the heparin infusion will be discontinued)

22. A nurse is preparing a patient for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Administering preoperative medication B. Ensuring the consent is signed C. Marking pulses with a pen D. Raising the siderails on the bed E. Recording baseline vital signs

D,E

3. A systematic approach to ECG analysis includes: A. Evaluation of waveforms and complexes: P wave, QRS complex, T wave B. Intervals and segments: PR interval, QRS duration, ST segment, QT interval C. Heart Rate D. Rhythm and regularity E. All of the above

E

36. The nurse is completing a neurovascular assessment on a patient who has under gone a hip arthroplasty (post-op day 2). The nurse understands that components of a neurovascular exam include all of the following except: A. Temperature of extremity B. Capillary refill C. Peripheral pulses D. Sensory and motor function E. Heart sounds

E

37. The nurse and orientee are caring for a patient who is postoperative day 1 from a total hip replacement. The nurse explains to the orientee that major nursing priorities for the patient include all of the following except: A. Pain control B. Decrease risk of infection C. DVT prophylaxis D. Regulate urination and bowel movements after surgery E. Only assess neurovascular assessment at discharge

E

38. The nurse and orientee are caring for a patient who is postoperative day 1 from a total hip replacement. The nurse explains to the orientee that a major complication of this surgery is hip dislocation. All of the following are interventions to prevent hip dislocation except: A. Prevent adduction of hip with abduction pillow B. Prevent hip flexion beyond 90 degrees (hip) C. Ensure the abduction pillow is in place before turning D. Do not cross legs E. Encourage adduction while the patient is sitting in a chair

E

6. Sinus tachycardia is associated with: A. Anxiety, fear, pain, fever B. Hyperthyroidism, hypovolemia C. Potential hemodynamic compromise due to inadequate time for cardiac filling D. Heart rates in excess of 100 bpm E. All of the above

E

7. Treatment of atrial dysrhythmias may include: A. Electrical cardioversion B. Beta blockers C. Digoxin D. Calcium channel blockers E. All of the above

E

9. Potential causes of PVCs include: A. Heart disease B. Hypoxia C. Hypokalemia D. Anxiety, pain, stress E. All of the above

E

1. A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? A. All B. patients C. take D. meds

A

24. The nurse is assessing a patient with left-sided heart failure. Which assessment findings does the nurse expect to see in this patient? Select all that apply A. Displacement of the apical impulse to the left B. S3 heart sound C. Paroxysmal nocturnal dyspnea D. Jugular vein distension E. Oligria during the day F. Wheezes or crackles

A, B, C, E, F

16. A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) A. Teach the client about dietary restrictions. B. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. C. Encourage the client to take a baby aspirin each day. D. Confirm that an echocardiogram has been completed. E. Consult a social worker for additional resources.

A, B, D

20. A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) A. Accompanied by shortness of breath B. Feelings of fear or anxiety C. Lasts less than 15 minutes D. No relief from taking nitroglycerin E. Pain occurs without known cause

A, B, D, E

25. A patient who was admitted for newly diagnosed heart failure is now being discharged. The nurse instructs the patient and family on how to manage heart failure at home. What major self-management categories should the nurse include? Select all that apply. A. Medications B. Weight C. Heart Transplants D. Activity E. Diet

A, B, D, E

47. The nurse is caring for a patient who had a PCI. Which post-procedure interventions are included in the care for this patient? Select all that apply A. Monitor for acute closure of the vessel B. Observe for bleeding from the insertion site C. Maintain bedrest for 48 hours. D. Observe for hypotension, hypokalemia, and dysrhythmias E. Teach about medications such as aspirin, beta blockers, or ACE inhibitors F. Instruct about lifestyle changes relating to CAD.

A, B, D, E, E, F

15. A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.) A. "Reposition the client every 2 hours." B. "Teach the client to perform deep-breathing exercises." C. "Accurately record intake and output." D. "Use the same scale to weigh the client each morning." E. "Place the client on oxygen if the client becomes short of breath."

A, C, D

Identify appropriate interventions for a pt experiencing inadequate oxygenation and tissue perfusion as a result of CAD A. notify the physician B. administer Tylenol for pain C. Maintain or initiatie an IV line D. apply oxygen via nasal cannula E. Encourage interaction with family F. Administer nitroglycerin sublingually

A, C, D, F

23. The nurse is assessing a patient with right sided heart failure. Which assessment findings does the nurse expect to see in this patient? Select all that apply A. Dependent edema B. Weight loss C. Polyuria at night D. Hypotension E. Hepatomegaly F. Angina

A, C, E

14. After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) A. "I'll read the nutritional labels on food items for salt content." B. "I will drink at least 3 liters of water each day." C. "Using salt in moderation will reduce the workload of my heart." D. "I will eat oatmeal for breakfast instead of ham and eggs." E. "Substituting fresh vegetables for canned ones will lower my salt intake."

A, D, E

13. A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) A. Pulmonary crackles B. Confusion, restlessness C. Pulmonary hypertension D. Dependent edema E. Cough that worsens at night

A,B, E

10. A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure? A. "Do you have trouble breathing or chest pain?" B. "Are you able to walk upstairs without fatigue?" C. "Do you awake with breathlessness during the night?" D. "Do you have new-onset heaviness in your legs?"

B

15. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? A. Increase the setting on the suction. B. Notify the provider immediately. C. Re-position the chest tube. D. Take the tubing apart to assess for clots.

B

36. The nurse expects what outcome in a patient who is taking a beta blocker for mild heart failure? A. Improved urinary output B. Improved activity tolerance C. Increased myocardial contractility D. Increased myocardial oxygen

B

5. A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) A. Assist the provider to place a central venous access device. B. Prepare for continuous blood pressure and pulse monitoring. C. Administer the client's prescribed beta blocker. D. Give the client nothing by mouth 3 to 6 hours before the procedure. E. Explain to the client that dobutamine will simulate exercise for this examination.

B, D, E

8. A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) A. Blood pressure of 140/88 mm Hg B. Serum potassium of 2.9 mEq/L C. Warmth and redness at the site D. Expanding groin hematoma E. Rhythm changes on the cardiac monitor

B, D, E

1. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)? A. Avoid contact sports. B. Get plenty of calcium. C. Lose weight if needed. D. Engage in weight-bearing exercise.

C

12. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? A. Administer an aspirin. B. Call for an electrocardiogram (ECG). C. Maintain airway patency. D. Notify the provider.

C

31. The nurse is teaching a patient with heart failure about signs and symptoms that suggest a return or worsening of heart failure. What does the nurse include in the teaching? Select all that apply A. Rapid weight loss of 3lbs in a week B. Increase in exercise tolerance lasting 2-3 days C. Cold symptoms (Cough) lasting more than 3-5 days D. Excessive awakening at night to urinate E. Development of dyspnea or angina at rest or worsening angina F. Increased swelling in the feet, ankles, or hands

C, D, E, F

10. A patient who recently had a valve replacement is taking warfarin (Coumadin) as prescribed. What health teaching will the nurse include before the patient is discharged? A. "Weigh yourself every day in the morning using the same scale." B. "Purchase a home kit to monitor your blood pressure every day." C. "You must take your pulse every day before taking this medication." D. "Avoid foods that are high in vitamin K, such as kale and spinach."

D

14. Mr. Jones is diagnosed with a 1.5mm abdominal aortic aneurysm (AAA). Part of the overall plan for Mr. Jones will include: A. Discussion of the diagnostic test. B. Evaluation of the non-modifiable risk factors that Mr. Jones has. C. Scheduling for further testing. D. Management of Mr. Jones's blood pressure to prevent expansion and rupture of the AAA.

D

18. A patient who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is the most important for the nurse to implement? A. Give 20 mEq of potassium chloride B. Initiate continuous cardiac monitoring C. Arrange a consultation with the dietician D. Teach the patient about the side effects of diuretics

B

24. When a patient returns from a cardiac catheterization, the nurse would expect to: A. Ambulate the patient in the hall. B. Check the puncture site. C. Monitor the gag reflex. D. Remove the gel from all sites on the skin.

B

26. The nurse is reviewing the laboratory results for a patient whose chief complaint is dyspnea. Which diagnostic test best differentiates between heart failure and lung dysfunction? A. Arterial blood gas B. B-type natriuretic peptide (BNP) C. Hemoglobin and hematocrit D. Serum electrolytes

B

27. A patient is prescribed diuretics for treatment of heart failure. Because of this therapy, the nurse pays particular attention to which laboratory test level. A. Peak and trough of the medication B. Serum potassium C. Serum sodium D. Prothrombin time (PT) and partial thrombin time (PTT)

B

25. The nurse is taking the history of a client with suspected coronary artery disease (CAD). Which situation correlates with stable angina? A. Chest discomfort at rest and inability to tolerate mowing the lawn B. Chest discomfort when mowing the lawn and subsiding with rest C. Indigestion and a choking sensation when mowing the lawn D. Jaw pain that radiates to the shoulder after mowing the lawn

B

11. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? A. Administer oxygen at 2 L/min. B. Allow continued bathroom privileges. C. Obtain a bedside commode. D. Suggest the client use a bedpan

B

11. A patient with a previously diagnosed abdominal aortic aneurysm (AAA) develops lower back pain that is sharp and tearing. What is the nurse's interpretation of this assessment finding? A. The aneurysm clotted and is obstructing blood flow. B. The aneurysm has ruptured. C. The patient feels the inflammation of the aneurysm D. This is a normal sensation with a stable AAA.

B

12. The nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching? A. "Walk until you become short of breath, and then walk back home." B. "Gather everything you need for a chore before you begin." C. "Pull rather than push or carry items heavier than 5 pounds." D. "Take a walk after dinner every day to build up your strength."

B

10. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? A. "The t-PA didn't dissolve the entire coronary clot." B. "The heparin keeps that artery from getting blocked again." C. "Heparin keeps the blood as thin as possible for a longer time." D. "The heparin prevents a stroke from occurring as the t-PA wears off."

B

8. A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which non-pharmacologic comfort measure should the nurse implement? A. Apply an ice pack to the client's chest. B. Provide a neck rub, especially on the left side. C. Allow the client to lie in bed with the lights down. D. Sit the client up with a pillow to lean forward on.

D

8. A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching? A. "Avoid drinking more than 3 quarts of liquids each day." B. "Eat six small meals daily instead of three larger meals." C. "When you feel short of breath, take an additional diuretic." D. "Weigh yourself daily while wearing the same amount of clothing."

D

A patient presents to the ED and is diagnosed with an acute ME. The pt's spouse asks what type of damage has been caused by the "heart attack". What is the appropriate nursing response?A. "The pain is controlled, so there is no damage." B. "It will take years to know the extent of the damage to the heart muscle." C. "The medication will dilate the blood vessels and any damage will be corrected." D. "A heart attack evolves over several hours. We won't know the extent of the damage immediately."

D