MedSurg I Cardio Section
A nurse is reinforcing discharge teaching with a client who has a prescription for furosemide 40 mg PO daily. The client should take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime
A. Pt should take furosemide, a diuretic, in AM so peak action & duration of med occurs during waking hours.
A 160-pound patient is to receive cyclosporine (Neoral) 12.5 mg/kg daily in two divided doses. How many milligrams will the patient receive with each dose? *fill in the blank*
454.5 mg per dose. 160/2.2 = 72.72x12.5 = 909/2 = 454.5
The nurse is evaluating a patient's preoperative teaching for a commissurotomy. The patient shows understanding for the purpose of this procedure by stating which of the following? A. "Fused valve flaps are separated to enlarge the valve opening." B. "A mechanical valve is inserted to replace a valve." C. "The valve flaps are repaired or reconstructed." D. "A biological valve is inserted to replace a valve."
A In commissurotomy, the valve flaps that have adhered to each other and closed the opening between them (known as the commissure) are separated to enlarge the valve opening
A patient who has been treated for HF is being discharged from the hospital on 20 mg furosemide (Lasix) daily. Which of the following statements by the patient would indicate understanding to the nurse for instructions on taking this medication? A. "I will take the Lasix in the morning." B. "I will take the Lasix at bedtime." C. "I will drink lots of fluids with the Lasix." D. "I will take it with meals."
A. A diuretic should be taken in the morning to prevent interference with sleep at night
The nurse is to give bumetanide (Bumex) to a patient and reviews laboratory results. Which of these results requires action by the nurse? A. potassium 3.0 mEq/L B. sodium 135 mEq/L C. International normalized ratio 0.8 D. Partial thromboplastin time 36 seconds
A. HTN contributes to left-sided HF b/c the left ventricle must pump against increased pressure in the aorta from HTN
The nurse evaluates the patient has understanding how to prevent rheumatic fever if the patient states that rheumatic fever can be prevented by treating streptococcal infections with which of the following? A. Penicillin B. Prednisone C. Cortisone D. Cyclosporin
A. A streptococcal infection is a bacterial infection treated with the antibacterial agent penicillin
The nurse is reinforcing teaching for a patient with chronic HF. Which of the following assessments should the nurse teach the patient to perform to monitor fluid status at home? A. Weigh daily B. Weigh weekly C. Weigh biweekly D. Weigh monthly
A. Daily weights reflect fluid volume changes as a weight gain or loss
The nurse is checking capillary refill on a patient. If it takes longer than 3 seconds for the color to return when assessing the capillary refill, the nurse would recognize that which of the following may be indicated? A. Decreased arterial flow to the extremity B. Increased arterial flow to the extremity C. Decreased venous flow from the extremity D. Increased venous flow from the extremity
A. Decreased arterial flow to the extremity is reflected in a slower capillary refill
A nurse is reinforcing teaching with a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? *select all that apply* A. 1 slice cheddar cheese B. 1 medium beef hot dog C. 3 oz. Atlantic salmon D. 3 oz. roasted chicken breast E. 2 oz. lean baked ham
A. 1 slice of cheddar cheese contains 180 mg Na+ C. 3 oz Atlantic salmon contains 37 mg Na+ D. 3 ox roasted chicken breast contains 62 mg Na+
A nurse is caring for a group of clients. Which of the following clients is at risk for development of a dysrhythmia? *select all that apply* A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery
A. A pt w/acid-base imbalance, i.e. metabolic alkalosis, is at risk for dysrhythmia. D. A pt w/lung disease, i.e. COPD, is at a risk for dysrhythmia. E. A pt w/cardiac disease & underwent stent placement is at risk for dysrhythmia.
A nurse is assisting with the care of a client who asks why her provider prescribed a daily aspirin. 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 medication."
A. Aspirin ↓ platelet aggregation that can cause an MI
A nurse is assisting with the plan of care for a client following a surgical placement of a synthetic graft to repair an aneurysm. Which of the following interventions should be included in the plan of care? *select all that apply* A. Check pedal pulses B. Monitor for an increase in pain below the graft site C. Maintain the client in high-Fowler's position D. Administer antiplatelet agents E. Report hourly urine output of 60 mL
A. Check pulses distal to graft site to detect possible occlusion of graft. B. Monitor for ↑ of pain below graft site, can be indication of graft occlusion or rupture D. Admin antiplatelet agents & anticoagulants to prevent thrombus formation
A nurse is collecting data on a client who has a new diagnosis of a thoracic aortic aneurysm. Which of the following manifestations should the nurse expect? *select all that apply* A. Cough B. Shortness of breath C. Upper chest pain D. Diaphoresis E. Altered swallowing
A. Cough is a manifestation of a thoracic aortic aneurysm B. SOB is a manifestation of a thoracic aortic aneurysm E. Difficulty swallowing is a manifestation of thoracic aortic aneurysm
The nurse is collecting data on a patient who had surgery. Which of the following signs and symptoms indicate to the nurse the possible presence of a deep venous thrombus in the patient's leg? *select all that apply* A. Calf swelling B. Crackles C. Jugular vein distension D. Positive Homan's sign E. Warmth F. Redness
A. D. E. F. These indicate a blood clot. B. and C. are seen with Heart Failure
The nurse is providing teaching for a patient undergoing a coronary angiography. Which of the following should be included in the teaching plan for a coronary angiography with femoral catheter insertion site? *select all that apply* A. Dye injection causes hot, flushing sensation B. General anesthesia is administered C. Claustrophobia may be experienced D. Ambulation is not possible immediately after procedure E. Allergies are assessed before testing F. Firm pressure must be applied to the insertion site
A. D. E. F. Types of allergies are asked b/d a dye is used that causes flushing sensations. Firm pressure is applied afterward to prevent bleeding, therefore ambulation & flexion are not allowed for several hours
A nurse is assisting with data collection from a client who has left-sided valvular heart disease. Which of the following findings should the nurse expect? *select all that apply* A. Dyspnea on exertion B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema
A. Dyspnea is a manifestation of left-sided valvular heart disease B. Fatigue is a manifestation of left-sided valvular heart disease E. Peripheral edema is a manifestation of left-sided valvular heart disease
A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. Which of the following data are 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 lbs in 1 year E. Diastolic murmur
A. Hx of congenital malformations is a risk factor for valvular heart disease C. HTN places a pt at risk for valvular heart disease E. A murmur indicates turbulent blood flow, often d/t valvular heart disease
A nurse is reinforcing teaching with a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? *select all that apply* A. Avoid consuming grapefruit while taking this medication B. Monitor for black, tarry stools C. Use an electric razor when shaving D. Take the medication when you have pain E. Limit food sources containing vitamin K while taking this medication
A. Instruct pt to avoid consuming grapefruit while taking clopidogrel as it interferes w/absorption of clopidogrel & can cause severe complications B. Instruct pt to monitor for evidence of GI bleed (abd pain, coffee-ground emesis, black tarry stools) and report to HCP C. Warn pt to use electric razor to prevent cuts; may take a long time to stop bleeding while taking antiplatelet meds
A nurse is reinforcing discharge teaching with a client who has heart failure and a fluid retention of 2000 mL/day. The client asks the nurse how to determine the amount of fluids he is allowed. Which of the following statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid.
A. Pouring amt of fluid consumed into an empty 2 L bottle provides a visual guide for pt as to the amt consumed & how to plan daily intake
A nurse is reviewing a client's laboratory test results. The nurse should identify that which of the following results indicates the client is at risk for heart disease? *select all that apply* A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin I 0.02 ng/mL
A. Pt w/total cholesterol level >200 mg/dL is at ↑ risk for heart disease C. Pt w/LDL level >130 mg/dL is at ↑ risk for heart disease
A nurse is assisting in the care of a client who began having chest pain 2 hrs ago. Which of the following laboratory findings should the nruse identify as an indication the client has sustained injury to the heart? A. Troponin T 0.8 ng/mL B. Creatine kinase (MB) 100 units/L C. Myoglobin 80 mcg/L D. Triglycerides 120 mg/dL
A. Pt w/troponin T level >0.1 ng/mL has sustained myocardial injury
A nurse is collecting data from a client who has splinter hemorrhages in the nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic carditis
A. Splinter hemorrhages in nail beds & report of fever are findings assoc. w/infective endocarditis
A nurse is assisting with admission of 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. Stable angina can be relieved with rest and nitroglycerin B. The pain of an MI resolves in less than 15 minutes C. The type of activity that causes an MI can be identified D. Stable angina can occur for longer than 30 minutes
A. Stable angina can be relieved by rest & nitroglycerin
A nurse is assisting with the admission data collection of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings? *select all that apply* A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick yellow sputum E. Orthopnea
A. Tachypnea is an expected finding in a pt w/pulmonary edema B. A persistent cough w/pink, frothy sputum is an expected finding in a pt w/pulmonary edema E. Orthopnea is an expected finding in a pt w/pulmonary edema
A nurse is assisting in the care of a client who underwent defibrillation. Which of the following should be included in the documentation of this procedure? *select all that apply* A. Follow-up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes
A. The ECG rhythm is documented following the procedure. B. Energy settings used during the procedure are documented. E. The condition of the pt skin where electrodes were placed is documented
The nurse is providing patient education. The patient asks the nurse what HF is. Which of the following is the nurse's best response? A. "The heart pumps too much blood into the pulmonary veins." B. "The heart is unable to pump enough blood for the body's oxygen needs." C. "HF is a buildup of blood in the aorta from the heart's left ventricle." D. "With a failing heart, the heart stops beating so the blood is not pumped out."
B In heart failure, the heart cannot pump enough blood to meet the body's oxygen needs.
The nurse is caring for a patient with cardiomyopathy. Which of the following symptoms, if reported by the patient, require priority action by the nurse? A. Left great toe pain B. Dyspnea C. Headache D. Decreased appetite
B. Dyspnea can indicate heart failure, which is a complication of cardiomyopathy
The nurse is to obtain orthostatic blood pressure measurements. Which of the following is an important safety intervention that should be used during this procedure? A. Reality orientation B. Gait or walking belt C. Liquids at bedside D. Standing patient quickly
B. Gait or walking belt should be used for pts who risk falling, which someone w/orthostatic hypotension could be
The nurse is evaluating patient teaching for mitral valve prolapse. The patient shows understanding of the prognosis of MVP by stating which of the following? A. "The prognosis is poor." B. "There are often no symptoms." C. "Heart failure often occurs." D. "Symptoms quickly progress."
B. Symptoms are not often present in MVP
A nurse is reinforcing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include has having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice toast with 1 tbsp peanut butter D. 1 large scrambled egg
B. A medium baked potato is best food source for K+ b/c it contains 926 mg K+ per serving
A nurse is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46 bpm and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of amiodarone PO
B. A pt w/bradycardia is a candidate for a pacemaker to ↑ HR
A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A. Elevate the legs for 10 minutes, 2 to 3 times daily while wearing 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 to relieve discomfort on the legs. D. Cross one leg over the other when sitting or reclining
B. Applying stockings in the AM upon awakening & before getting out of bed ↓ venous stasis & assists in venous return of blood to heart. Legs are less edematous at this time
A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Weigh the client B. Assist client into high-Fowler's position C. Auscultate lung sounds D. Check oxygen saturation with pulse oximeter
B. Assist pt into high-Fowler's position - it opens pts airway for maximum use of lung space & muscles assoc. w/ breathing, ↓ venous return to the heart (preload) & helps relieve lung congestion
A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following 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 analagesic E. Pulse of 2+ in the affected limb
B. Capillary refill greater than 4 seconds is outside the expected reference range & should be reported to HCP C. Mottled appearance of the affected extremity indicates poor tissue perfusion & should be reported to HCP
The nurse is reinforcing teaching about a high-fiber diet for a cardiac patient. The patient asks what the purpose of the diet is. Which of the following replies by the nurse would be appropriate? A. "To increase absorption of nutrients in your diet." B. "It will reduce your heart's workload." C. "To prevent edema from developing." D. "To reduce your appetite."
B. Fiber helps prevent constipation & straining during bowel movements, which reduces cardiac workload
A nurse is reinforcing teaching with a client scheduled for cardioversion. Which of the following client statements should the nurse identify as an indication the teaching has been understood? A. "I should stop taking my warfarin 1 week prior to the procedure B. "I will receive an electrocardiogram following the procedure." C. "Mechanical ventilation will be required during the procedure." D. "Palpations are an expected effect following the procedure."
B. Following procedure, nurse should ensure pt airway remains patent, obtain an ECG, & monitor vital signs
A nurse is reinforcing teaching with a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in my heart rate to my provider." C. "I should replace the salt shaker on my table with a salt substitute." D. "I will decrease the dose of this medication when I no longer have headaches and facial redness."
B. Instruct pt to monitor HR & report changes to HCP
A nurse is screening a client for hypertension. Which of the following actions by the client increases the risk for hypertension? *select all that apply* A. Drinking 8 oz of nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz of beer daily E. Getting a massage once a week
B. Popcorn at a movie theater contains large quantity of Na+ & fat, ↑ risk for HTN D. Consuming more than 24 oz beer per day for male pt or more than 12 oz beer for female pt ↑ risk for HTN
A nurse is reinforcing teaching with a client who is scheduled for stress test. Which of the following statements should the nurse include in the teaching? A. "You should not have anything to eat or drink for 8 hours prior to the test." B. You will exercise your heart by walking on a treadmill." C. "A chest x-ray will be obtained following the test." D. "The test will be delayed if your troponin I level is less than 0.5 ng/mL."
B. The stress test is performed w/pt walking on treadmill or receiving meds to stimulate the heart
A nurse is caring for a team of patients. After completing morning rounds, which of the following patients require priority care? A. A patient who is 2 days postsurgery reporting severe constipation B. A patient with a DVT has peripheral edema C. A patient with aortic stenosis who is reporting chest pain D. A patient with mitral valve prolapse has lost 2 pounds of weight this morning
C. Angina indicates cardiac ischemia and requires prompt intervention
The nurse is caring for a patient receiving bumetanide (Bumex) to reduce preload for HF. While collecting data, the nurse sees the patient has less ankle edema and jugular vein distention than earlier. The next dose of bumetanide is scheduled in 1 hour. Which of the following action should the nurse take? A. Notify the physician B. Hold the bumetanide C. Give the bumetanide as scheduled D. Give the bumetanide early
C. Bumetanide should be given as scheduled b/d it is working effectively to control the edema
The nurse reviews medication orders and is to give warfarin (Coumadin). Which of the following actions should the nurse take first? A. Obtain a glass of water B. Prepare the medication for administration C. Review international normalized ratio result D. Document the medication administration
C. INR is checked to determine if it is safe to give warfarin (Coumadin)
A nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The purpose of this action is to alert personnel of which of the following? A. A cardioverter is being charged to the appropriate setting. B. They should initiate CPR due to the pulseless electrical activity. C. They cannot be in contact with equipment connected to the client. D. A time-out is being called to verify correct protocols.
C. A safety concern for personnel performing cardioversion is to "stand clear" pt & equipment connected to pt when shock is delivered to prevent them from also receiving a shock
A nurse is assisting with the admission of a client who has a suspected occlusion of a graft of the abdominal aorta. Which of the following manifestation should the nurse expect? A. Increase in urine output B. Bounding pedal pulse C. Increase in abdominal girth D. Redness of the lower extremities
C. Abd distention is an expected finding w/occlusion of a graft of the aorta
A nurse is caring for a client following an angioplasty through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following complications should the nurse suspect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incision site D. Heart failure
C. Bleeding is occurring from the incision site & then draining under the pt. Check incision for hematoma, apply pressure, monitor pt, notify HCP
A nurse is assisting with the care of a client who is admitted to the emergency department with a blood pressure of 266/147 mmHg. The client reports a headache and double vision. The client reports running out of diltiazem 3 days ago, and inability to purchase more. Which of the following actions should the nurse take first? A. Administer acetaminophen for headache B. Reinforce teaching regarding the importance of not abruptly stopping an antihypertensive C. Obtain IV access and ask the charge nurse to administer an IV antihypertensive D. Call social services for a referral for financial assistance in obtaining prescribed medication
C. Greatest risk to pt is injury d/t BP of 266/147 mmHg, can be life-threatening & should be lowered ASAP. Obtaining IV access will permit admin of IV antihypertensive, which will act more quickly than oral route
A nurse is reinforcing discharge teaching with a client following an atherectomy using the right femoral artery as access. Which of the following client statements indicates an understanding of the teaching? A. "I should expect moderate swelling of the insertion site on my right groin." B. "I will limit my fluid intake for the first 24 hours following the procedure." C. "I should restrict lifting to 5 pounds." D. "I can resume high-impact aerobic exercises right away."
C. Lifting restrictions of 5 lbs (2.27 kg) can prevent ↑ strain on operative site & limit risk of bleeding or hematoma formation
A nurse is in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast
C. Metoprolol can mask effect of hypoglycemia in pts w/DM
A nurse is assisting with an community educational 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. Tobacco cessation D. Exercise routine
C. Recommend pt to stop using tobacco products. NIcotine causes vasoconstriction, ↑ BP & narrows coronary arteries
A nurse is reviewing the laboratory findings of a client who has myocardial infarction (MI) and reports that dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin
C. Troponin T will still be evident 10-14 days following an MI
A patient is scheduled for vascular surgery. The patient is taking digoxin (Lanoxin), furosemide (Lasix), potassium, warfarin (Coumadin), and famotidine (Pepcid). Which medications would the nurse question the possible need to stop several days before surgery? A. Digoxin (Lanoxin) B. Furosemide (Lasix) C. Warfarin (Coumadin) D. Famotidine (Pepcid)
C. Warfarin (Coumadin) affects clotting and is usually stopped before surgery to prevent bleeding issues
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. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C. "It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis."
C. Warfarin depresses synthesis of clotting factors but does not have effect on clotting factors present. Takes 3 to 4 days for clotting factors present to decay & for therapeutic effects of warfarin to occur
A nurse is assisting with the care of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A. Administer pain medication B. Provide warm environment C. Administer IV fluids D. Initiate a 12-lead ECG
C. greatest risk to pt is injury or death following hypovolemic shock; priority is admin IVF. Pt at risk of inadequate circulatory volume d/t impaired blood flow thru major arteries
The nurse is evaluating understanding after a teaching session for mechanical cardiac valve replacement surgery. Which statement by the patient indicates understanding of the teaching? A. "You will need anticoagulants for the first month of surgery." B. "You will not need to be on anticoagulant therapy." C. "You will need anticoagulant therapy for the first year after valve replacement." D. "You will need anticoagulant therapy for life."
D. Mechanical valves require lifelong anticoagulation to prevent emboli, unlike biological valves, which are less likely to create emboli
The nurse is contributing to the plan or care for a patient with heart disease. Which of the following is a modifiable cardiovascular risk factor identified during patient tata collection that should be included in the teaching plan? A. 56 years old B. Male C. Asian D. Tobacco use
D. Tobacco use can be modified through smoking cessation
A nurse is collecting data from a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechia B. Murmur C. Rash D. Friction rub
D. A friction rub can be heard during auscultation of a pt w/pericarditis
A nurse is assisting with the admission of a client who has suspected rheumatic endocarditis. The nurse should expect a prescription 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. A throat culture can reveal presence of streptococcus, the leading cause of rheumatic endocarditis
A nurse is reinforcing teaching with a client who is scheduled for a echocardiogram. Which of the following statements should the nurse include in the teaching? A. "You may experience a warm feeling when the dye is injected B. "The test will require 2 hours to complete." C. "You will be place onto your right side during the procedure." D. "The test allows us to see how your heart valves work."
D. An echocardiogram is an ultrasound test that is used to evaluate the heart's position & function of the valves
A nurse is reinforcing teaching with a client who has a new diagnosis of an aneurysm. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following statements should the nurse give? A. "This happens when the wall of an artery becomes thin and flexible." B. "This happens when there is turbulence in blood flow in the artery." C. "It is due to abdominal enlargement." D. "It is due to hypertension."
D. Aneurysm ruptures as a result of HTN ↑ pressure w/in arterial walls
A nurse is collecting data on a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Edema round the ankles and feet B. Ulceration around the medial malleoli C. Brownish discoloration of the lower legs and ankles D. Depended rubor with pallor following limb elevation
D. In pt w/chronic PAD, pallor is seen in extremities when limbs are elevated & rubor occurs when they are lowered
A nurse is reinforcing teaching with a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting C. Apply an heating pad to both legs for comfort D. Place both legs in dependent position while sleeping
D. Instruct pt to place legs in dependent position, i.e. hanging off edge of bed, while sleeping to alleviate swelling & discomfort of legs
A nurse is reinforcing teaching with a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? A. "You should have nothing to eat of drink for 4 hours prior to the procedure." B. "You will be given general anesthesia during the procedure." C. "You should not have this procedure done if you are allergic to eggs." D. "You will need to keep your affected leg straight following the procedure."
D. Instruct pt to remain on bed rest in supine position w/affected leg straight for a prescribed amt of time. Positioning ↓ pt risk for bleeding & hematoma formation @ catheter insertion site
A nurse is contributing to the plan of care for a client who has transferred from the coronary care unit following coronary artery bypass graft surgery. Which of the following interventions should the nurse include? A. Provide percussion chest physiotherapy to loosen pulmonary secretions. B. Report urinary output less than 300 mL in 8 hr. C. Limit administration of opioid analgesics for pain ratings greater than 7 out of 10. D. Instruct the client to splint chest when deep breathing
D. Instruct pt to splint chest when deep breathing & coughing - will ↓ pain assoc. w/expansion of thoracic cage w/inspiration & ↑ intrathoracic pressure w/coughing for pt post-op following a CABG
The nurse is caring for a patient on bedrest who is on diuretic therapy. In which area should the nurse check for the presence of edema? A. Arms B. Ankles C. Sternum D. Sacrum
D. On bedrest, edema will be found in dependent areas such as the sacrum
A nurse is reinforcing teaching with a client who has angina about a new prescription for metoprolol. 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 check 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. Pt advised to notify HCP if bradycardia occurs (HR <60 bpm)
A nurse is collecting data from a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left food D. Report of intermittent claudication in the affected leg
D. Pt w/peripheral artery disease may report numbness or burning pain in extremity ceases w/rest (intermitten claudication)
