Cardiac question with rationals
8. A client has just returned from cardiac catheterization. Which nursing intervention would be most appropriate? 1. Help the client ambulate to the bathroom. 2. Restrict fluids. 3. Monitor peripheral pulses. 4. Insert an indwelling urinary catheter.
Answer. 3. Monitor peripheral pulses. Rationale: After cardiac catheterization, monitor peripheral pulses to assess peripheral perfusion. Helping the client ambulate to the bathroom is incorrect because the client should be on bed rest for 4 to 8 hours after the procedure to reduce the risk of bleeding at the insertion site. Restricting fluids is incorrect because the client should be encouraged to drink fluids after the procedure, unless contraindicated. Adequate hydration reduces the risk of nephrotoxicity that can occur with the use of contrast dye. Although urine output is monitored following cardiac catheterization, the insertion of a urinary catherter isn't necessary.
15. A cardiologist prescribes digoxin (Lanoxin)125 mcg by mouth every morning for a client diagnosed with heart failure. The pharmacy dispenses tablets that contain 0.25 mg each. How many tablets should the nurse administer in each dose? Record your answer using one decimal place.
Answer: 0.5 tablet(s) Rationale: 0.5 tablets. The nurse should begin by converting 125 mcg to milligrams. 125 mcg / 1,000 = 0.125 mg. The following formula is used to calculate drug dosages: dose on hand / quality on hand = dose desired./ X. The nurse should use the following equations: 0.25 mg / 1 tablet = 0.125 mg / X. The equation then becomes 0.25(x) = 0.125. Which is 0.125 / 0.25 = X = 0.5 tablet
86. Which parameter is elevated in right-sided heart failure? 1. CVP 2. Left-ventricular end-diastolic pressure 3. PAWP 4. Cardiac output
Answer: 1 Rational: CVP is elevated in right-sided heart failure
85. Which drug is effective in managing mild to moderate hypotension? 1. Phenylephrine (Neo-Synephrine) 2. Amiodraone (Cordarone) 3. Ibutilide (Covert) 4. Milrione
Answer: 1 Rational: Phenylephrine is indicated for mild to moderate hypotension
83. If a hypertensive client with asthma takes the maximal dose of his diuretic and his blood pressure still isn't controlled, the nurse understands the next step in controlling his hypertension would be to: 1. Add enalapril, an ACE inhibitor 2. Change him to Metoprolol, a beta blocker 3. Add another diuretic 4. Increase the drug dosage above recommended dosing levels
Answer: 1 Rational: if the maximal dosage of an antihypertensive fails to control a client's hypertension, the client should be switched to a new drug in the same class or a new drug from a different class should be added to his regimen. Metoprolol is contraindicated in asthma secondary to bronchoconstriction. Another diuretic shouldn't be added because any drug added should be from a different class than the drug the client already takes. Never increase a drug dosage able the established guidelines.
73. Good conduction of electricity from the patient's heart to the monitor requires that the critical care nurse 1. Periodically change electrode pads for good conduct 2. Place electrodes over the ribs as they are excellent conductors 3. Place electrodes with contacts on their anterior and posterior surfaces 4. Place electrodes further apart if they pick up respiratory movement
Answer: 1 Rationale: Electrodes dry out rather quickly, so replace them periodically, especially if the patient is febrile. They are placed anteriorly over intercostal spaces with all surfaces making good contact. To avoid respiratory movement, place the electrodes closer together.
69. The nurse is assessing the laboratory values for a patient with chronic heart failure before administering furosemide. Which of the following values would cause the nurse to withhold this drug and notify the primary care provider? 1. Potassium level of 3.5 mEq/L 2. Digoxin level of 0.7 ng/mL 3. Calcium level of 5 mg/dL 4. Magnesium level of 1 mg/dL
Answer: 1 Rationale: Even though this potassium level is on the low side and it will go even lower without potassium supplementation. The other values are within normal limits.
62. A 75-year-old individual is admitted with a diagnosis of left-sided heart failure and is administered Lasix 80 mg by slow IV push. Which nursing assessment indicates that the Lasix (furosemide) is NOT having the desired effect? 1. Oliguria 2. Decrease in blood pressure 3. Absence of crackles 4. Polydipsia
Answer: 1 Rationale: Furosemide (Lasix) is a loop diuretic, which should increase urinary output. Oliguria is scant or severely decreased urinary output
66. A nurse is monitoring a patient newly admitted with acute heart failure (HF). Which of the following laboratory/diagnostic results would indicate the presence of significant HF? 1. BNP of 1000 pg/mL 2. Sodium of 150 3. Potassium of 5.7 mEq/L 4. pH of 7.30
Answer: 1 Rationale: The BNP is a significant diagnostic and monitoring tool for HF. Any value greater than 400 pg/mL indicates significant HF. Although all of the additional laboratory values may be elevated (sodium and potassium) or decreased (pH) in HF, BNP is the most accurate predictor.
79. Which of the following pacemakers is usually used in an emergency and attached by the critical care nurse to the patient? 1. Transcutaneous pacer 2. Epicardial pacer 3. Transvenous pacer 4. Permanent pacer
Answer: 1 Rationale: Transcutaneous pacers are placed on the anterior and posterior chest via electrodes by the critical care nurse. All other pacers are inserted by the physician.
60. The nurse would assess for which of the following manifestations in a client with suspected arterial embolism to the left hand? Select all that apply. 1. Pain 2. Pale skin 3. Bounding radial pulse 4. Parasthesias 5. Pitting edema
Answer: 1, 2,4 Rationale: The client would exhibit pain, pallor of the affected skin, diminished or absent radial pulse, parasthesias (altered local sensation), paralysis (weakness or inability to move extremity), and poikilothermia (cooler temperature). The client would not have a bounding radial pulse(opposite finding is true) or pitting edema, indicating a fluid volume excess or heart failure. Strategy: The core issue of the question is knowledge of assessment findings in arterial embolism. Visualize a clot in the local circulation and use that image to determine the effect of the blockage on circulation to the affected area.
71. A patient is suspected of having a decreased cardiac output due to dysrhythmias. Which of the following assessments would be included in a decreased cardiac output? Select all that apply 1. Elevated jugular venous distention 2. Polyuria 3. Full and bounding pulses 4. Diaphoresis 5. Constricted pupils 6. Crackles and gurgles 7. Muffled heart sounds
Answer: 1, 3, 4 and 6 Rationale: A, C, D and F are associated with fluid buildup in the body from a lack of pumping (cardiac) action. Patients have oliguria due to poor kidney perfusion, dilated pupils due to sympathetic activation, and do not usually have muffled heart sounds, which is associated with cardiac tamponade.
82. Right-sided heart failure may develop as a result of pulmonary embolus. What is a hallmark sign of right-sided heart failure? 1. P pulmonale 2. A physiologic second heart sound (S2) split 3. Pericardial friction rub 4. Expiratory wheezing
Answer: 1. Rationale: The elevated pulmonary pressures present with pulmonary embolus can lead to right-sided heart failure, leading to an increase in right atrial volume. The increase atrial volume will appear as an altered P wave (known as P pulmonale) on the electrocardiogram. The P wave will be taller and morepeaked than a normal P wave. A physiologic S2 split is normal. When pulmonary pressures become severly elevated, the split becomes pathologic. Lung sounds are generally clear in a client with pulmonary emboli. In extreme cases, there may be crackles in the bases. A pleural friction rub may be heard in clients with pulmonary emboli and must be differentiated from pericardial friction rub.
43. The nurse is caring for a client with a dignosis of aortic stenosis. The client reports episodes of angina and passing out recently at home. The client has surgery scheduled in 2 weeks. Which of the following would be the nurse's best explanation about activity at this time? 1. "It is best to avoid strenuous exercise, stairs, and lifting before your surgery." 2. "Take short walks three times daily to prepare for postoperative rehabilitation." 3. "There are no activity restrictions unless the angina reoccurs; then please call the office." 4. "Gradually increase activity before surgery to build stamina for the postoperative period."
Answer: 1. "It is best to avoid strenuous exercise, stairs, and lifting before your surgery." Rationale: Symptomatic aortic stenosis has a poor prognosis without surgery. Restricting activity limits myocardial oxygen consumption. Since the incidence of sudden death is high in this population, it is prudent to decrease the strain on the heart while awaiting surgery. Strategy: The core issue of the question is the level of activity that will minimize the client's risk of complications or sudden death until surgery. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
37. The registered nurse has finished reviewing the 7:00 a.m shift report on a telemetry unit. Which of the following clients would be the best for the RN to assign to the licensed practical nurse? 1. A 7-day postoperative CABG client with an infection in the sternal surgical incision, requiring dressings and irrigation. 2. A client who has just arrived on the unit from the emergency room for observation to rule out a myocardial infarction. 3. A client who has had successful valve replacement therapy and will be discharged this morning. 4. A client who is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) at 10:00 a.m.
Answer: 1. A 7-day postoperative CABG client with an infection in the sternal surgical incision, requiring dressings and irrigation. Rationale: A stable client with complex dressing is an appropriate assignment for a LPN because the task is appropriate for an LPN. Initial assessment (new admission from the Ed), the assessment of a client before and after a complex procedure (PTCA), and discharge teaching are all responsibilities of the professional registered nurse and may not be delegated to the LPN. Strategy: Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
1. A client complains of crushing chest pain that radiates to his left arm. He should be presented with the following treatment: 1. Aspirin, oxygen, nitroglycerin, and morphine 2. Aspirin, oxygen, nitroglycerin, and codeine 3. Oxygen, nitroglycerin, meperidine, and thrombolytics 4. Aspirin, oxygen, nitroprusside, and morphine
Answer: 1. Aspirin, oxygen, nitroglycerin, and morphine
51. Which of the following suggestions should the nurse include when conducting health teaching for clients with arterial insufficiency? 1. Avoid long periods of sitting and standing. 2. Keep the legs and feet in a raised position. 3. Decrease ambulation to decrease pain. 4. Apply moist heat twice a day.
Answer: 1. Avoid long periods of sitting and standing. Rationale: The client should avoid long periods of standing or sitting to promote adequate blood flow. The legs and feet should be below heart level to increase peripheral circulation. Regular exercise enhances development of collateral circulation, increases vascular return, and is recommended for clients with either arterial or venous insufficiency. Moist heat is helpful for venous problems. Strategy: A critical word in the stem of the question is arterial, which tells you that the correct answer is an option that is beneficial to the client with impaired circulation toe the legs. Choose option 1 over the others because it is a generally helpful measure to increase circulation, while option 2 and 4 are helpful with venous problems. Option 3 does not help either arterial or venous circulatory problems.
17. A client reports substernal chest pain. Test results show electrocardiographic changes and an elevated cardiac troponin level. What should be the focus of nursing care? 1. Improving myocardial oxygenation and reducing cardiac workload. 2. Confirming a suspected diagnosis and preventing complications. 3. Reducing anxiety and relieving pain. 4. Eliminating stressors and providing a nondemanding environment.
Answer: 1. Improving myocardial oxygenation and reducing cardiac workload. Rationale: The client is exhibiting clinical signs and symptoms of a myocardial infarction (MI); therefore, nursing care should focus on improving myocardial oxygenation and reducing cardiac workload. Confirming the diagnosis of MI and preventing complications, reducing anxiety and relieving pain, and providing a nondemanding environment are secondary to improving myocardial oxygenation and reducing workload. Stressors can't be eliminated, only reduced.
22. A client with dilated cardiomyopathy, pulmonary edema, and severe dyspnea is placed on dobutamine. Which assessment finding indicates that the drug is effective? 1. Increased activity tolerance 2. Absence of arrhythmias 3. Negative Homans' sign 4. Blood pressure of 160/90 mm Hg
Answer: 1. Increased activity tolerance Rationale: Dobutamine should improve the client's symptoms and the client should experience an increase tolerance for activity. The absence of arrhythmias doesn't indicate effectiveness of dobutamine. A negative Homans' sign indicates absence of blood clots, which isn't a therapeutic effect of dobutamine.
11. A client has developed acute pulmonary edema. Which test result should the nurse expect? 1. Interstitial edema by chest X-ray 2. Metabolic alkalosis by ABG analysis 3. Bradycardia by ECG 4. Decreased PAWP by hemodynamic monitoring
Answer: 1. Interstitial edema by chest X-ray Rationale: The chest X-ray of a client with acute pulmonary edema shows interstitial edema as a result of the heart's failure to pump adequately. Metabolic alkalosis is incorrect because the ABG analysis of a client in acute pulmonary edema shows respiratory alkalosis or acidosis. Bradycardia is incorrect because the ECG would most likely indicate tachycardia. Decreased PAWP is incorrect because PAWP rises in the client with acute pulmonary edema.
58. A toddler with Kawasaki's disease is going home on salicylate (aspirin) therapy. Which is the priority teaching at the time of discharge? 1. Monitor the child for gastrointestinal bleeding. 2. Avoid contact with other children. 3. Report complaints of tingling extremities. 4. Maintain a low-calorie diet.
Answer: 1. Monitor the child for gastrointestinal bleeding. Rationale: Salicylates prevent platelet agglutination. Gastrointestinal bleeding is often a side effect of aspirin therapy. It is not necessary to avoid other children. Tingling of extremities is not a concern, although ringing in the ears could be a sign of salicylate toxicity. A low-calorie diet is not indicated. Strategy: The core issue of the question is knowledge of adverse drug effects of salicylate therapy for the child with Kawasaki's disease. Use this knowledge and the precess of elimination to make a selection.
7. A nurse administers heparin to a client with deep vein thrombophlebitis. Which laboratory value should the nurse monitor to determine the effectiveness of heparin? 1. PTT 2. HCT 3. CBC 4. PT
Answer: 1. PTT Rationale: The therapeutic effectiveness of heparin is determined by monitoring the patient's PTT, PT, HCT, and CBC don't monitor the therapeutic effectiveness of heparin. Monitoring the PT determines warfarin's effectiveness.
45. A client undergoes ligation of varicose veins. The nurse includes in the plan of care which of the following important interventions for the nursing diagnosis of ineffective tissue perfusion? 1. Teach client to remove compression stockings for at least 1 hour per day. 2. Teach client to flex lower extremities four times a day. 3. Teach client that numbness is common after vein ligation. 4. Encourage client to briskly scrub lower extremities to improve circulation.
Answer: 1. Teach client to remove compression stockings for at least 1 hour per day. Rationale: Compression stockings exert pressure on the veins of the lower extremities, promoting venous return back to the heart. Stockings are removed for at least an hour per day to allow for inspection and ensure blood flow through small, superficial vessels. Flexing the extremities does not aid tissue perfusion, although it maintains joint range of motion. However, after this surgery clients are taught to either stand or lie down and avoid flexing at the hip and knee. Numbness is a temporary or rarely permanent complication of surgery. Briskly scrubbing the extremities will not aid tissue perfusion. Strategy: The core issue of the question is a measure that will improve tissue perfusion for a client following vein ligation. Using principles of blood flow, choose the option that will aid circulation. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
46. A client's angiogram demonstrates the final stage of atherosclerosis. The nurse concludes that this client's pathophysiology includes which of the following elements? 1. The presence of atheromas. 2. Fatty deposits in the intima 3. Lipoprotein accumulation in the intima 4. Inflammation of the arterial wall
Answer: 1. The presence of atheromas. Rationale: The final stage of the atherosclerotic process is the development of atheromas, which are complex lesions consisting of lipids, fibrous tissue, collagen, calcium, cellular waste, and capillaries. The calcified lesions may rupture or ulcerate, stimulating thrombosis. The other options are not consistent with the ultimate or final changes in the atherosclerotic process. Strategy: Note the critical words final stage. Evaluate each option carefully, and use knowledge of pathophysiology and the process of elimination to make a selection.
33. An infant age 2 months has a tentative diagnosis of congenital heart defect. During physical assessment, the nurse notes that the infant has a pulse rate of 168 beats/minute and a respiratory rate of 72 breaths/minute. In which position should the nurse place the infant? 1. Upright in an infant seat 2. Lying on the back 3. Lying on the abdomen 4. Sitting in high Fowler's position
Answer: 1. Upright in an infant seat Rationale: Because these signs suggest development of respiratory distress, the nurse should position the infant with the head elevated at a 45-degree angle to promote maximum chest expansion. This can be accomplished by placing the infant in an infant seat. Placing an infant flat on the back or abdomen or in high Fowler's position could increase respiratory distress by preventing maximum chest expansion.
57. A 6-year-old child has been diagnosed with coarctation of the aorta. Lately, he has been complaining when he comes in from recess. The health nurse should question the child about which of the following? 1. Weakness and pain in legs. 2. Blurred vision. 3. Increased respiratory rate. 4. Bruises on shins.
Answer: 1. Weakness and pain in legs. Rationale: Decreased circulation to lower extremities would contribute to muscle fatigue and pain in the legs. Many of the children returning from recess will have increased respiratory rate secondary to play activities. Blurred vision and bruises are not related to coarctation. Strategy: The core issue of the question is knowledge of signs of exercise intolerance in a 6-year-old client with a cyanotic heart defect. Use principles of gas exchange and knowledge of normal and abnormal findings after exercise to make a selection.
28. A nurse checks an infant's apical pulse before digoxin (Lanoxin) administration and finds that the pulse rate is 90 beats/minute. Which action is most appropriate for the nurse? 1. Withhold the digoxin and notify the physician. 2. Administer the digoxin and notify the physician. 3. Administer the digoxin and document the infant's pulse rate. 4. Withhold the digoxin and document the infant's pulse rate.
Answer: 1. Withhold the digoxin and notify the physician. Rationale: The nurse should withhold the digoxin and notify the physician because an apical pulse below 100 beats/minute in an infant is considered bradycardic. The nurse should also document her findings and interventions in the medical record. Administering the drug to a bradycardic infant could further decrease his heart rate and compromise his status. Withholding the drug and not notifying the physician could compromise the existing treatment plan.
4. A complication of peripheral vascular disease may be: 1. stasis ulcer. 2. Pressure ulcer. 3. Gastric ulcer. 4. Duodenal ulcer.
Answer: 1. stasis ulcer.
80. A nurse is preparing drugs for a cardiac arrest victim. Which of the following drug is used in almost all cardiac arrest scenarios? 1. Atropine 2. Epinephrine 3. Adenosine 4. Sodium bicarbonate
Answer: 2 Rationale: "Epi" or epinephrine is used in almost all cardiac arrest scenarios. Atropine is reserved for asystole. Adenosine might be given for fast tachydysrhyhmias. Sodium bicarbonate is reserved for after a set of arterial blood gasses are obtained if the patient is in acidosis.
68. A patient is admitted with and ST segment myocardial infarction. The patient's wife overhears the physician talking about this and asks you, the nurse, what the physician means by this type of heart attack. The nurse's BEST response would include 1. "Your husband has permanent changes that will stay on his ECG and the practitioner will always be able to tell that he has an MI." 2. "Your husband has had a smaller MI that goes through only part of the wall of the heart and therefore causes small areas to stay elevated." 3. "Your husband has had a rather large heart attack that has caused the death of the heart muscle through all of its three layers." 4. "Your husband is lucky; his cardiac markers are not elevated but he has had a severe heart attack that we can take care of with medication."
Answer: 2 Rationale: An ST segment MI is one that is usually referred to as a smaller, less severe type where the enzymes are elevated but the depth of tissue death has not penetrated all three muscular coats. The ECG changes are not permanent; therefore, a trained practitioner would not see a "Q" wave that is permanent on the ECG.
65. A patient is admitted in acute distress with unrelieved back pain that radiates to his groin. This patient has a history of abdominal aortic aneurysm (AAA). What additional signs and symptoms might the patient state? 1. Midsternal chest pressure relieved with nitroglycerin paste 2. Bruit to left of the midline in the abdominal area 3. Extreme headache 4. Numbness and tingling in the hands and arms
Answer: 2 Rationale: Bruits are associated with turbulence of blood flow and are ausculated in 50% of patients with an AAA. Otherwise the patient is asymptomatic. A is more associated with angina, and C is associated with stroke. Numbness and tingling in the lower extremities is usually due to a decreased blood supply to the lower extremities from hemorrhage into the peritoneal cavity.
81. A nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include: 1. Sunken eyeballs and poor skin turgor 2. Thirst or confusion 3. Increase heart rate with hypotension 4. Coma or seizures
Answer: 2 Rationale: Early signs and symptoms of dehydration include thirst, irritability, confusion, dizziness, coma, seizures, sunken eyeballs, poor skin turgor, and increase heart rate with hypotension are all later signs.
72. A nurse is analyzing a patient's rhythm and counts a heart rate of 46. There are no "P" waves at all in this rhythm and the other components are normal. This rhythm is most likely 1. A normal sinus rhythm 2. A junctional rhythm 3. Atrial fibrillation 4. A ventricular rhythm
Answer: 2 Rationale: a junctional rhythm is known by a rate of between 60 and 40. Junctional rythms are started in the AV junction, so they are not caused by atrial depolarization, hence no "P" waves. Everything else about them is normal. Atrial fibrillation is very fast and the P waves cannot be counted. A ventricular rhythm is known by a ventricular rate around 30.
78. A patient is being taught how to care for his pacemaker site by the critical care nurse. Which of the following indicates that this patient understands safe care of the device? 1. "I will not handle the pacemaker leads at the same time as the toaster." 2. "I will obtain a medic alert tag as soon as I can." 3. "Since it was implanted in the OR I do not have to worry about infection." 4. "I must not be around a home microwave."
Answer: 2 The patient needs to get a medical alert tag as health care providers need to avoid the generator box site during defibrillation. There are no external wires, so electrical safety is not an issue. All surgical sites need to be monitored for infection, and home microwaves do not interfere with newer permanent pacers.
84. Which sign is characteristic of cardiac tamponade? 1. Shortness of breath 2. Beck's triad 3. Holosystolic murmur 4. Bounding peripheral pulse
Answer: 2 Rational: Beck's triad comprises the three classic signs of cardiac tamponade: elevated CVP with jugular vein distention, muffled heart sounds, and a drop in systolic blood pressure.
29. A child has been diagnosed with rheumatic fever. Which statement by the mother indicates an understanding of rheumatic fever? 1. "I should avoid giving my child aspirin for the arthritic pain." 2. "It's very upsetting that my child must take penicillin until he's 20 years old." 3. "I need to wear a gown, gloves, and mask to stay in my child's room." 4. "I don't know how I'll be able to keep my child away from his sister when he gets home."
Answer: 2. "It's very upsetting that my child must take penicillin until he's 20 years old." Rationale: Rheumatic fever is an acquired autoimmune-complex disorder that occurs 1 to 3 weeks after an infection of group A beta-hemolytic streptococci, in many cases as a result of strep throat that hasn't been treated with antibiotics. To prevent additional heart damage from future attacks, the child must take penicillin or another antibiotic until the age of 20 or for 5 years after the attack, whichever is longer. Children shouldn't be given aspirin because it may result in Reye's syndrome. Rheumatic fever isn't contagious, so isolation precautions aren't necessary.
19. A client with unstable angina receives routine applications of nitroglycerin ointment. The nurse should delay the next dose if the client has: 1. atrial fibrillation. 2. A systolic blood pressure below 90 mm Hg. 3. A headache. 4. Skin redness at the current site.
Answer: 2. A systolic blood pressure below 90 mm Hg. Rationale: Nitroglycerin is a vasodilator and can lower arterial blood pressure. As a rule, when the client's systolic blood pressure is below 90 mm Hg, the nurse should delay the dose and notify the physician. Nitroglycerin isn't contraindicated in a client with atrial fibrillation. Headache, a common occurrence with nitroglycerin isn't a cause for withholding a dose. Application sites should be changed with each dose, especially if skin irritation occurs.
38. The nurse is caring for a client with a history of hypertension. The client is being treated with metoprolol (Lopressor), hydrochlorothiazide (Hydrodiuril), and captopril (Capoten). The client has a blood pressure of 120/80 mmHg and a pulse rate of 48. Which of the following is the best action by the nurse? 1. Administer the metoprolol (Lopressor) and the hydrochlorothiazide (HydroDiuril), hold the captopril (Copoten), and notify the physician. 2. Administer the captopril (Capoten) and the hydrochlorothiazide (HydroDiuril), hold the metoprolol (Lepressor), and notify the physican. 3. Administer all the medications and notify the physician. 4. Withhold all the medications and notify the physician.
Answer: 2. Administer the captopril (Capoten) and the hydrochlorothiazide (HydroDiuril), hold the metoprolol (Lepressor), and notify the physican. Rationale: The client's heart rate is bradycardic, and metoprolol, a beta-blocker, decreases the heart rate. Neither the captopril nor the hydrochlorothiazide lower the heart rate, and either may be safely administered to maintain control of he hypertension. When a dose of medication is withheld, it is the responsibility of the nurse to notify the physician of the action and rational. Strategy: The core issue of the question is determining which medication is responsible for the adverse effects on client status and acting accordingly. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
56. During the acute phase of rheumatic fever, which of the following is a priority action of the nurse? 1. Encourage ambulation at least four times per day. 2. Assess for early signs of endocarditis. 3. Maintain hydration by encouraging sips of water. 4. Manage pain with strong narcotic analgesics.
Answer: 2. Assess for early signs of endocarditis. Rationale: The main complication of rheumatic fever is carditis. The nurse must assess for early signs of bacterial endocarditis. The client should be encouraged to rest during the acute phase, and hydration needs may not be sufficiently met with sips of water. Narcotic analgesics may not be necessary, although NSAIDs are likely to be ordered. Strategy: The core issue of the question is the ability to set priorities for a client with rheumatic fever. Omit option 1 because of the words at least, knowing that rest is encouraged. Likewise, eliminate option 3 because of the word sips. Choose option 2 over 4 knowing that NSAIDs are likely to be effective in managing pain and inflammation from rheumatic fever.
3. A client's cardiac monitor alarm sounds, indicating ventricular tachycardia. The nurse should: 1. perform immediate defibrillation. 2. Assess the client. 3. Call the physician. 4. Administer a precordial thump.
Answer: 2. Assess the client.
5. A key diagnostic test for heart failure is: 1. serum potassium. 2. B-type natriuretic peptide. 3. Troponin I 4. cardiac enzymes.
Answer: 2. B-type natriuretic peptide.
10. A nurse is evaluating a client with left-sided heart failure. Which finding should the nurse expect to assess? 1. Ascites 2. Dyspnea 3. Hepatomegaly 4. Jugular vein distention
Answer: 2. Dyspnea Rationale: Dyspnea may occur in a client with left-sided heart failure. Ascites, hepatomegaly, and jugular vein distention are assessment findings in right-sided heart failure.
50. An important outcome of care for a female client with hypertension has been met when the client is able to do which of the following? 1. Return to her usual activities of daily living 2. Identify actions to counteract two of her modifiable risk factors 3. Lower her blood pressure by 10% 4. Discontinue lifestyle modifications
Answer: 2. Identify actions to counteract two of her modifiable risk factors Rationale: An important outcome in care of the hypertensive client is the ability to identify and counteract personal risk factors that the client has the ability to change. Modifiable risk factors for hypertension include smoking, hypercholesterolemia, diabetes mellitus, sedentary lifestyle, obesity, stress, and alcohol use. Option 1 is not likely to be an issue. Option 3 may or may not be sufficient. Option 4 is contraindicated. Strategy: The core issue of the question is the ability to identify an indicator that is a positive effect of care for the hypertensive client. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
16. A client is prescribed diltiazem (Cardizem) to manage his hypertension. The nurse should tell the client the diltiazem will: 1. lower his blood pressure only. 2. Lower his heart rate and blood pressure. 3. Lower his blood pressure and increase his urine output 4. lower his heart rate and blood pressure and increase his urine output.
Answer: 2. Lower his heart rate and blood pressure. Rationale: Diltiazem, a calcium channel blocker, will reduce both the heart rate and blood pressure. It doesn't directly affect urine output.
25. A child returns to his room after a cardiac catheterization. Which nursing intervention is most appropriate? 1. Maintain the child on bed rest with no further activity restrictions. 2. Maintain the child on bed rest with the affected extremity immobilized. 3. Allow the child to get out of bed to go to the bathroom, if necessary. 4. Allow the child to sit in a chair with the affected extremity immobilized.
Answer: 2. Maintain the child on bed rest with the affected extremity immobilized. Rationale: The child should be maintained on bed rest with the affected extremity immobilized after cardiac catheterization to prevent hemorrhage. Allowing the child to move the affected extremity while on bed rest, allowing the child bathroom privileges, or allowing the child to sit in a chair with the affected extremity immobilized places the child at risk for hemorrhage.
59. A toddler requires supplemental oxygen therapy for a cyanotic heart defect. In planning for home care, the nurse would discuss which of the following with the parents? 1. The need to maintain the child on bedrest. 2. Means of promoting mobility while meeting the need for supplemental oxygen. 3. Symptoms of oxygen toxicity. 4. How to draw blood for blood gases.
Answer: 2. Means of promoting mobility while meeting the need for supplemental oxygen. Rationale: Allowing mobility is helpful to promote growth and development in the toddler. Strategies should be discussed to promote mobility while maintaining the supplemental oxygen. Option 1 and 4 are unnecessary. Signs of oxygen toxicity are not the priority based on the information in the question. Strategy: The core issue of the question is home care needs of a toddler receiving oxygen therapy. Use principles of needs related to normal growth and development to help select the correct option.
31. A nurse is caring for an infant with tetralogy of Fallot. Which drug should the nurse anticipate administering during a tet spell? 1. Propranolol (Inderal) 2. Morphine 3. Meperidine (Demerol) 4. Furosemide (Lasix)
Answer: 2. Morphine Rationale: The nurse should anticipate administering morphine during a tet spell to decrease the associated infundibular spasm. Propranolol may be administered as a preventive measure in an infant with tetralogy of Fallot but isn't administered during a tet spell. Furosemide and meperidine aren't appropriate agents for an infant experiencing a tet spell.
23. A nurse administers warfarin (Coumadin) to a client with deep vein thrombophlebitis. Which laboratory valve indicates that the client has a therapeutic level of warfarin? 1. Partial thromboplastin time (PTT) 1 ½ to 2 times the control 2. Prothrombin time (PT) 1 ½ to 2 times the control 3. International Normalized Ratio (INR) of 3 to 4 4. Hematocrit (HCT) of 32%
Answer: 2. Prothrombin time (PT) 1 ½ to 2 times the control Rationale: Warfarin is at a therapeutic level when the PT is 1 ½ to 2 times the control. Values greater than this increase the risk of bleeding and hemorrhage; lower values increase the risk of blood clot formation. Heparin, not warfarin, prolongs PTT. The INR may also be used to determine whether warfarin is at a therapeutic level; however, an INR of 2 to 3, not 3 to 4, is considered therapeutic. HCT doesn't provide information on the effectiveness of warfarin. However, a falling HCT in a client taking warfarin may be a sign of hemmorrhage.
6. While auscultating the heart sounds of a client with mitral insufficiency, the nurse hears an extra heart sound immediately after the S2. The nurse should document this extra heart sound as a: 1. S1. 2. S3. 3. S4. 4. mitral murmur.
Answer: 2. S3. Rationale: An S3, is heard following an S2. This indicates that the client is experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before S1 and is caused by resistance to ventricular filling. A murmur of mitral insufficiency occurs during systole and is heard when there's turbulent blood flow across the valve.
52. A client with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. The nurse's initial action should be to: 1. Elevate the leg above the level of the heart. 2. Wrap the leg in a loose blanket. 3. Notify the physician about the findings. 4. Perform passive ROM exercises to stimulate circulation.
Answer: 2. Wrap the leg in a loose blanket. Rationale: The client is exhibiting symptoms of acute arterial occlusion. Without immediate intervention, ischemia and necrosis will result within hours. The nurse should first wrap the leg to maintain warmth and protect it from further injury, and should then quickly notify the physician. The leg should not be elevated above heart level because doing so would worsen the tissue ischemia, and passive range of motion will also increase ischemia by increasing tissue demand for oxygen. Strategy: The core issue of the question is recognizing the complication of acute arterial occlusion and then determining which action should be taken first. Choose an option that is client-focused rather than physician-notification focused, if one is available. In this case, the nurse can protect the client from further injury with option 2.
12. A nurse is performing discharge teaching for a client with PVD. The nurse should teach the client to: 1. inspect his feet weekly 2. begin a daily walking program 3. wear constrictive clothing 4. stand rather than sit when possible
Answer: 2. begin a daily walking program Rationale: The nurse should encourage the client with PVD to follow a program of walking and other leg exercises. Inspecting the feet weekly is incorrect because the nurse should teach the client to inspect his feet daily. Wearing constrictive clothing is incorrect because the client should wear loose clothing that doesn't restrict circulation. Standing when possible—rather than sitting—is incorrect because the client should avoid standing for long periods.
67. A patient is admitted with severe uncompensated pulmonary edema secondary to chronic heart failure. After diagnostic testing, it is found that the left coronary artery is blocked, which has led to his pulmonary edema. Which of the following signs and symptoms is consistent with this diagnosis? 1. Elevated central venous pressure 2. Elevated blood pressure 3. Elevated pulmonary artery wedge pressure (PAWP) or PAOP 4. Increased oxygen saturation
Answer: 3 Rationale: An increased PAWP (PAOP) is consistent with fluid buildup in the lungs and inability of the left side of the heart to pump to the body. A would be correct if this patient had a right ventricular infarction causing right sided heart failure. The BP and oxygen saturation are usually lower in left-sided HF.
76. A patient has multiple saw-toothed P waves at a rate of 300 beats per minute. This patient's rhythm is most likely 1. Paroxysmal atrial tachycardia (PAT) 2. Premature atrial contractions (PACs) 3. Atrial flutter 4. Atrial fibrillation
Answer: 3 Rationale: Atrial flutter is detected by its multiple, saw-toothed-patterned P waves that are fast, countable, and regular. PAT is fast but has only one P wave/one QRS. PACs can fall on any underlying rhythm, but they are limited to one or two beats with premature P waves. Atrial fibrillation has uncountable P waves.
75. A nurse is measuring a waveform of the ECG strip and determines it is normally around 0.06 to 0.1 the waveform s/he is measuring is the 1. P wave 2. PRI 3. QRS 4. QT interval
Answer: 3 Rationale: The QRS is around 0.06 to 0.1 seconds. The P wave is not usually measured but we look to see that it is upright, rounded, and symmetrical. The PRI is from 0.12 to 0.2 seconds, and the QT is rate related but is around 0.36 to 0.42 seconds.
63. A newly admitted patient, diagnosed with a myocardial infarction and left ventricular heart failure might exhibit which of the following physical symptoms? Choose all that apply. 1. Jugular vein distention 2. Hepatomegaly 3. Dyspnea 4. Crackles 5. Tachycardia 6. Right-upper-quadrant pain
Answer: 3, 4 and 5 are some of the signs and symptoms of left-sided hear failure, which backs up into the lungs. A, B and F are indicators of right-sided heart failure, which is cause by systemic congestion.
70. A patient is admitted to your acute coronary care unit with the diagnosis of ACS. The nurse has seen ECG changes that are indicative of an anterior wall infarction and is observing the patient for signs/symptoms of complications. The nurse has noted the following vital sign trends: 1100-HR 92, RR 24, BP 140/88, Cardiac rhythm NSR 1115-HR 96, RR 26, BP 128/82, Cardiac rhythm NSR 1130-HR 104, RR 28, BP 102/68, Cardiac rhythm ST 1145-HR 120, RR 32, BP 80/52, Cardiac rhythm ST with frequent PVC's The nurse should be alert for which of the following complications? Choose all that apply. 1. Syncope 2. Pericarditis 3. Cardiogenic shock 4. Cardiac tamponade 5. Ventricular aneurysm 6. Acute respiratory failure
Answer: 3, 4and 5 Rationale: Because there is a progressive downward spiral in the BP and a dramatic increase in the HR and RR with rhythm disturbances, this patient could be experiencing cardiogenic shock and tamponade. In shock, the hear fails to keep the BP elevated to nourish the tissues, so the HR elevates causing tacycardias and tachydysrhythmias. The same sequela can occur when the heart is compressed and no blood can enter or exit as in a cardiac tamponade as well as an aneurysem, where the hear pumping can be compromised by lack of pumping in the ballooned out or weakened areas. Pericarditis is noted by a friction rub and elevated temperature with constant, dull chest pain. Syncope could look like the above but it is associated with activity, which this patient is not doing in an acute situation. Acute respiratory failure would look like the above if the BP were elevated.
26. A child is scheduled for echocardiography. The nurse is providing teaching to the child's mother. Which statement by the mother about echocardiography indicates the need for further teaching? 1. "I'm glad my child won't have an I.V catheter inserted for this procedure." 2. "I'm glad my child won't need to have dye injected into him before the procedure." 3. "How am I going to explain to my son that he can't have anything to eat before the test?" 4. "I know my child may need to lie on his left side and breathe in and out slowly during the procedure."
Answer: 3. "How am I going to explain to my son that he can't have anything to eat before the test?" Rationale: Echocardiography is a noninvasive procedure used to evaluate the size, shape, and motion of various cardiac structures. Therefore, it isn't necessary for the client to have an I.V catheter inserted, dye injected, or nothing by mouth, as would be the case with a cardiac catheterization. The child may need to lie on his left side and inhale and exhale slowly during the procedure.
44. The nurse is caring for a client who has just undergone cardiac angiography. The catheter insertion site is free from bleeding or signs of hematoma. The vital signs and distal pulses remain in the client's normal range. The intravenous fluids were discontinued. The client is not hungry or thirsty and refuses any food or fluids, asking to be left alone to rest. Which of the following is the nurse's best response? 1. "You are recovering well from the procedure and resting is a good idea." 2. "It is important for you to walk, so I will be back in 1 hour to walk with you." 3. "It is important to drink fluids after this procedure, to protect your kidney function. I will bring you a pitcher of water, and I encourage you to drink." 4. "You will need to do the leg exercises that you practiced before the procedure to keep good circulation to your legs. After your exercises, you can rest."
Answer: 3. "It is important to drink fluids after this procedure, to protect your kidney function. I will bring you a pitcher of water, and I encourage you to drink." Rationale: The dye used in angiography is nephrotoxic, and a client should have adequate fluids after the procedure to eliminate the dye. The client should lie with the affected leg extended for 6 to 8 hours. Leg exercises are not recommended because exercise could disrupt the clot that formed at the insertion site. Option 1 is incorrect because it gives false reassurance to a client who could be at risk if fluids are not taken in. Strategy: The core issue of the question is knowledge of the correlation between lack of fluid intake and risk of kidney complications following angiography. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
54. Which of the following clients is most at risk for developing a deep-vein thrombosis? 1. A 30-year-old client who is 1 week postpartum. 2. A 63-year-old client post-CVA on anticoagulant therapy. 3. A 40-year-old woman who smokes and uses oral contraceptives. 4. A 41-year-old female who underwent laparoscopic cholecystectomy.
Answer: 3. A 40-year-old woman who smokes and uses oral contraceptives. Rationale: A major risk factor for formation of thrombophlebitis is oral contraceptive use in woman who smoke. Being 1-week postpartum does not place a client at risk since mobility is usually restored. Anticoagulant therapy is used to prevent development of thrombi. Laparoscopic surgical procedures are associated with more rapid recovery times with reduced immobility, keeping this client at lower risk than the client in option 3. Strategy: The critical words in the stem of the question are most at risk, telling you that the correct option is the one that contains the most severe or greatest number of risk factors for thrombophlebitis. With this in mind, evaluate each option and use the process of elimination to make a selection.
39. The nurse has finished reviewing the shift report on a cardiac unit. The nurse should plan to see which of the following assigned clients first? 1. A client with hypertrophic cardiomyopathy who is reporting dyspnea. 2. A client who had a cardiac caterterization and will be ambulating for the first time. 3. A client receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain. 4. A client who is recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101 F.
Answer: 3. A client receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain. Rationale: A client with endocarditis is at risk for thrombus formation, and chest pain and anxiety are signs of pulmonary embolism (PE), which is a life-threatening complication requiring immediate attention. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment; a temperature of 101 F requires additional assessment, and a client who is ambulating for the first time will be assessed by the nurse. However, the client who needs to be assessed for PE is the most emergent. Strategy: The key to determining the answer to priority-setting questions is to evaluate which client is the most unstable or has the greatest risk for developing a complication. Evaluate each option carefully using these methods, and use nursing knowledge and the process of elimination to make a selection.
21. Following a left anterior myocardial infarction, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? 1. A drop in central venous pressure 2. An increase in the cardiac index 3. A rise in pulmonary artery diastolic pressure 4. A decline in mean pulmonary artery pressure
Answer: 3. A rise in pulmonary artery diastolic pressure Rationale: A rise in pulmonary artery diastolic pressure suggests left-sided heart failure. Central venous pressure would rise in heart failure. The cardiac index would decline in heart failure. The mean pulmonary artery pressure would increase in heart failure.
14. A client comes to the clinic and states he has a history of hypertension. Which type of medication might the nurse expect the client to be taking to control his blood pressure? 1. Antilipemics 2. Antibiotics 3. ACE inhibitors 4. Antidiabetics
Answer: 3. ACE inhibitors Rationale: ACE inhibitors may be prescribed to help control high blood pressure. Other types of medications that may be prescribed include diuretics, calcium channel blockers, angiotensin II receptor blockers, and beta-adrenergic blockers. Antilipemics help lower serum cholesterol levels. Antibiotics are used to fight infection, and antidiabetics help control serum glucose levels.
18. A client with a myocardial infarction and cardiogenic shock is placed on an intra-aortic ballon pump (IAPB). If the device is functioning properly, the balloon inflates when the: 1. tricuspid valve is closed. 2. Pulmonic valve is open. 3. Aortic valve is closed. 4. Mitral valve is closed.
Answer: 3. Aortic valve is closed. Rationale: An intra-aortic ballon pump (IAPB) inflates during diastole when the tricuspid and mitral valves are open and the aortic and pulmonic valves are closed.
41. The nurse is caring for a client with a history of renal failure and a new myocardial infarction. The nurse who is reviewing laboratory findings would call the doctor to report which of the following results? 1. Potassium level of 5.0 mEq/L 2. Sodium level of 145 mEq/L 3. Calcium level of 7.0 mg/dL 4. Digoxin/digitalis level of 0.8 ng/mL
Answer: 3. Calcium level of 7.0 mg/dL Rationale: Renal failure is a common cause of hypocalcemia, and a value of 7.0 mg/dL is below the normal range of serum calcium. Options 1 and 2 are within the upper limits for potassium and sodium, and option 4 is within the therapeutic range of digoxin. Strategy: The core issue of the question is knowledge of normal and abnormal values that are important to report in a client with an acute cardiac problem and a history of renal failure. The best strategy in question such as these is to pick the value with the most abnormal number and/or one that relates to the underlying disorder(s).
30. A nurse is caring for a child with a cyanotic heart defect. Which signs should the nurse expect to observe? 1. Cyanosis, hypertension, clubbing, and lethargy. 2. Cyanosis, hypotension, crouching, and lethargy. 3. Cyanosis, irritability, clubbing, and crouching. 4. Cyanosis, confusiion, clonus, and crouching.
Answer: 3. Cyanosis, irritability, clubbing, and crouching. Rationale: The child with a cyanotic heart defect has cyanosis along with crabiness (irritability), clubbing of the digits, and crouching or squatting. The child with cyanotic heart defect doesn't typically have hypertension, lethargy, confusion, or clonus.
47. When assessing a client with peripheral arterial disease, the nurse assesses the client for which of the following signs and symptoms that would be consistent with tissue ischemia? 1. Peripheral edema 2. Widened pulse pressure 3. Leg pain while walking 4. Brownish discoloration to the skin on the leg
Answer: 3. Leg pain while walking Rationale: Leg pain (also called intermittent claudication) is a primary manifestation of peripheral arterial disease. Intermittent claudication is muscle pain caused by interruption in arterial flow, resulting in tissue hypoxia. Peripheral edema and brownish discoloration to the skin on the leg would be consistent with venous disease, not arterial disease. Widened pulse pressure would be an unrelated finding. Strategy: The critical words in the question are peripheral arterial disease, which direct you to look for manifestations that are abnormal and that are consistent with arterial but not venous disease. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
9. A client is in the first postoperative day after left femoropopliteal revascularization. Which position would be most appropriate for this client? 1. On his left-sided 2. In high Fowler's position 3. On his right side 4. In a left lateral decubitus position
Answer: 3. On his right side Rationale: Following revascularization, avoid positioning the client on the surgical side. Because this client had left femoropoliteal revascularization, he may be positioned on the right side. Placing the client on the left side is incorrect because this would position the client on the operative side. Positioning the client in high Fowler's position is incorrect because the client should avoid flexion at the surgical site. Placing the client in a left lateral decubitus position is incorrect because this would place the client on the surgical side and cause flexion at the site.
20. A client experiences acute myocardial ischemia. The nurse administers oxygen and sublingual nitroglycerin. When assessing an electrocardiogram (ECG) for evidence that blood flow to the myocardium has improved, the nurse should focus on the: 1. widening of the QRS complex. 2. Frequency of ectopic beats. 3. Return of the ST segment to baseline. 4. Presence of a significant Q wave.
Answer: 3. Return of the ST segment to baseline. Rationale: During episodes of myocardial ischemia, an ECG may show ST-segmant elevation or depression. With successful treatment, the ST segment should return to baseline. Widening QRS complex, presence of a Q wave, and frequent ectopic beats aren't directly indicative of myocardial ischemia.
87. ACE inhibitors correct heart failure by: 1. Increasing preload 2. Causing vasoconstriction 3. Increasing afterload. 4. Reducing afterload
Answer: 4 Rational: ACE inhibitors reduce afterload through vasodilation, thereby reducing heart failure.
64. A patient is admitted to your telemetry unit with chest pain that has been increasing in intensity and duration. The critical care nurse can identify that this type of angina is called 1. Stable 2. Variant 3. Predictable 4. Unstable
Answer: 4 Rationale: Unstable angina increases in intensity and occurs more frequently with longer events. Stable angina is predictable; the patient can tell you when it is going to occur. Variant or Prinzmetal's angina is atypical and occurs at rest.
74. A nurse is describing one of the waveforms to a novice critical care nurse. S/he describes this wave as being upright rounded and symmetrical and occurring after the QRS. The nurse is describing the 1. P wave 2. QRS 3. ST segment 4. T wave
Answer: 4 Rationale: the T wave is after the ST segment and is upright, rounded, and symmetrical. The P wave is upright, rounded, and symmetrical but it is after the T wave and is smaller. The QRS is after the P wave and can have three phases. The St segment is after the QRS and before the T wave
61. Which isoenzyme most quickly reflects that a patient has suffered an acute and recent myocardial infarction? 1. LDH 2. CK-MM 3. SGOT 4. Troponin
Answer: 4 Rationale: this enzyme is found in cardiac tissue and will rapidly increase with the onset of a myocardial infarction
2. Which lifestyle changes should a client diagnosed with coronary artery disease consider? 1. Smoking cessation 2. Establishing a regular exercise routine 3. Weight reduction 4. All of the Above
Answer: 4. All of the Above
27. An infant with a ventricular septal defect is receiving digoxin (Lanoxin). Which intervention by the nurse is most appropriate before digoxin administration? 1. Take the infant's blood pressure. 2. Check the infant's respiratory rate for 1 minute. 3. Check the infant's radial pulse for 1 minute. 4. Check the infant's apical pulse for 1 minute.
Answer: 4. Check the infant's apical pulse for 1 minute. Rationale: Before administering digoxin, the nurse should check the infant's apical pulse for 1 minute. Checking the radial pulse may be inaccurate. Checking the blood pressure and respiratory rate isn't necessary before digoxin administration because the medication doesn't affect these parameters.
48. In providing community education on prevention of peripheral arterial disease, the nurse is careful to include which of the following as a major risk factor? 1. Dysrhythmias 2. Low-protein intake 3. Exposure to cool weather 4. Cigarette smoking
Answer: 4. Cigarette smoking Rationale: Nicotine in cigarettes promotes vasoconstriction. The three most significant risk factors for development of peripheral arterial disease are smoking, hyperlipidemia, and hypertension. The presence of dysrhythmias, low-protein intake, and exposure to cool weather are not risk factors for the disease, although cool weather could worsen the symptoms when disease is already present. Strategy: Note the critical word prevention to focus on the option that contains information that will affect the likelihood of whether the client will develop peripheral arterial disease. Evaluate each option carefully, using nursing knowledge and the process of elimination to make a selection.
42. The nurse is caring for a client who had a permanent pacemaker inserted because of a complete heart block. The nurse determines that which of the following client outcomes indicates a successful procedure? 1. Client ambulating in the hall within 4 hours of the procedure without dyspnea or chest pain. 2. Client's ECG monitor demonstrates normal sinus rhythm. 3. Heart rate of 80 beats per minute, blood pressure 120 systolic, and 80 diastolic. 4. Client's ECG monitor shows paced beats at the rate of 68 per minute.
Answer: 4. Client's ECG monitor shows paced beats at the rate of 68 per minute. Rationale: The client is not allowed to ambulate for 24 hours to prevent dislodging of the electrodes. Normal sinus rhythm, heart rate of 80, and a BP of 120 over 80 do not reflect pacemaker function. Paced beats indicate that the pacemaker is functioning. Strategy: Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
36. The nurse is preparing to discharge a client after CABG surgery. The client is taking several new medications, including digoxin (Lanoxin), metoprolol (Lopressor), and furosemide (Lasix). The client complains of nausea and anorexia. The nurse is preparing to report this finding to the physician before discharging the client. Which laboratory result will the nurse check before calling the physician? 1. Potassium level 2. Sodium level 3. PT / INR 4. Digoxin level
Answer: 4. Digoxin level Rationale: Nausea and anorexia are signs of digitalis toxicity. The other laboratory values would not explain the client's symptoms and therefore are not priorities to assess before telephoning the physician. Strategy: The core issue of the question is the ability to correlate early signs of digoxin toxicity with a need to check digoxin level in a client with cardiac disease. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
53. In coordinating care for a client with venous stasis ulcers, the nurse explains to unlicensed assistive personnel that which of the following is the most important intervention in ulcer healing? 1. Surgical debridement 2. Meticulous cleaning of the ulcers to prevent infection. 3. Performance of leg exercises to increase collateral circulation. 4. Elevation of the extremities to increase venous return.
Answer: 4. Elevation of the extremities to increase venous return. Rationale: The client with venous ulcers must keep the legs elevated above the level of the heart as much as possible. Elevation of the extremities enhances venous return and improves circulation, providing oxygen and nutrients to the lower extremities. The client with a leg ulcer should avoid exercise to prevent further damage to tissues at risk. Option1 may or may not be indicated. Asepsis is important, but no ulcer will heal unless the edema and stagnant tissue metabolites can be reduced through leg elevation. Strategy: The critical words in the stem of the question are most important intervention, indicating that more than one option, or all options, may be correct, but one is better than the others. Look at the question carefully and note that the nurse is talking to an ancillary caregiver. Consider that the correct option is one that is within the scope of practice of that caregiver in making a selection.
40. The nurse is discharging a client to home with a new diagnosis of atrial fibrillation.. The nurse explains that which of the following is the most important symptoms to report to the physician? 1. Irregular pulse 2. Fever 3. Fatigue 4. Hemoptysis
Answer: 4. Hemoptysis Rationale: A serious complication of atrial fibrillation is pulmonary embolism. Chest pain and hemoptysis are common symptoms of pulmonary embolism. Irregular pulse is expected with atrial fibrillation. Fatigue may accompany atrial fibrillation in some individuals. Fever is not associated with atrial fibrillation and is not necessarily included in discharge teaching. However, it could be a sign of illness that could increase the workload of the heart, and therefore it would be the second-most important item to report if it occurred. Strategy: The core issue of the question is knowledge of signs and symptoms of complications to report to the physician in the presence of atrial fibrillation. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
34. An infant with a congenital cyanotic heart defect has a complete blood count drawn, revealing an elevated red blood cell (RBC) count. Which condition do these findings indicate? 1. Anemia 2. Dehydration 3. Jaundice 4. Hypoxia compensation
Answer: 4. Hypoxia compensation Rationale: A congenital cyanotic heart defect alters blood flow through the heart and lungs, which produces hypoxia. To compensate for this, the body increases the oxygen-carring capacity by increasing RBC production, which causes the hemoglobin level and hematocrit to increase. The hemoglobin level and hematocrit are typically decreased in anemia. Altered electrolyte levels and other laboratory values provide better evidence of dehydration. An elevated hemoglobin level and hematocrit aren't associated with jaundice.
32. An infant is diagnosed with patent ductus arteriosus. Which drug should the nurse anticipate administering to attempt to close the defect? 1. Digoxin (Lanoxin) 2. Predinisone. 3. Furosemide (Lasix) 4. Indomethacin (Indocin)
Answer: 4. Indomethacin (Indocin) Rationale: Indomethacin is administered to an infant with patent ductus arteriosus in the hope of closing the defect. Digoxin and furosemide may be used to treat the symptoms associated with patent ductus arteriosus, but they don't achieve closure. Prednisone isn't used to treat the condition.
49. When teaching a client with an aneurysm what signs and symptoms may indicate impending rupture, the nurse considers which of the following? 1. Medication therapy the client is receiving 2. Client's usual blood pressure 3. Age and gender of the client 4. Size and location of the aneurysm
Answer: 4. Size and location of the aneurysm Rationale: Aneurysms vary by size and location. Signs of rupture depend on the location of the aneurysm. Dissection can occur anywhere but most often occurs in the ascending aorta where pressure is the highest. The medication the client is receiving is vague and is not directly related. The blood pressure relates to whether the aneurysm may rupture, not to the associated signs and symptoms. The age and gender of the client are unrelated to the size and symptoms of aneurysm rupture. Strategy: With the critical words signs and symptoms in mind, choose the option that most directly relates to the core issue of the question. Evaluate each option carefully, and choose option 4 as the only one that could affect the specific list of signs and symptoms that the nurse would teach related to aneurysm rupture.
24. A client comes to the emergency department with a dissecting aortic aneurysm. The client is at greatest risk for: 1. septic shock 2. anaphylactic shock 3. cardiogenic shock 4. hypovolemic shock
Answer: 4. hypovolemic shock Rationale: A dissecting aortic aneurysm is a precursor to aortic rupture, which leads to hemorrhage and hypovolemic shock. Septic shock occurs with overwhelming infection. Anaphlactic shock is an allergic response. Cardiogenic shock is the result of ineffective cardiac function
77. A patient has a VVIR mode pacemaker. The nurse knows that this pacemaker is characterized by which of the following? a. atrial (pacing), atrial (sensing), triggered (response to sensing), and none (rate modulation) b. atrial (pacing), ventricular (sensing), inhibited (response to sensing), and rate modulated (rate modulation) c. ventricular (pacing), atrial (sensing), triggered (response to sensing), and rate modulated (rate modulation) d. ventricular (pacing), ventricular (sensing), inhibited (response to sensing), rate modulated (rate modulation)
Answer: D Rationale: This is the most common mode for permanent ventricular pacing. V= Ventricular, I= inhibited, and R= rate modulated.
13. If a nurse knows a client's heart rate, what other value and formula does she need to know to calculate CO?
Answer: Stroke Volume Rationale: Cardiac output equals stroke volume (the amount of blood ejected with each beat) times heart rate. [CO = SV X HR]
35. The nurse has admitted a client to the emergency room with complaints of chest pain over the previous 2 hours. There are no clear changes on the 12-lead. The nurse would expect which laboratory test to provide confirmation of a myocardial infarction (MI)? 1. Potassium of 5.2 mEq/L 2. Creatinine kinase (CK) of 545 with MB of 4% 3. CK of 320 with MB of 12% 4. WBC of 11,400 / mm3
Answer:3. CK of 320 with MB of 12% Rationale: A CK level above 150 with over 5% MB isoenzyme indicates myocardial damage from acute myocardial infarction. Elevated potassium is not indicative of myocardial infarction. Elevated WBC is an indicator of many conditions, including MI. Strategy: The core issue of the question is the ability to correlate indicators of myocardial damage with a client situation. Evaluate each option carefully, and use nursing knowledge and the process of elimination to make a selection.
55. The nurse is caring for a 2-month-old child with transposition of the great vessels. Which of these interventions has highest priority? 1. Providing comfort for parents. 2. Maintaining proper caloric intake. 3. Reducing stressors for infant. 4. Documenting vital signs.
Answers: 3. Reducing stressors for infant. Rationale: The open ductus arteriosus will allow a small amount of mixing of oxygenated and unoxygenated blood. Stress will increase the cardiac workload and therefore is a priority for the nurse to avoid. Maintaining caloric intake and comfort are the next priorities using Maslow's hierarchy. Documenting vital signs is a routine activity and not a priority when compared to actual care activities. Strategy: Using Maslow's hierarchy of needs to review each option and choose the one that most closely relates to the ABC's and thus cardiac workload. Use this knowledge and the process of elimination to make a selection.
