Saunders Questions Exam #2

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1."I should notify my cardiologist if my feet or legs start to swell." 2."I am supposed to report to my cardiologist if my pulse rate decreases below 60." 3."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4."My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

"My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."

The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction? 1. "A cardiac output of 2 L/min is normal." 2. "A cardiac output of 4 L/min is normal." 3. "A cardiac output of 6 L/min is normal." 4. "A cardiac output of 7 L/min is normal."

1. "A cardiac output of 2 L/min is normal."

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1. "Pulse rate will increase." 2. "Blood pressure will decrease." 3. "Edema will be present in the legs." 4. "Crackles in the lungs will be present."

1. "Pulse rate will increase."

A client has a problem with sleeping at night. The nurse encourages the client to do which measure to best enhance nighttime sleep? 1. Drink a glass of milk. 2. Eat a large bedtime snack. 3. Eat a snack with spicy ingredients. 4. Avoid caffeine products 1 hour before sleep.

1. Drink a glass of milk.

The nurse has just completed education on myocardial infarction (MI) to a group of new nurses. Which statement made by one of the nurses indicates that the teaching has been effective? 1."Chest pain is caused by tissue hypoxia in the myocardium." 2."Chest pain is caused by tissue hypoxia in the vessels of the heart." 3."Chest pain is caused by tissue hypoxia in the parietal pericardium." 4."Chest pain is caused by tissue hypoxia in the visceral pericardium."

1."Chest pain is caused by tissue hypoxia in the myocardium."

The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective? 1."Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." 2."Failure of the aortic valve to close completely allows blood to flow retrograde through the left ventricle to the left atrium." 3."Failure of the aortic valve to close completely allows blood to flow retrograde through the right ventricle to the right atrium." 4."Failure of the aortic valve to close completely allows blood to flow retrograde through the pulmonary artery to the right ventricle."

1."Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle."

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1."I will eat enough daily fiber to prevent straining at stool." 2."I will try to exercise vigorously to strengthen my heart muscle." 3."I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4."Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

1."I will eat enough daily fiber to prevent straining at stool."

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education? 1."It is important that I limit protein intake." 2."I need to maintain a regular exercise program." 3."I understand that I need to avoid adding salt to foods." 4."It is important that I begin reducing and then maintaining weight."

1."It is important that I limit protein intake."

The nurse is listening to a lecture about angina. Which statement by the nurse indicates that the teaching has been effective? 1."Stable angina is chronic." 2."Variant angina is caused by emotional stress." 3."Unstable angina is not a life-threatening condition." 4."Intractable angina rarely limits the client's lifestyle."

1."Stable angina is chronic."

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? 1."Where is the pain located?" 2."Are you having any nausea?" 3."Are you allergic to any medications?" 4."Do you have your nitroglycerin with you?"

1."Where is the pain located?"

A client is prescribed an eye drop and an eye ointment for the right eye. How should the nurse best administer the medications? 1.Administer the eye drop first, followed by the eye ointment. 2.Administer the eye ointment first, followed by the eye drop. 3.Administer the eye drop, wait 15 minutes, and administer the eye ointment. 4.Administer the eye ointment, wait 15 minutes, and administer the eye drop.

1.Administer the eye drop first, followed by the eye ointment.

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1.Ambulates 10 feet (3 meters) farther each day 2.Verbalizes the benefits of increasing activity 3.Chooses a healthy diet that meets caloric needs 4.Sleeps without awakening throughout the night

1.Ambulates 10 feet (3 meters) farther each day

The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? 1.Asymptomatic 2.Shortness of breath 3.Visual disturbances 4.Frequent nosebleeds

1.Asymptomatic

The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? 1.Breath sounds 2.Peripheral edema 3.Hepatojugular reflux 4.Jugular vein distention

1.Breath sounds

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? 1.Chest pain 2.Urge to cough 3.Warm, flushed feeling 4.Pressure at the insertion site

1.Chest pain

The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Encourage coughing with deep breathing. 2.Place in high-Fowler's position for eating. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables.

1.Encourage coughing with deep breathing. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? 1.Hypotension 2.Flat neck veins 3.Complaints of nausea 4.Complaints of headache

1.Hypotension

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1.Listening to lung sounds 2.Palpating for organomegaly 3.Assessing for jugular vein distention 4.Assessing for peripheral and sacral edema

1.Listening to lung sounds

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan? 1.Maintain activity level as prescribed. 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

1.Maintain activity level as prescribed.

The nurse is preparing to measure the apical pulse on an assigned client. The nurse places the diaphragm of the stethoscope over which cardiac site? 1.Mitral area 2.Right atrium 3.Right ventricle 4.Pulmonic valve

1.Mitral area

The nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do first? 1.Review intake and output records for the last 2 days. 2.Prescribe daily weights starting on the following morning. 3.Request a sodium restriction of 1 g/day from the cardiologist. 4.Change the time of diuretic administration from morning to evening.

1.Review intake and output records for the last 2 days.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm

1.Sinus tachycardia

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value comes back elevated? 1.Troponin 2.Myoglobin 3.C-reactive protein 4.Creatine kinase (CK)

1.Troponin

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal? 1.Using a bedside commode 2.Sleeping in the supine position 3.Elevating the legs when in bed 4.Using seasonings to improve the taste of food

1.Using a bedside commode

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept? 1.Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. 2.Vagus nerve stimulation causes an increase in heart rate and cardiac contractility. 3.Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. 4.Sympathetic nerve stimulation causes an increase in heart rate and cardiac contractility.

1.Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility.

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply. 1.Wash hands. 2.Put gloves on. 3.Place the drop in the conjunctival sac. 4.Pull the lower lid down against the cheekbone. 5.Instruct the client to squeeze the eyes shut after instilling the eye drop. 6.Instruct the client to tilt the head forward, open the eyes, and look down.

1.Wash hands. 2.Put gloves on. 3.Place the drop in the conjunctival sac. 4.Pull the lower lid down against the cheekbone.

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1.Weigh self on a daily basis. 2.Sleep with the head of the bed flat. 3.Take a double dose of the diuretic if peripheral edema is noted. 4.Withhold prescribed digoxin if slight respiratory distress occurs.

1.Weigh self on a daily basis.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1. "I will avoid using table salt with meals." 2. "It is best to exercise once a week for 1 hour." 3. "I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations."

2. "It is best to exercise once a week for 1 hour."

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1."I'll need to become a strict vegetarian." 2."I should use polyunsaturated oils in my diet." 3."I need to substitute eggs and whole milk for meat." 4."I should eliminate all cholesterol and fat from my diet."

2."I should use polyunsaturated oils in my diet."

The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective? 1."Left ventricle to aorta narrowing will impede flow of blood." 2."Left atrium to left ventricle narrowing will impede flow of blood." 3."Right atrium to right ventricle narrowing will impede flow of blood." 4."Right ventricle to pulmonary artery narrowing will impede flow of blood."

2."Left atrium to left ventricle narrowing will impede flow of blood."

The nurse is educating the client about variant angina. Which statement by the client indicates that the teaching has been effective? 1."Variant angina is induced by exercise." 2."Variant angina occurs at the same time each day." 3."Variant angina occurs at lower levels of activity." 4."Variant angina is less predictable and a precursor of myocardial infarction."

2."Variant angina occurs at the same time each day."

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client? 1.Use the knee gatch on the bed. 2.Cover the legs lightly when sitting in a chair. 3.Encourage the client to cross the legs when sitting in a chair. 4.Provide pillows for the client to place under the knees as desired.

2.Cover the legs lightly when sitting in a chair.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1.Keep the legs aligned with the heart. 2.Elevate the legs higher than the heart. 3.Clean the skin with alcohol every hour. 4.Position the client onto the side during every shift.

2.Elevate the legs higher than the heart.

The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion? 1.The cardiac output is above the normal range. 2.The cardiac output is below the normal range. 3.The cardiac output is in the low-normal range. 4.The cardiac output is in the high-normal range.

2.The cardiac output is below the normal range.

After instruction on the application of antiembolism stockings, the nurse determines that the client requires further teaching if which of these actions is performed? 1.The client puts on the stockings before getting out of bed. 2.The client bunches up the stockings for easier application. 3.The client ensures that stockings are pulled up all the way. 4.The client ensures that the rough seams of the stockings are on the outside.

2.The client bunches up the stockings for easier application.

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? 1. Ascites 2. Pedal edema 3. Bilateral lung crackles 4. Jugular vein distention

3. Bilateral lung crackles

The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. The nurse provides education to the client about increased cardiac response based on which physiological concept? 1. Pulse rate is not a reflection of cardiac response. 2. Cardiac index is the mechanism that allows blood to flow better. 3. Cardiac output is the body's attempt to meet metabolic demands. 4. Stroke volume is an artificial number used to determine the adequacy of cardiac output.

3. Cardiac output is the body's attempt to meet metabolic demands.

The cardiologist has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? 1. Questions the client about allergies to iodine or shellfish 2. Has the client sign an informed consent form for an invasive procedure 3. Tells the client that the procedure is painless and takes 30 to 60 minutes 4. Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure

3. Tells the client that the procedure is painless and takes 30 to 60 minutes

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1. The client is not experiencing dyspnea. 2. The client is not experiencing nausea or vomiting. 3. The pain has not been relieved by rest and nitroglycerin tablets. 4. The client says the pain began while she was trying to open a stuck dresser drawer.

3. The pain has not been relieved by rest and nitroglycerin tablets.

The nurse educator is teaching the new registered nurse (RN) how to care for clients with a decrease in blood pressure. Which statement by the new RN indicates the need for further instruction? 1."Decreased contractility occurs." 2."Decreased heart rate is not a side effect." 3."Decreased myocardial blood flow is not a concern." 4."Increased resistance to electrical stimulation often occurs."

3."Decreased myocardial blood flow is not a concern."

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question should best help the nurse discriminate pain caused by a noncardiac problem? 1."Can you describe the pain to me?" 2."Have you ever had this pain before?" 3."Does the pain get worse when you breathe in?" 4."Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

3."Does the pain get worse when you breathe in?"

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? 1."I need to start exercising more to improve my health." 2."I will be sure to keep my appointment with the cardiologist." 3."I don't have anyone to help me with doing heavy housework at home." 4."I think I have a good understanding of what all my medications are for."

3."I don't have anyone to help me with doing heavy housework at home."

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1."I swim 3 times a week." 2."I have stopped smoking cigars." 3."I drink hot chocolate before bedtime." 4."I read for 40 minutes before bedtime."

3."I drink hot chocolate before bedtime."

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? 1."I need to cut down on cigarette smoking." 2."I am so relieved that my heart is repaired." 3."I need to adhere to my dietary restrictions." 4."I am so relieved that I can eat anything I want to now."

3."I need to adhere to my dietary restrictions."

The registered nurse (RN) is listening to a lecture on pulmonary edema. Which statement by the RN indicates that the teaching has been effective? 1."The client may have mild anxiety." 2."The client will not experience anxiety." 3."The client will experience extreme anxiety." 4."The client will only experience anxiety in a stressful environment."

3."The client will experience extreme anxiety."

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? 1."Oxygen has a calming effect." 2."Oxygen will prevent the development of any thrombus." 3."The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." 4."Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."

3."The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells."

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1.A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer 4.A venous stasis ulcer

3.An arterial ulcer

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1.Ad lib activities as tolerated 2.Strict bed rest for 24 hours after transfer 3.Bathroom privileges and self-care activities 4.Unsupervised hallway ambulation for distances up to 200 feet (60 meters)

3.Bathroom privileges and self-care activities

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1.Call a code. 2.Call the primary health care provider. 3.Check the client's status and lead placement. 4.Press the recorder button on the electrocardiogram console.

3.Check the client's status and lead placement.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1.Rhonchi 2.Wheezes 3.Crackles in the bases 4.Crackles throughout the lung fields

3.Crackles in the bases

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1.Left atrium 2.Right atrium 3.Left ventricle 4.Right ventricle

3.Left ventricle

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1.Heart failure 2.Atrial fibrillation 3.Myocardial infarction 4.Ventricular tachycardia

3.Myocardial infarction

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? 1.Absent bowel sounds 2.Client complaints of wound pain 3.Pain with dorsiflexion of the foot 4.Crackles on auscultation of the lungs

3.Pain with dorsiflexion of the foot

The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? 1.Bundle of His 2.Purkinje fibers 3.Sinoatrial (SA) node 4.Atrioventricular (AV) node

3.Sinoatrial (SA) node

A client's total cholesterol level is 344 mg/dL (8.6 mmol/L), low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL (4.25 mmol/L), and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL (1.2 mmol/L). Based on analysis of the data, how should the nurse direct client teaching? 1.The client should maintain the current dietary regimen but increase activity level. 2.Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. 3.The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. 4.The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen.

3.The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught.

A client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. The nurse exercising nearby is correct when cautioning the client to check the pulse on only one side, primarily for which reason? 1.It is unnecessary to use both hands. 2.The client could occlude the trachea. 3.The heart rate and blood pressure could drop. 4.Feeling dual pulsations may lead to an incorrect measurement.

3.The heart rate and blood pressure could drop.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? 1."It will really hurt when the catheter is first put in." 2."I will receive general anesthesia for the procedure." 3."I will have to go to the operating room for this procedure." 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? 1."I'm not supposed to eat cold cuts." 2."I can have most fresh fruits and vegetables." 3."I'm going to weigh myself daily to be sure I don't gain too much fluid." 4."I'm going to have a ham and cheese sandwich and potato chips for lunch."

4."I'm going to have a ham and cheese sandwich and potato chips for lunch."

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking? 1."None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2."Because most of the damage has already been done, it will be all right to cut down a little at a time." 3."If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

The nurse has completed an educational course covering first-degree heart block. Which statement by the nurse indicates that teaching has been effective? 1."Presence of Q waves indicates first-degree heart block." 2."Tall, peaked T waves indicate first-degree heart block." 3."Widened QRS complexes indicate first-degree heart block." 4."Prolonged, equal PR intervals indicate first-degree heart block."

4."Prolonged, equal PR intervals indicate first-degree heart block."

A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further teaching on the anatomy and physiology of the heart? 1."The coronary arteries branch from the aorta." 2."The coronary arteries supply the heart muscle with blood." 3."The left coronary artery provides blood for the left atrium and the left ventricle." 4."The left coronary artery supplies the right atrium and right ventricle with blood."

4."The left coronary artery supplies the right atrium and right ventricle with blood."

The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? 1.Walk for as long as possible each day. 2.Cross the legs at the ankle only, not at the knee. 3.Sit in a chair 3 times a day for 3 hours at a time. 4.Lie down with the legs elevated and avoid sitting.

4.Lie down with the legs elevated and avoid sitting.

The nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope to hear the first heart sound (S1) the loudest? 1.Over the second intercostal space at the left sternal border 2.Over the fourth intercostal space at the right sternal border 3.Over the second intercostal space at the right sternal border 4.Over the fifth intercostal space in the left midclavicular line

4.Over the fifth intercostal space in the left midclavicular line

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1.Apnea monitor 2.Oxygen flowmeter 3.Telemetry cardiac monitor 4.Oxygen saturation monitor

4.Oxygen saturation monitor

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin, which laboratory result should the nurse review as the priority? 1.Sodium level 2.Digoxin level 3.Creatinine level 4.Potassium level

4.Potassium level

The nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit? 1.4+ edema noted in lower extremities 2.Crackles auscultated from lung bases to apices 3.Blood pressure rises from 116/68 to 118/74 mm Hg 4.Pulse rate increases from 100 beats/min to 136 beats/min

4.Pulse rate increases from 100 beats/min to 136 beats/min

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? 1.Tea 2.Cola 3.Coffee 4.Raspberry juice

4.Raspberry juice

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? 1.Oxygen saturation decreased from 96% to 91%. 2.Pulse rate increased from 80 to 104 beats per minute. 3.Blood pressure decreased from 140/86 to 112/72 mm Hg. 4.Respiratory rate increased from 16 to 19 breaths per minute.

4.Respiratory rate increased from 16 to 19 breaths per minute.

A client is experiencing chronic insomnia. The nurse interprets this to mean that which areas of the brain are involved? 1.Hippocampus and frontal lobe 2.Temporal lobe and frontal lobe 3.Limbic system and cerebral hemispheres 4.Reticular activating system and cerebral hemispheres

4.Reticular activating system and cerebral hemispheres

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1.Blood pressure 2.Airway patency 3.Oxygen flow rate 4.Level of consciousness

Airway Patency

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities

Encouraging active range-of-motion exercises

The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? 1. Ventrogluteal 2.Lateral deltoid 3.Rectus femoris 4.Vastus lateralis

Vastus Lateralis