TEST 2 for Nursing 240B -ATI
A nurse in the emergency department is assisting with the admission of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following is the priority nursing intervention? A. Administer pain medication as prescribed. B. Ensure a warm environment. C. Administer IV fluids as prescribed. D. Initiate a 12-lead ECG.
C. CORRECT: Using the ABC priority-setting framework, the greatest risk to the client is inadequate circulatory volume. The priority nursing intervention is to administer IV fluids.
A nurse is discussing a new diagnosis of an aneurysm with a client. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following is an appropriate response by the nurse? A. "The wall of an artery becomes thin and flexible." B. "It is due to turbulence in blood flow in the artery." C. "It is due to abdominal enlargement." D. "It is due to hypertension."
D. CORRECT: Hypertension increases pressure within the arterial walls, resulting in rupture.
A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 min. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 min.
A. CORRECT: Angina can be relieved by rest and nitroglycerin
A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. Which of the following is an appropriate response by the nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relieves the pain due to myocardial ischemia." C. "Aspirin dissolves clots that are forming in your coronary arteries." D. "Aspirin relieves headaches that are caused by other medications."
A. CORRECT: Aspirin decreases platelet aggregation that can cause a myocardial infarction.
A nurse is reviewing clinical manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following should the nurse include in the discussion? (Select all that apply.) A. Cough B. Shortness of breath C. Upper chest pain D. Diaphoresis E. Altered swallowing
A. CORRECT: Cough is a manifestation of a thoracic aortic aneurysm. B. CORRECT: Shortness of breath is a manifestation of a thoracic aortic aneurysm. E. CORRECT: Difficulty swallowing is a manifestation of a thoracic aortic aneurysm.
A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema
A. CORRECT: Dyspnea is a clinical manifestation of right-sided valvular heart disease. B. CORRECT: A client's report of fatigue is a clinical manifestation of right-sided valvular heart disease. E. CORRECT: Peripheral edema is a clinical manifestation of right-sided valvular heart disease.
A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should be reported to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 IU/L
A. CORRECT: Long-term NSAID therapy can lower platelets. This finding is outside the expected reference range and should be reported to the provider.
A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following manifestations support this diagnosis? (Select all that apply.) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein
A. CORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus. An erythema marginatum (rash) is a clinical manifestation. E. CORRECT: Rheumatic fever is caused by Group A β-hemolytic streptococcus. An increase in C-reactive protein is a clinical manifestation
A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? A. With the affected limb hanging from the bed B. With the affected limb elevated on pillows C. With the head of the bed raised D. In a side-lying, recumbent position
A. CORRECT: The client will prefer sleeping with the affected extremity in a dependent position because this relieves pain
A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following should be included in the discussion? (Select all that apply.) A. The client's demand for oxygen is lowered. B. Motion of the heart ceases. C. Rewarming of the client takes place. D. The client's metabolic rate is increased. E. Blood flow to the heart is stopped.
A. CORRECT: The use of cardiopulmonary bypass reduces the client's demand for oxygen, which reduces the risk of inadequate oxygenation of vital organs. B. CORRECT: Motion of the heart ceases during cardiopulmonary bypass to allow for placement of the graft near the affected coronary artery. C. CORRECT: The core body temperature is lowered for the procedure, and rewarming then occurs through heat exchanges on the cardiopulmonary bypass machine.
A nurse is assessing an infant. Which of the following should the nurse recognize as clinical manifestations of heart failure? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring
B. CORRECT: A client who has heart failure will exhibit cool extremities as the heart is unable to adequately circulate oxygenated blood. C. CORRECT: A client who has heart failure will exhibit peripheral edema as the heart is unable to adequately circulate blood through the body and back to the heart. E. CORRECT: A client who has heart failure will exhibit nasal flaring due to inadequate oxygenation of blood.
A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. "I will have my prothrombin time checked on a regular basis." C. "I will talk to my dentist about no longer needing antibiotics before dental exams." D. "I will continue to limit my intake of foods containing potassium."
B. CORRECT: Anticoagulant therapy with warfarin (Coumadin) is necessary for the client following placement of a mechanical heart valve; the client's prothrombin time will be checked on a regular basis
A nurse is caring for a 2-year-old child who is cyanotic and is in the hospital for a cardiac catheterization to repair cardiac defects. The child will be transferred to the pediatric ICU following the procedure. Which of the following is an appropriate nursing action when providing care to this child? A. Place on NPO status for 12 hr prior to the procedure. B. Check for iodine or shellfish allergies prior to the procedure. C. Elevate the affected extremity following the procedure. D. Limit fluid intake following the procedure
B. CORRECT: Iodine-based dyes may be used in this procedure, so the child is assessed for allergies to iodine or shellfish which could lead to anaphylaxis
A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following is an appropriate nursing intervention? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia.
B. CORRECT: Providing adequate analgesia and returning in 15 min will reduce pain and improve coughing effectiveness.
A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following is an appropriate response by the nurse? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C. "This will prolong your mother's life." D. "This will reverse the effects to the damaged area."
B. CORRECT: Surgery is indicated for older adult clients when clinical manifestations interfere with activities of daily living.
A nurse is admitting a client with a suspected occlusion of a graft of the abdominal aorta. Which of the following is an expected clinical finding? A. Increased urine output B. Bounding pedal pulse C. Increased abdominal girth D. Redness of the lower extremities
C. CORRECT: Abdominal distention is an expected finding with occlusion of a graft of the aorta.
A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following is an expected finding? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg
D. CORRECT: A client who has peripheral artery disease may report that numbness or burning pain in the extremity ceases with rest (intermittent claudication).
A nurse is caring for a client who has pericarditis. Which of the following expected findings should the nurse anticipate? A. Petechiae B. Murmur C. Rash D. Friction rub
D. CORRECT: A friction rub can be heard during auscultation of a client who has pericarditis.
A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture
D. CORRECT: A throat culture can reveal the presence of streptococcus, which is the leading cause of rheumatic endocarditis.
A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? A. Edema around the client's ankles and feet B. Ulceration around the client's medial malleoli C. Scaling eczema of the client's lower legs with stasis dermatitis D. Pallor on elevation of the client's limbs and rubor when his limbs are dependent
D. CORRECT: In a client who has chronic PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered.
A nurse is instructing a client who has angina about a new prescription for metoprolol tartrate (Lopressor). Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue." B. "I should have my clotting time checked weekly." C. "I will report any ringing in my ears." D. "I will call my doctor if my pulse rate is less than 60."
D. CORRECT: The client is advised to notify the provider if bradycardia (pulse rate less than 60) occurs
A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present
A. CORRECT: A history of congenital malformations is a risk factor for valvular heart disease. C. CORRECT: Hypertension places a client at risk for valvular heart disease. E. CORRECT: A murmur indicates turbulent blood flow, which is often due to valvular heart disease.
A nurse is caring for an infant. Which of the following are clinical manifestations of coarctation of the aorta? (Select all that apply.) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Heart failure
A. CORRECT: Narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in weak or absent femoral pulses. B. CORRECT: Narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in cool skin of the lower extremities. E. CORRECT: Heart failure occurs when the heart is unable to meet the body's demands, and is a clinical manifestation of coarctation of the aorta.
A nurse is planning caring for a client who had a surgical placement of an synthetic graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care? A. Assess pedal pulses. B. Monitor for an increase in pain below the graft site. C. Maintain client in high Fowler's position. D. Administer prescribed antiplatelet agents. E. Report an hourly urine output of 60 mL.
A. CORRECT: Pulses distal to the graft site should be monitored to detect possible occlusion of the graft. B. CORRECT: Pain below the graft site can be an indication of graft occlusion or rupture. D. CORRECT: Antiplatelet agents and anticoagulants are prescribed to prevent thrombus formation.
A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. For which of the following conditions is the client at risk? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis
A. CORRECT: Splinter hemorrhages in nail beds and a report of fever are findings associated with infective endocarditis
A nurse is teaching a client who has a new prescription for clopidogrel (Plavix). Which of the following should be included in the teaching? (Select all that apply.) A. Effects may not be apparent for several weeks. B. Monitor for the presence of black, tarry stools. C. Instruct the client to use an electric razor. D. Schedule a weekly PT test. E. Advise the client about food sources containing vitamin K.
A. CORRECT: Therapeutic benefits may not occur for several weeks when taking Plavix. B. CORRECT: Evidence of GI bleeding, such as abdominal pain, coffee-ground emesis, or black, tarry stools should be monitored and reported to the provider.
Which of the following clients has the greatest risk of acquiring rheumatic endocarditis? A. An older adult who has chronic obstructive pulmonary disease B. A child who has an upper respiratory streptococcal infection C. A middle-age adult who has lupus erythematosus D. A young adult who is at 24 weeks of gestation
B. CORRECT: A child who has an upper respiratory due to streptococcal bacteria is at highest risk for developing rheumatic endocarditis. Approximately 50% of clients who have rheumatic fever develop rheumatic endocarditis
A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to A. massage both legs firmly with lotion prior to applying the stockings. B. apply the stockings in the morning upon awakening and before getting out of bed. C. roll the stockings down to the knees if they will not stay up on the thighs. D. remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest.
B. CORRECT: Applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at this time.
A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following client findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb
B. CORRECT: Capillary refill greater than 2 to 4 seconds is outside the expected reference range and should be reported to the provider. C. CORRECT: Mottled appearance of the affected extremity is an unexpected finding and should be reported to the provider.
A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet modification B. Relaxation exercises C. Smoking cessation D. Taking omega-3 capsules
C. CORRECT: According to the airway, breathing, and circulation (ABC) priority-setting framework, adequate oxygenation is the priority. Nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries. Therefore, smoking cessation should be the first recommended lifestyle change.
A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. The nurse should suspect A. retroperitoneal bleeding. B. cardiac tamponade. C. bleeding from the incisional site. D. heart failure.
C. CORRECT: Bleeding is occurring from the incision site and then draining under the client. The nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider.
A nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. Which of the following is an expected finding? A. Hoarseness B. Petechiae C. Crackles in lung bases D. Splenomegaly
C. CORRECT: Crackles in the lung bases is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency.
A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the infarction occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin
C. CORRECT: The Troponin T level will still be evident 14 to 21 days following an MI.
A nurse is providing teaching to the mother of an infant who is to start taking digoxin (Lanoxin). Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C. "Give the correct dose of medication at regularly scheduled times." D. "If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."
C. CORRECT: The correct amount of digoxin should be administered at regularly scheduled times to maintain therapeutic blood levels.
A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin (Coumadin). The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? A. "I will remind your provider that you are already receiving heparin." B. "Laboratory findings indicated that two anticoagulants were needed." C. "It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis."
C. CORRECT: Warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. Therefore, it takes 3 to 4 days before the clotting factors that are present decay and the therapeutic effects of warfarin occur.