nurning anninants exam 2 med surg

The client comes to the emergency department saying, "I am having a heart attack." Which question is most pertinent when assessing the client? 1. "Can you describe your chest pain?" 2. "What were you doing when the pain started?" 3. "Did you have a high-fat meal today?" 4. "Does the pain get worse when you lie down?"

1. "Can you describe your chest pain?" The chest pain for an MI usually is described as an elephant sitting on the chest or a belt squeezing the substernal midchest, often radiating to the jaw or left arm.

The client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is most appropriate? 1. "You are at risk of developing an infection in your heart." 2. "Your teeth will not bleed as much if you have antibiotics." 3. "This procedure may cause your valve to malfunction." 4. "Antibiotics will prevent vegetative growth on your valves."

1. "You are at risk of developing an infection in your heart." The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure.

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bed rest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.

The occupational nurse for a mining company is planning a class on the risks of working with toxic substances to comply with the "Right to Know" law. Which information should the nurse include in the presentation? Select all that apply. 1. A client who smokes cigarettes has a drastically increased risk for lung cancer. 2. Floors need to be clean and dust needs to be wet to prevent transfer of dust. 3. The air needs to be monitored at specific times to evaluate for exposure. 4. Surface areas need to be painted every year to prevent the accumulation of dust. 5. Employees should wear the appropriate personal protective equipment.

1. A client who smokes cigarettes has a drastically increased risk for lung cancer. 2. Floors need to be clean and dust needs to be wet to prevent transfer of dust. 3. The air needs to be monitored at specific times to evaluate for exposure. 5. Employees should wear the appropriate personal protective equipment. (1-Clients who smoke cigarettes and work with toxic substances have increased risk of lung cancer because many of the substances are carcinogenic, 2- When floors and surfaces are kept clean, toxic dust particles, such as asbestos and silica, are controlled and this decreases exposure. Covering areas with water controls dust, 3- The quality of air is monitored to deter mine what toxic substances are present and in what amount. The information is then used in efforts to minimize the amount of exposure, 5- Employees must wear protective coverings, goggles, and other equipment needed to eliminate exposure to the toxic substances.)

The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question? 1. Administer intravenous fluids of normal saline at 125 mL/hr. 2. Provide supplemental oxygen per nasal cannula at 2 L/min. 3. Continuous telemetry monitoring with strips every four (4) hours. 4. Administer a loop diuretic intravenously every six (6) hours.

1. Administer intravenous fluids of normal saline at 125 mL/hr. Normal mean pulmonary artery pressure is about 15 mm Hg and an elevation indicates right ventricular heart failure or cor pulmonale, which is a comorbid condition of chronic obstructive pulmonary disease. The nurse should question this order because the rate is too high.

Which nursing interventions should the nurse implement for the client who has a respiratory disorder? Select all that apply. 1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake.

1. Administer oxygen via a nasal cannula. 2. Assess the client's lung sounds. 3. Encourage the client to cough and deep breathe. 4. Monitor the client's pulse oximeter reading. 5. Increase the client's fluid intake. (1-a client with a respiratory disorder may have decreased oxygen saturation; therefore, administering oxygen via a nasal cannula is appropriate, 2-The client's lung sounds should be assessed to determine how much air is being exchanged in the lungs, 3-Coughing and deep breathing will help the client expectorate sputum, thus clearing the bronchial tree. 4-The pulse oximeter evaluates how much oxygen is reaching the periphery, 5-Increasing fluids will help thin secretions, making them easier to expectorate.)

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's INR is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (AquaMephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal

1. Administer the medication as ordered. The therapeutic range for most clients' INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld.

The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health care provider to order for this client? 1. Amiodarone. 2. Atropine. 3. Digoxin. 4. Adenosine.

1. Amiodarone. Amiodarone suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q)

1. An elevated B-type natriuretic peptide (BNP). BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF.

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client is sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and CRT less than three (3) seconds.

1. Apical pulse rate of 110 and 4+ pitting edema of feet. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

1. Assess the client's bilateral lung sounds. Assessment of the lung sounds could indicate the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted.

The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer the client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.

1. Be sure to allow for uninterrupted rest and sleep. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client? 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein

1. Confusion and lethargy. The elderly client diagnosed with pneumonia may present with weakness, fatigue, lethargy, confusion, and poor appetite but not have any of the classic signs and symptoms of pneumonia.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP.

1. Demonstrate the correct technique for giving a bed bath. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the nurse should demonstrate the proper way to bathe a client in the bed.

The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? 1. Discuss the order with the health-care provider. 2. Take the client's apical pulse rate before administering. 3. Check the client's potassium level before giving the medication. 4. Determine if a digoxin level has been drawn.

1. Discuss the order with the health-care provider. This dosage is 10 times the normal dose for a client with CHF. This dose is potentially lethal.

The client's telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes.

1. Document this as normal sinus rhythm. The P wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.

The nurse is caring for a female client who is anxious, has a respiratory rate of 40, and is complaining of her fingers tingling and her lips feeling numb. Which intervention should the nurse implement first? 1. Have the client take slow, deep breaths. 2. Instruct her to put her head between her legs. 3. Determine why she is feeling so anxious. 4. Administer Xanax, an antianxiety agent.

1. Have the client take slow, deep breaths. The client is hyperventilating and blowing off too much CO2, which is why her fingers are tingling and her mouth is numb; she needs to retain CO2 by taking slow, deep breaths.

The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

1. Increase fluid intake to two (2) to three (3) L/day. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE.

Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? Select all that apply. 1. Instruct the client to stop smoking. 2. Encourage the client to exercise three (3) days a week. 3. Teach about coronary vasodilators. 4. Prepare the client for a carotid endarterectomy. 5. Eat foods high in monosaturated fats.

1. Instruct the client to stop smoking. 2. Encourage the client to exercise three (3) days a week. 3. Teach about coronary vasodilators. (1-Smoking is the one risk factor that must be stopped totally; there is no compromise, 2-Exercising helps develop collateral circulation and decrease anxiety; it also helps clients to lose weight, 3-Clients with coronary artery disease are usually prescribed nitroglycerin, which is the treatment of choice for angina.)

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

1. Instruct the client to use a soft-bristle toothbrush. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

1. Keep protamine sulfate readily available. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered. (1- Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant, 3- Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for, 4- Invasive procedures increase the risk of tissue trauma and bleeding, 5- Stool softeners help prevent constipation and straining, which may precipitate bleeding from hemorrhoids.)

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum.

1. Low arterial oxygen when administering high concentration of oxygen. The classic sign of ARDS is decreased arterial oxygen level (Pao2) while administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1. Medicate the client and have the client take deep breaths. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis.

The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.

1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. (1-The nurse should monitor the vital signs for any client who has just undergone, 2-A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure, 3-The pericardial fluid is documented as output, 4-Evaluating the client's cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis.)

The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.

1. Muffled heart sounds. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider.

The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

1. Notify the health-care provider immediately. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction.

Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. 4. Pericardial friction rub. 5. Pulsus paradoxus.

1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. (1-Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress, usually occurring at night because of the reclining position, and occurs in valvular disorders, 2-This is an abnormal condition in which a client must sit or stand to breathe comfortably and occurs in valvular disorders, 3-Coughing occurs when the client with long-term valvular disease has difficulty breathing when walking or performing any type of activity.)

Which information should the nurse include in the teaching plan for the mother of a child diagnosed with cystic fibrosis (CF)? Select all that apply. 1. Perform postural drainage and percussion every four (4) hours. 2. Modify activities to accommodate daily physiotherapy. 3. Increase fluid intake to one (1) liter daily to thin secretions. 4. Recognize and report signs and symptoms of respiratory infections. 5. Avoid anyone suspected of having an upper respiratory infection.

1. Perform postural drainage and percussion every four (4) hours. 2. Modify activities to accommodate daily physiotherapy. 4. Recognize and report signs and symptoms of respiratory infections. 5. Avoid anyone suspected of having an upper respiratory infection. (1- Clients and family members should be taught chest physiotherapy, including postural drainage, chest percussion, and vibration and breathing techniques to keep the lungs clear of the copious secretions, 2- Daily activities should be modified to accommodate the client's treatments, 4- Clients should be taught the signs and symptoms of infections to report to the health-care provider, 5- Clients with CF are susceptible to respiratory infections and should avoid anyone who is suspected of having an infection.)

The client is suspected of having a pulmonary embolus. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gasses. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).

1. Plasma D-dimer test. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a CT or V/Q scan to then confirm the diagnosis.

The client is admitted to a medical unit with a diagnosis of pneumonia. Which signs and symptoms should the nurse assess in the client? 1. Pleuritic chest discomfort and anxiety. 2. Asymmetrical chest expansion and pallor. 3. Leukopenia and CRT <three (3) seconds. 4. Substernal chest pain and diaphoresis.

1. Pleuritic chest discomfort and anxiety. Pleuritic chest pain and anxiety from diminished oxygenation occur along with fever, chills, dyspnea, and cough.

The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement? 1. Restrict the client's fluids as ordered. 2. Keep the client in the supine position. 3. Maintain oxygen saturation at 90%. 4. Monitor the total parenteral nutrition.

1. Restrict the client's fluids as ordered. Fluid intake may be restricted to reduce the cardiac workload and pressures within the heart and pulmonary circuit.

The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

1. Start cardiopulmonary resuscitation. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP. (1-Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted, 3-Defibrillation is the treatment of choice for ventricular fibrillation, 4-The crash cart has the defibrillator and is used when performing advanced cardio pulmonary resuscitation, 5-Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias.)

A client is being seen in the clinic to rule out (R/O) mitral valve stenosis. Which assessment data would be most significant? 1. The client complains of shortness of breath when walking. 2. The client has jugular vein distention and 3+ pedal edema. 3. The client complains of chest pain after eating a large meal. 4. The client's liver is enlarged and the abdomen is edematous.

1. The client complains of shortness of breath when walking. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis.

Which datum requires immediate intervention by the nurse for the client diagnosed with asbestosis? 1. The client develops an S3 heart sound. 2. The client has clubbing of the fingers. 3. The client is fatigued in the afternoon. 4. The client has basilar crackles in all lobes.

1. The client develops an S3 heart sound. The appearance of S3 heart sounds indicates the client is developing heart failure, which is a medical emergency.

Which data would cause the nurse to question administering digoxin to a client diagnosed with congestive heart failure? 1. The potassium level is 3.2 mEq/L. 2. The digoxin level is 1.2 mcg/mL. 3. The client's apical pulse is 64. 4. The client denies yellow haze.

1. The potassium level is 3.2 mEq/L. This potassium level is below normal levels; hypokalemia can potentiate digoxin toxicity and lead to cardiac dysrhythmias.

The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take? 1. Wait until the machine discharges. 2. Shout "all clear" and don't touch the bed. 3. Make sure the client is all right. 4. Increase the joules and redischarge.

1. Wait until the machine discharges. Cardioversion involves the delivery of a timed electrical current. The electrical impulse discharges during ventricular depolarization and, therefore, there might be a short delay. The nurse should wait until it discharges.

The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"

2. "Did you have rheumatic fever as a child?" Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of people who develop it.

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meat I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

2. "I should bake or grill any meat I eat." The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.

The client diagnosed with influenza A is being discharged from the emergency department with a prescription for antibiotics. Which statement by the client indicates an understanding of this prescription? 1. "These pills will make me feel better fast and I can return to work." 2. "The antibiotics will help prevent me from developing a bacterial pneumonia." 3. "If I had gotten this prescription sooner, I could have prevented this illness." 4. "I need to take these pills until I feel better; then I can stop taking the rest."

2. "The antibiotics will help prevent me from developing a bacterial pneumonia." Secondary bacterial infections often accompany influenza, and antibiotics are often prescribed to help prevent the development of a bacterial infection resulting from a weakened client immune system

Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency? 1. A loud S1, S2 split, and a mitral opening snap. 2. A holosystolic murmur heard best at the cardiac apex. 3. A midsystolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the third left intercostal space.

2. A holosystolic murmur heard best at the cardiac apex. The murmur associated with mitral valve insufficiency is loud, high pitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. (2-Aspirin is an antiplatelet medication and should be administered orally, 3-Oxygen will help decrease myocardial ischemia, thereby decreasing pain.)

The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.

2. Administer atropine, an antidysrhythmic. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

2. Assess chest tube drainage system frequently. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema. (2-The system must be patent and intact to function properly, 4- Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube, 5- Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.)

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

2. Assess the client's chest dressing and vital signs. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication

Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.

2. Decreased cardiac output. Any abnormal electrical activity of the heart causes decreased cardiac output.

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool, clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.

2. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.

Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position with the legs elevated. 2. Discuss a heart transplant, which is the definitive treatment. 3. Prepare the client for coronary artery bypass graft. 4. Teach the client to take a calcium channel blocker in the morning.

2. Discuss a heart transplant, which is the definitive treatment. Without a heart transplant, this client will end up in end-stage heart failure. A transplant is the only treatment for a client with dilated cardiomyopathy.

The nurse in a long-term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy (PEG) feeding tube used for bolus feedings. Which intervention should the nurse include in the plan of care? 1. Inspect the insertion line at the naris prior to installing the formula. 2. Elevate the head of the bed (HOB) after feeding the client. 3. Place the client in the Sims position following each feeding. 4. Change the dressing on the feeding tube every three (3) days.

2. Elevate the head of the bed (HOB) after feeding the client. Elevating the head of the bed uses gravity to keep the formula in the gastric cavity and help prevent it from refluxing into the esophagus, which predisposes the client to aspiration.

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to breathe without any pain.

2. No fluctuation (tidaling) in the water-seal compartment. At three (3) days post insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.

The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotics. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.

2. Obtain blood cultures times two (2). Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify.

Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

2. Sudden onset of chest pain and dyspnea. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath.

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify the health-care provider of a weight gain of more than one (1) pound in a week 2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the salt shaker from the dinner table. 4. Encourage the client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the salt shaker from the dinner table. (2-The client should not take digoxin if the radial pulse is less than 60, 3-The client should be on a low-sodium diet to prevent water retention.)

The health care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1.Instruct the client to take a cough suppressant if a cough develops 2.Teach the client how to prevent orthostatic hypotension 3.Encourage the client to eat bananas to increase potassium level 4.Explain the importance of taking medication with food.

2. Teach the client how to prevent orthostatic hypotension Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

2. The UAP has the chest tube attached to suction. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP.

The nurse suspects the client admitted with a near-drowning is developing acute respiratory distress syndrome (ARDS). Which data support the nurse's suspicion? 1. The client's arterial blood gasses are within normal limits. 2. The client appears anxious, has dyspnea, and is tachypneic. 3. The client has intercostal retractions and is using accessory muscles. 4. The client's bilateral lung sounds have crackles and rhonchi.

2. The client appears anxious, has dyspnea, and is tachypneic. Initial clinical manifestations of ARDS usually develop 24 to 48 hours after the initial insult leading to hypoxia and include anxiety, dyspnea, and tachypnea.

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

2. The client has an apical pulse of 56. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.

The client diagnosed with tonsillitis is scheduled to have surgery in the morning. Which assessment data should the nurse notify the health-care provider about prior to surgery? 1. The client has a hemoglobin of 12.2 g/dL and hematocrit of 36.5%. 2. The client has an oral temperature of 100.2˚F and a dry cough. 3. There are one (1) to two (2) white blood cells (WBCs) in the urinalysis. 4. The client's current international normalized ratio (INR) is 1.

2. The client has an oral temperature of 100.2˚F and a dry cough. A low-grade temperature and a cough could indicate the presence of an infection, in which case the health-care provider would not want to subject the client to anesthesia and the possibility of further complications. The surgery would be postponed.

The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor? 1. The client was admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) days post-myocardial infarction being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation has an INR of five (5).

2. The client three (3) days post-myocardial infarction being discharged tomorrow. Because this client is being discharged, it would be an appropriate assignment for the new graduate.

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? 1. The client will be able to ambulate in the hall congestive heart failure 2. The client will have an audible S1 and S2 with no S3 heard by end of shift. 3 The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day two (2) of care.

2. The client will have an audible S1 and S2 with no S3 heard by end of shift. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure, which could be life threatening.

The client is admitted to the emergency department with chest trauma. Which signs/ symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

2. Unequal lung expansion and dyspnea. Unequal lung expansion and dyspnea indicate a pneumothorax.

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client's teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays (CXRs)?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

3. "Are you sexually active?" Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual

The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

3. "I will have no problems as long as I take my medication." Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.

The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement? 1. Notify the health-care provider. 2. Document that the pericarditis has resolved. 3. Ask the client to lean forward and listen again. 4. Prepare to insert a unilateral chest tube.

3. Ask the client to lean forward and listen again. Having the client lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard.

The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.

3. Assess the client for cardiac complications. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider.

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

3. Assess the respiratory status and pulse oximeter reading. Assessment is the first part of the nursing process and is the first intervention the nurse should implement when caring for a client on a ventilator.

The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation (CPR).

3. Call a STAT code. The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.

The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client? 1. Do not lift or carry more than 23 kg. 2. Have someone drive the car for the rest of your life. 3. Carry the cell phone on the opposite side of the ICD. 4. Avoid using the microwave oven in the home.

3. Carry the cell phone on the opposite side of the ICD. Cell phones may interfere with the functioning of the ICD if they are placed too close to it.

The nurse is assessing the client diagnosed with a lung abscess. Which information supports this diagnosis of lung abscess? 1. Tympanic sounds elicited by percussion over the site. 2. Inspiratory and expiratory wheezes heard over the upper lobes. 3. Decreased breath sounds with a pleural friction rub. 4. Asymmetric movement of the chest wall with inspiration.

3. Decreased breath sounds with a pleural friction rub. Diminished or absent sounds are heard with intermittent pleural friction rubs. A lung abscess is the accumulation of pus in an area where pneumonia was present that becomes encapsulated and can extend to the bronchus or pleural space.

Which intervention should the nurse implement first when administering the first dose of intravenous antibiotic to the client diagnosed with a respiratory infection? 1. Monitor the client's current temperature. 2. Monitor the client's white blood cells. 3. Determine if a culture has been collected. 4. Determine the compatibility of fluids.

3. Determine if a culture has been collected. A culture needs to be collected prior to the first dose of antibiotic, or the culture and sensitivity will be skewed and the appropriate antibiotic needed to treat the respiratory infection may not be identified.

Which preprocedure information should be taught to the female client having an exercise stress test in the morning? 1. Wear open-toed shoes to the stress test. 2. Inform the client not to wear a bra. 3. Do not eat anything for four (4) hours. 4. Take the beta blocker one (1) hour before the test.

3. Do not eat anything for four (4) hours. NPO decreases the chance of aspiration in case of emergency. In addition, if the client has just had a meal, the blood supply will be shunted to the stomach for digestion and away from the heart, perhaps leading to an inaccurate test result.

The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

3. Instruct the client to take the medication with food. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain.

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

3. Prepare for insertion of a pacemaker. The client is symptomatic and will require a pacemaker.

The nurse is planning the activities for the client diagnosed with asbestosis. Which activity should the nurse schedule at 0900 if breakfast is served at 0800? 1. Assist with the client's bath and linen change. 2. Administer an inhalation bronchodilator treatment. 3. Provide The client with a one (1)-hour rest period. 4. Have respiratory therapy perform chest physiotherapy.

3. Provide the client with a one (1)-hour rest period. Periods of rest should be alternated with periods of activity.

The charge nurse on a surgical floor is making assignments. Which client should be assigned to the most experienced registered nurse (RN)? 1. The 36-year-old client who has undergone an antral irrigation for sinusitis yesterday and has moderate pain. 2. The six-(6)-year-old client scheduled for a tonsillectomy and adenoidectomy this morning who will not swallow medication. 3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has purulent drainage on the drip pad. 4. The 45-year-old client diagnosed with a peritonsillar abscess who requires VPB antibiotic therapy four (4) times a

3. The 18-year-old client who had a Caldwell Luc procedure three (3) days ago and has purulent drainage on the drip pad. The postoperative client with purulent drainage could be developing an infection. The experienced nurse would be needed to assess and monitor the client's condition.

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

3. The 75-year-old client scheduled for a cardiac catheterization. A new graduate should be able to complete a pre procedure checklist and get this client to the catheterization laboratory.

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

3. The client has asymmetrical chest expansion. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of mechanical ventilator.

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention.

3. The client is able to perform ADLs without dyspnea. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.

The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.

3. The client is complaining of numbness in the right foot. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

3. The client refuses to keep the leg straight. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.

The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity.

3. The client takes an enteric-coated aspirin daily. Aspirin and nonsteroidal anti inflammatory drugs (NSAIDs) interfere with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore, the client should not take aspirin daily.

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain on inspiration and a nonproductive

3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this

The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3. The client's pulse oximeter reading is 90%. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60.

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells

3. Troponin Troponin is the enzyme that elevates within 1 to 2 hours.

Which arterial blood gas (ABG) results support the diagnosis syndrome (ARDS) after the client has received O2 at 10 LPM? 1. pH 7.38, Pao2 94, Paco2 44, Hco3 24. 2. pH 7.46, Pao2 82, Paco2 34, Hco3 22. 3. pH 7.48, Pao2 59, Paco2 30, Hco3 26. 4. pH 7.33, Pao2 94, Paco2 44, Hco3 20.

3. pH 7.48, Pao2 59, Paco2 30, Hco3 26. ABGs initially show hypoxemia with a Pao2 of less than 60 mm Hg and respiratory alkalosis resulting from tachypnea in a client with ARDS.

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client was diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client was diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine

3.The client diagnosed with myocardial infarction who has an audible S3 heart sound. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER." The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.

Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching? 1. "If I lose weight I may not need treatment for sleep apnea." 2. "The CPAP machine holds my airway open with pressure." 3. "The CPAP will help me stay awake during the day while I am at work." 4. "It is all right to have a couple of beers because I have this CPAP machine."

4. "It is all right to have a couple of beers because I have this CPAP machine." Drinking alcohol before sleep sedates the client, causing the muscles to relax, which, in turn, causes an obstruction of the client's airway. Drinking alcohol should be avoided even if the client uses a CPAP machine

Which nursing diagnosis would be a priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function.

4. Activity intolerance related to impaired cardiac muscle function. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.

Which population is at a higher risk for dying from a myocardial infarction? 1. Caucasian males. 2. Hispanic females. 3. Asian males. 4. African American females.

4. African American females. African American females are 35% more likely to die from coronary artery disease than any other population. This population has significantly higher rates of hypertension and it occurs at a younger age. The higher risk of death from an MI is also attributed to a delay in seeking emergency care—an average of 11 hours.

Which intervention should the nurse implement first when caring for a client with a respiratory disorder? 1. Administer a respiratory treatment. 2. Check the client's radial pulses daily. 3. Monitor the client's vital signs daily. 4. Assess the client's capillary refill

4. Assess the client's capillary refill Assessing the client's capillary refill time has the highest priority for the nurse because it indicates the oxygenation of the client.

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

4. Assist the client to a sitting position. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's

The client is three (3) hours post-myocardial infarction. Which data would warrant immediate intervention by the nurse? 1. Bilateral peripheral pulses 2+. 2. The pulse oximeter reading is 96%. 3. The urine output is 240 mL in the last four (4) hours. 4. Cool, clammy, diaphoretic skin.

4. Cool, clammy, diaphoretic skin. Cold, clammy skin is an indicator of car diogenic shock, which is a complication of MI and warrants immediate intervention.

The unlicensed assistive personnel (UAP) tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first? 1. Tell the UAP to go take the client's vital signs. 2. Ask the UAP to have the telemetry nurse read the strip. 3. Notify the client's health-care provider. 4. Go to the room and assess the client's chest pain.

4. Go to the room and assess the client's chest pain. Assessment is the first step in the nursing process and should be implemented first; chest pain is priority.

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit (ICU) via a stretcher. 3. Provide the client going home discharge teaching instructions. 4. Help position the client who is having a portable x-ray done.

4. Help position the client who is having a portable x-ray done. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment.

The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

4. Increased chest pain with inspiration. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements (deep inspiration, coughing), changes in body position, and swallowing.

The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.

4. Institute and maintain bedrest. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs.

The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement? 1. Assess the client's chest tube output. 2. Monitor the client's chest dressing. 3. Evaluate the client's endotracheal (ET) lip line 4. Keep the client's affected leg straight.

4. Keep the client's affected leg straight. In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to prevent hemorrhaging at the insertion site.

The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)g sodium diet. 3. Weigh the client daily. 4. Plan for frequent rest periods.

4. Plan for frequent rest periods. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome

The client is being evaluated for valvular heart disease. Which information would be most significant? 1. The client has a history of coronary artery disease. 2. There is a family history of valvular heart disease. 3. The client has a history of smoking for 10 years. 4. The client has a history of rheumatic heart disease.

4. The client has a history of rheumatic heart disease. Rheumatic heart disease is the most common cause of valvular heart disease.

The nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. Which data require immediate intervention by the nurse? 1. The client refuses to perform shoulder exercises. 2. The client complains of a sore throat and is hoarse. 3. The client has crackles that clear with cough. 4. The client is coughing up pink frothy sputum.

4. The client is coughing up pink frothy sputum. Pink frothy sputum indicates pulmonary edema and would require immediate intervention.

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/58

4. The client's blood pressure is 90/58 The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

According to the 2010 American Heart Association Guidelines, which steps of cardiopulmonary resuscitation for an adult suffering from a cardiac arrest should the nurse teach individuals in the community? Rank in order of performance. 1. Place the hands over the lower half of the sternum. 2. Look for obvious signs of breathing. 3. Begin compressions at a ratio of 30:2. 4. Call for an AED immediately. 5. Position the victim on the back.

5,2,4,1,3

The client in the intensive care unit (ICU) on a mechanical ventilator is bucking the ventilator, causing the alarms to sound, and is in respiratory distress. Which assessment data should the nurse obtain? List in order of priority. 1. Assess the ventilator alarms. 2. Assess the client's pulse oximetry reading. 3. Assess the client's lung sounds. 4. Assess for symmetry of the client's chest expansion. 5. Assess the client's endotracheal tube for secretions.

5. Assess the client's endotracheal tube for secretions. 2. Assess the client's pulse oximetry reading. 3. Assess the client's lung sounds. 4. Assess for symmetry of the client's chest expansion. 1. Assess the ventilator alarms. 4. Assess for symmetry of the client's chest expansion. (5-The most common cause of bucking the ventilator is obstructed airway, which could be secondary to secretions in the airway, so assessing the client would be most appropriate, 2-Clients in the ICD are constantly monitored by pulse oximetry; therefore, the nurse should determine if the client has decreased oxygen saturation and if so, the nurse should start to "bag" the client. The client is in respiratory distress, 3-The nurse should assess the client's lung fields to determine if air movement is occurring because the client is in respiratory distress, 4-A complication of mechanical ventilation is a pneumothorax, and the nurse should assess for this because the client is in respiratory distress, 1-The machine is alerting the nurse there is a problem with the client; because the client is in respiratory distress, the client should be assessed first. If the client were not in distress, then the nurse should assess the machine first to determine which alarm is sounding.)