ADULT EXAM 2 PRACTICE QUESTIONS

a 58 y/o woman has been feeling heart palpitations and SOB for a few weeks. today she went to the ED with increased weakness. nursing assessment reveals the following: apical pulse 160bpm and irregular BP 168/98, RR 24, temp 99.4. SpO2 95% on room air. EKG shows atrial fibrillation with rapid ventricular response. skin is warm, flushed, and dry. determine if the following are indicated, contraindicated, or nonessential: 1. administer acetaminophen 2. assess vs frequently 3. ambulate pt every hour 4. administer oxygen at 10L via NC 5. place patient on telemetry monitor 6. initial Diltiazem infusion

1. nonessential 2. indicated 3. contraindicated 4. contraindicated 5. indicated 6. indicated

In the patient with chest pain, which results distinguish unstable angina from an MI? a. serum troponin levels increased 4-6 hours after onset of pain b. a chest xray showing left ventricular hypertrophy c. CK-MB elevations that peak 6 hours after the infarct D. ECG changes present at the onset of pain

A

a client comes into the E.R. with acute SOB and a cough that produces pink, frothy sputum. admission assessment reveals crackles and wheezes, a BP of 85/46, a HR of 122 BPM, and a RR of 38. the client's medical history included DM, HTN, and heart failure. which of the following disorders should the nurse suspect? a. pulmonary edema b. pneumothorax c. cardiac tamponade d. pulmonary embolus

A

a client has developed afib with a ventricular rate of 150bpm. a nurse assesses the client for: a. hypotension and dizziness b. N/V c. HTN and HA d. flat neck veins

A

a client is having frequent premature ventricular contractions. a nurse would place priority on assessment of which of the following items? a. BP and peripheral perfusion b. sensation of palpitations c. causative factors such as caffeine d. precipitating factors such as infection

A

after a myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? a. left-sided HF b. pulmonic valve malfunction c. right-sided HF d. tricuspid valve malfunction

A

client is admitted to the telemetry unit diagnosed with acute exacerbation of HF. which clinical assessment findings would the nurse expect? a. apical pulse 110 and 4+ pitting edema of feet b. bilateral inspiratory and expiratory wheezes c. the client sleeping without a pillow and eupnea d. radial pulse rate of 90 and CRT < 3 seconds

A

still caring for the patient in the previous question, after administering the first dose of nitroglycerin sublingual the patient's BP is now 68/42. the patient is still having chest pain and T-wave inversion on the cardiac monitor. what is your next nursing intervention? a. hold further doses of nitroglycerin and notify the doctor immediately for further orders b. administer morphine IV and place the patient in reverse Trendelenburg position c. administer nitroglycerin and monitor the patient's BP d. repeat another 12-lead EKG

A

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 a. "you are at risk of developing an infection in your heart." b. "your teeth will not bleed as much if you have antibiotics." c. "this procedure may cause your valve to malfunction." d. "antibiotics will prevent vegetation growth on your valves."

A

the nurse has received shift report. which client should the nurse see first? a. the client diagnosed with CAD complaining of severe indigestion b. the client diagnosed with heart failure who has 3+ pitting edema c. client diagnosed with atrial fibrillation whose apical rate is 100 and irregular d. the client diagnosed with sinus bradycardia who is complaining of constipation

A

the patient with chronic heart failure is being discharged from the hospital. what information should the nurse emphasize in the patient's discharge teaching to prevent progression of the disease to acute decompensated heart failure (ADHF)? a. take medications as prescribed b. use oxygen when feeling SOB c. direct questions only to the HCP d. encourage most activity in the morning when rested

A

when teaching a client about metoprolol, the nurse should base the information on the knowledge that metropolol a. blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction b. increases norepinephrine secretion and thus decreases BP and heart rate c. is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers BP d. is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II

A

a 74 y/o female presents to the ER with complaints of dyspnea, persistent cough, and unable to sleep at night d/t difficulty breathing. on assessment, you note crackles throughout the lung fields, respiratory rate of 25, and an oxygen saturation of 90% room air. which of the following lab results confirm your suspicions of heart failure? a. K+ 5.6 b. BNP 820 c. BUN 9 d. troponin <0.02

B

a client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. the client suddenly complains of chest pain. which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? a. "have you ever had this pain before?" b. "can you describe the pain to me?" c. "does the pain get worse when you breath in?" d. "can you rate the pain on a scale of 1-10?"

B

a patient calls the cardiac clinic you are working at and reports that they have taken 3 sublingual doses of Nitroglycerin as prescribed for chest pain, but the chest pain is not relieved. what do you educate the patient to do next? a. take another dose of nitroglycerin in 5 minutes b. call 911 c. lie down and rest to see if that helps with relieving the pain d. take two doses of nitroglycerin in 5 minutes

B

along with persistent, crushing chest pain, which clinical assessment finding would make the nurse suspect that the client is experiencing a MI? a. pain that worsens with an intake of breath b. diaphoresis and cool, clammy skin c. intermittent claudication adn pallor d. JVD and dependent edema

B

an asymptomatic patient with HF needs to ambulate to the bathroom and suddenly becomes dyspneic. before dangling the patient at the bedside, what should the nurse assess first? a. urine output b. heart rhythm c. orientation d. BP

B

the client diagnosed with heart failure is complaining of leg cramps at night. what would be the priority intervention? a. check client for peripheral edema and make sure the client takes a diuretic early in the day b. monitor client's potassium level and assess the client's intake of bananas and orange juice c. determine if the client has gained weight and instruct the client to keep the legs elevated d. instruct client to ambulate frequently and perform calf muscle stretching exercises daily

B

the client is scheduled for a right femoral cardiac catheterization. what is the priority nursing intervention? a. perform passive ROM exercises b. assess the client's neurovascular status c. keep client in high fowler's position d. assess the gag reflex prior to feeding the client

B

the nurse is discussing angina with a client who is diagnosed with CAD. which action should the client take first when experiencing angina? a. put a nitroglycerin tablet under the tongue b. stop the activity immediately and rest c. document when and what activity caused the angina d. notify physician immediately

B

the nurse is preparing to administer digoxin to a patient with HF. in preparation, lab results are reviewed with the following findings: sodium 139, potassium 5.6, chloride 103, and glucose 106. what is the priority action by the nurse? a. withhold the daily dose until the following day b. withhold the dose and report the potassium level c. give digoxin with a salty snack, such as crackers d. give digoxin with extra fluids to dilute the sodium level

B

what is the most common finding in people at risk for sudden cardiac death? a. mitral valve stenosis b. left ventricular dysfunction c. atherosclerotic heart disease d. aortic valve disease

B

which of the following actions is the first priority of care for a client exhibiting s/s of CAD? a. decrease anxiety b. enhance myocardial oxygenation c. administer sublingual nitroglycerin d. educate the client about his symptoms

B

which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? a. pulmonary embolus b. cerebrovascular accident c. hemoptysis d. DVT

B

your patient reports having substernal chest pain two times this week after carrying laundry up the stairs. after sitting down and resting, the pain went away. how would the nurse best classify this? a. anxiety b. stable angina c. unstable angina d. variant angina

B

in the patient with SVT, which assessment indicates decreased CO? a. dyspnea and HTN b. palpitations and chest pain c. tachypnea and abdominal distention d. bounding pulses and systolic murmur

B remember: palpitations and chest pain are results of decreased CO!!!!

select all the correct statements about educating the patient with heart failure a. it is important patients with heart failure notify their physician if they gain more than 6 pounds in a day or 10 pounds in a week b. patients with heart failure should receive an annual influenza vaccine and be up-to-date with the pneumonia vaccine c. heart failure patients should limit sodium intake to 2-3g per day d. heart failure is exacerbated by illness, too much fluid intake, and arrhythmias e. patients with heart failure should limit exercise because of the risks

B, C, D

which patients are most at risk for developing CAD? select all that apply a. 25 y/o who exercises 3x a week for 30 min and has a history of cervical cancer b. 35 y/o male with BMI of 30 and reports smoking 2 packs of cigs a day c. 45 y/o female that reports her father died at the age of 42 from a MI d. 55 y/o with Type 2 Diabetes

B, C, D

which of the following are NOT typical signs and symptoms of right-sided heart failure? select all that apply a. JVT b. persistent cough c. weight gain d. crackles e. hepatomegaly f. orthopnea

B, D, F

What causes the pain that occurs with myocardial ischemia? A. death of myocardial tissue b. dysrhythmias caused by cellular irritability c. lactic acid accumulation during anaerobic metabolism d. increased pressure in the arteries and pulmonary vessels

C

What should the nurse teach women about CAD? a. estrogen replacement in postmenopausal women decreases risk of CAD b. cholesterol levels are not as significant a risk factor for women as men c. CAD is the leading cause of death in women d. women typically have substernal crushing chest pain

C

as an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg giving sublingually. this drug's principle effects are produced by... a. antispasmodic effect on the pericardium b. causing an increased myocardial oxygen demand c. vasodilation of peripheral vasculature d. improved conductivity in the myocardium

C

in what position should the nurse place a patient who is having a HF exacerbation? a. supine b. trendlenberg c. high fowler's d. tripod

C

one hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. which of the following electrolyte imbalances should the nurse suspect? a. hypocalcemia b. hypermagnesemia c. hypokalemia d. hypernatremia

C

the client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. which action should the nurse implement first? a. administer sublingual nitroglycerin b. obtain a STAT ECG c. have the client sit down immediately d. assess client's vital signs

C

the client is exhibiting ventricular tachycardia on the telemetry monitor. which intervention should the nurse implement first? a. administer amiodarone, an antidysrhythmic, IVP b. prepare to defibrillate the client c. assess the client's apical pulse and BP d. start CPR

C

to evaluate a client's condition following cardiac catheterization, it is most important for the nurse to palpate the pulse: a. in all extremities b. at insertion site c. distal to the catheter insertion d. above the catheter insertion

C

which of the following blood tests is most indicative of cardiac damage? a. alkaline phosphatase b. basic metabolic panel (BMP) c. troponin I d. creatine kinase (CK)

C

which of the following positions would best aid breathing for a client with acute pulmonary edema? a. lying flat in bed b. left side-lying c. in high-fowler's position d. in semi-fowler's position

C

which diagnostic test is most useful in differentiating dyspnea related to pulmonary effects of HF versus dyspnea related to pulmonary disease? a. stress test b. cardiac catheterization c. BNP levels d. echocardiogram

C explanation: if someone is SOB and trying to figure out if it's related to HF or lung disease, the BNP will tell you if it's heart failure

a client with chest pain is admitted to the ED and all of the following items are ordered. which one should be completed first? a. chest x-ray b. troponin level c. electrocardiogram d. insertion of peripheral IV

C explanation: takes 30 seconds to a minute to do and it will give you very important information about the patient's heart

Which drugs should the nurse anticipate for clients with mechanical valves? a. nitrates b. antidysrhythmics c. beta blockers d. anticoagulants

D

a client admitted with angina complains of severe chest pain and suddenly becomes unresponsive. after establishing unresponsiveness, which of the following actions should the nurse take first? a. activate the resuscitation team b. open the client's airway c. check for breathing d. check for signs of circulation

D

a client has frequent bursts of ventricular tachycardia on the cardiac monitor. a nurse is most concerned with this dysrhythmia because: a. it is uncomfortable for the client, giving a sense of impending doom b. it produces a high CO that quickly leads to cerebral and myocardial ischemia c. it is almost impossible to convert to a normal sinus rhythm d. it can develop into ventricular fibrillation at any time

D

a nurse is assessing the BP of a client diagnosed with primary HTN. the nurse ensures accurate measurement by avoiding which of the following? a. seating client with arm bared, supported, and at heart level b. measuring BP after client has been seated quietly for 5 minutes c. using a cuff with a rubber bladder that encircles at least 80% of the limb d. taking a BP within 15 minutes after nicotine or caffeine ingestion

D

a patient is being discharged home after hospitalization of left ventricular systolic dysfunction. as the nurse providing discharge teaching to the patient, which is NOT a correct statement about this condition? a. "signs and symptoms of this type of heart failure can include: dyspnea, peristent cough, difficulty breathing while lying down, and weight gain." b. "it is important to monitor your daily weights, fluid, and salt intake." c. "left-sided heart failure can lead to right-sided heart failure if left untreated." d. "this type of heart failure can build up pressure in the hepatic veins and cause them to become congested with fluid which leads to peripheral edema."

D

the client is POD 1 from an aortic valve replacement and is exhibiting sinus tachycardia with a heart rate of 122. what is the appropriate intervention. a. assess the apical for 1 full minute b. notify the client's cardiac surgeon c. bring the crash cart to the bedside d. determine if the client is having pain

D

the nurse coming on duty receives the report from the nurse going off duty. which of the following clients should the on-duty nurse assess first? a. the 58 y/o who was admitted 2 days ago with HF, BP of 126/76, and a RR of 22 b. the 88 y/o hospice client with end-stage right-sided HF, BP of 78/50 and a DNR order c. the 62 y/o who was admitted one day ago with DVT and receiving IV heparin D. a 76 y/o client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem)

D

the nurse enters the client's room and notes an unconscious client with no pulse or BP. which action should the nurse implement first? a. notify HCP b. call rapid response team c. determine the telemetry monitor reading d. initiate a code

D

the physician's order says to administer Lasix 40mg IV twice a day. the patient has the following morning labs: Na+ 148, BNP 900, K+ 2.3, and BUN 10. which of the following is a nursing priority? a. administer Lasix as ordered b. notify physician of BNP level c. assess patient for edema d. hold the dose and notify physician about the potassium level

D

which of the following conditions is the predominant cause of angina? a. increased preload b. decreased afterload c. coronary artery spasm d. inadequate oxygen supply to the myocardium

D

a nurse is caring for a client receiving IV lasix and morphine for decompensated heart failure with orthopnea. Which clinical finding is the best indicator that the treatment has been effective? a. weight loss of 2lb in 24 hours b. hourly urine output of 50 mL c. client denies chest pain or pressure d. reduced dyspnea with HOB at 30 degrees

D explanation: it is measurable - indicator that HOB is all the way down to 30 degrees and client is getting better

the home health nurse is assigned a client diagnosed with heart failure. which of the following should the nurse implement? select all that apply a. request a dietary consult for a sodium restricted diet b. instruct the client to elevate the feet during the day c. teach the client to weigh every morning wearing the same type of clothing d. assess for edema in the dependent areas of the body e. encourage the client to drink at least 2500mL/day f. have the client repeat back instructions to the nurse

A, B, C, D, F

which of the following patients are MOST at risk for developing endocarditis? select all that apply a. 25 y/o male who reports using intravenous drugs on a daily basis b. 55 y/o male who is post op from an aortic valve replacement c. 63 y/o female who is newly diagnosed with hyperparathyroidism and is taking aspirin d. 66 y/o female who recently had an invasive dental procedure performed a month ago and is having a fever

A, B, D

which of the following nursing diagnoses would be appropriate for a client with heart failure? (select all that apply) a. ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased CO b. activity intolerance related to increased CO c. decreased CO related to structural and functional changes d. impaired gas exchange related to decreased sympathetic nervous system activity

A, C

what are manifestations of Acute Coronary Syndrome? select all that apply a. dysrhythmia b. stable angina c. unstable angina d. ST segment elevation MI (STEMI) e. non-ST segment elevation MI (non-STEMI)

A, C, D, E

which of the following patients are MOST at risk for developing HF? select all that apply a. 69 y/o male with history of alcohol abuse and is recovering from an MI b. 55 y/o female with a health history of asthma and hypoparathyroidism c. 30 y/o male with a history of endocarditis and has severe mitral stenosis d. 45 y/o female with lung cancer stage 2 e. 58 y/o female with uncontrolled HTN and is being treated for influenza

A, C, E

a patient is complaining of chest pain. on the beside cardiac monitor, you observe pronounced T-wave inversion. you obtain the patient's vital signs and find the following: BP 190/98, HR 110, o2 sat 96% room air, RR 20. select all that apply in regard to the MOST important nursing interventions based on pts current status a. obtain 12-lead EKG b. place patient in supine position c. assess urinary output d. administer nitroglycerin sublingual as ordered e. collect cardiac enzymes as ordered per protocol f. encourage patient to cough and deep breathe g. administer morphine IV as ordered per protocol h. place patient on oxygen via nasal cannula

A, D, E, G, H