MOSBY's Book Questions

A nurse is avising a client about the risk associated with failure to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? A. Asthma B. Anemia C. Endocarditis D. Reye syndrome

C. Endocarditis Rationale: Streptococcal infection can be spread through the circulation to the heart; endocarditis results and affects the valves of the heart

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)? A. "Increase your intake of fiber and fluid." B. "Take the medication before you go to bed." C. "Check your pulse before taking the medication." D. "Contact your HCP if your skin or sclera turn yellow."

A. "Increase your intake of fiber and fluid." Rationale: Fiber and fluids help prevent the most common adverse effect of constipation and its complication-fecal impaction

For which complication of myocardial infarction should the nurse monitor clients in the coronary care unit? A. Dysrhythmia B. Hypokalemia C. Anaphylactic shock D. Cardiac enlargement

A. Dysrhythmia Rationale: Myocardial infarction may cause increased irritability of tissue or interruption of normal transmission of impulses. Dysrhythmias occur in about 90% of clients after an MI.

While a pacemaker catheter is being inserted, the clients heart rate drops to 38bpm. What medication should the nurse expect the health care provider to prescribe? A. Digoxin (Lanoxin) B. Lidocain (Xylocain) C. Amiodaron (Codarone) D. Atropine Sulfate (Atropine)

D. Atropine Sulfate (Atropine) Rationale: Atropine blocks vagal stimulation of the SA node, resulting in an increased heart rate

Which hereditary disease is most closely linked to aneurysm? A. Cystic fibrosis B. Lupus erythematosus C. Marfan's syndrome. D. Myocardial infarction

C. Marfan's syndrome. Rationale: Marfan's syndrome results in the degeneration of the elastic fibers of the aortic media. Therefore, clients with the syndrome are more likely to develop an aortic aneurysm. Although cystic fibrosis is hereditary, it hasn't been linked to aneurysms. Lupus erythematosus isn't hereditary. Myocardial infarction is neither hereditary nor a disease

When caring for a patient who has Guillain-Barré syndrome, which assessment data obtained by the nurse will require the most immediate action? a. The patient complains of severe tingling pain in the feet. b. The patient has continuous drooling of saliva. c. The patient's blood pressure (BP) is 106/50 mm Hg. d. The patient's quadriceps and triceps reflexes are absent.

b. The patient has continuous drooling of saliva. Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.

A nurse is instructing the client to use an incentive spirometer. What client action indicates the need for further instruction? A. Blowing vigorously into the mouthpiece B. Getting into a chair to use the spirometer C. Coughing deeply after using the spirometer D. Using lips to form a seal around the mouthpiece

A. Blowing vigorously into the mouthpiece Rationale: the client should exhale before inhaling slowly and deeply through the spirometer to maximize lung expansion

A client with left ventricular heart failure is taking digoxin (Lanoxin) 0.25mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? Select all that apply: A. Diuresis B. Tachycardia C. Decreased edema D. Decreased pulse rate E. Reduced heart murmur F. Jugular vein distention

A. Diuresis C. Decreased edema D. Decreased pulse rate Rationale: Digoxin increases kidney perfusion, which results in urine formation and diuresis. Because of digoxins inotropic and chronotropic effects, the heart will decrease. The urine output increases because of improved cardiac output and kidney perfusion, resulting in a reduction in edema.

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply: A. Tachycardia B. Hypertension C. Increased CVP D. Increased UOP E. Jugular Vein Distention

A. Tachycardia C. Increased CVP E. Jugular Vein Distention Rationale: Blood in the pericardial sac compresses the hear so the ventricles cannot fill; this leads to a rapid thready pulse. As the tamponade increases, pressure on the heart interferes with the ejection of the blood from the left ventricle, resulting in an increased pressure in the right side of the hears and the systemic circulation. The increased venous pressure associated with cardiac tamponade causes JVD.

A patient is admitted with syncope, exertional dyspnea, and a systolic murmur. Cardiac catheterization reveals significantly increased left ventricular end-diastolic pressure (LVEDP) and: A. aortic stenosis. B. mitral stenosis. C. tricuspid stenosis. D. pulmonary regurgitation

A. aortic stenosis. Rationale: Symptoms of aortic stenosis include syncope, exertional dyspnea, increased LVEDP, and systolic murmur. Mitral and tricuspid stenoses are associated with a diastolic murmur as is pulmonary regurgitation.

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102 degrees F. What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client's temperature? A. A fever may lead to diaphoresis B. A fever increases the cardiac output C. An increased temperature indicates cerebral edema D. An increased temperature may be a sign of hemorrhage

B. A fever increases the cardiac output Rationale: Temperatures of 102 degrees F or greater lead to an increased metabolism and cardiac workload.

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space? A. Cerebral embolism B. Pulmonary embolism C. Dry gangrene of a limb D. Coronary vessel occlusion

B. Pulmonary embolism Rationale: The pulmonary capillary beds are the first small vessels that the embolus encounters once it is released from the calf veins.

What is the most important nursing at ion when measuring a client pulmonary capillary wedge pressure? A. Deflate the balloon as soon as the PCWP is measured B. Have the client bear down when measuring the PCWP C. Place the client in a supine position before measuring the PCWP D. Flush the catheter with a heparin solution after the PCWP is determined

A. Deflate the balloon as soon as the PCWP is measured Rationale: Although the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung

A client is receiving warfarin (Coumadin). Which test rest should the nurse use to determine if the daily dose of this anticoagulant is therapeutic? A. INR B. APTT C. Bleeding time D. Sedimentation Rate

A. INR Rationale: warfarin (Coumadin) initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin time.

A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for an aneurysm in the left femoral artery. Place an X over the site of the pulse that should be assessed to determine maximum arterial perfusion distal to the operative site

The pulse most distal to the graft should be assessed first to determine adequacy of circulation. The pedal pulse is located on top of the foot and is the most distal peripheral pulse

What client response indicates to the nurse that a vasodilator medication is effective? A. Pulse rate decreases from 110 to 75 B. Absence of adventitious breath sounds C. Increase in the daily amount of urine produced D. BP changes from 154/90 to 126/72

D. BP changes from 154/90 to 126/72 Rationale: Vasodilation lowers the BP

A client is stared on a continuous infusion of heparin. which finding does the nurse use to conclude that the intervention is therapeutic? A. INR is between 2 and 3 B. PT is 2.5 times the control value C. APTT is 2 times the control value D. ACT is in the range of 70-120

C. APTT is 2 times the control value Rationale: APTT should be 1.5 to 2.5 the control for heparin therapy

A client being treated for hypertension repairs having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medication? A. ACE inhibitors B. Thiazide diuretics C. Calcium Channel Blockers D. Angiotensin receptor blockers

A. ACE inhibitors Rationale: ACE (angiotensin-converting enzyme) increases the sensitivity of the cough reflex, leading to the common adverse effect sometimes referred to as an ACE cough

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? Select all that apply: A. Absence of hair on the toes B. Superficial ulcer with irregular edges C. Pitting edema of the lower extremities D. Reports of pain associated with exercising E. Increased pigmentation of the medial malleolus area

A. Absence of hair on the toes D. Reports of pain associated with exercising Rationale: The absence of hair on the toes occurs b/c pf diminished circulation. Reports of pain associated with exercising (intermittent claudication) are common b/c the increased need for oxygen leads to ischemia when arterial flow is impaired.

A nurse is teaching a group of clients about risk factors for heart disease. Which factors increase a client risk for myocardial infarction? Select all that apply: A. Obesity B. Hypertension C. Increased HDL D. Diabetes Insipidus E. Asian American Ancestry

A. Obesity B. Hypertension Rationale: Obesity increases cardiac workload associated with vascular changes that lead to ischemia which causes an MI. Hypertension damages blood vessels and increases peripheral resistance and cardiac workload, which may lead to an MI.

A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply: A. Stasis ulcer B. Necrotic tissue C. Ecchymotic areas D. Diminished pulses E. Brown discoloration

A. Stasis ulcer E. Brown discoloration Rationale: Stasis ulcers result from edema or minor injury to the limb; they frequently form over the medial malleolus (inner ankle). The release of iron from hemoglobin as erythrocytes disintegrate in tissue results in ferrous sulfide formation, causing darkening of the tissues. B & D are associated with PAD

An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective? A. A reduction in confusion B. An APTT twice the usual value C. An absence of ecchymotic areas D. A decreased viscosity of the blood

B. An APTT twice the usual value Rationale: Desired anticoagulant effect is achieved when the activated partial thromboplastin time is 1.5 to 2 times the normal

What instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? Select all that apply: A. Increase dietary intake of potassium B. Avoid prolonged exposure to the sun C. Schedule regular opthalmic examinations D. Take the medication at least a half hour before meals E. Contact your HCP if skin becomes gray-bronze

B. Avoid prolonged exposure to the sun C. Schedule regular opthalmic examinations E. Contact your HCP if skin becomes gray-bronze Rationale: Simvastatin increases photosensitivity. The client should be monitored for the adverse effects of glaucoma and cataracts. Gray-bronze skin and unexplained muscle pain are signs of rhabdomyalysis-a life threatening response which is the disintegration of muscle associated with myoglobin in the urine.

A nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse plans to allow which client position or activity following the procedure? A. Bed rest in high Fowler's position B. Bed rest with bathroom privileges only C. Bed rest with head elevation at 60 degrees D. Bed rest with head elevation no greater than 30 degrees

B. Bed rest with bathroom privileges only Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4-6 hours. If the femoral artery was used, bed rest is enforced for 3-4 hours (or as prescribed by the physician). The client may turn from side to side. The affected leg is kept straight and the head is elevated no more than 30 degrees (although some HCP prefer the flat position) until hemostasis is adequately achieved.

Two hours after a cardiac catheterization that was accessed via the right femoral route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? A. Call the HCP B. Check the clients pedal pulses C. Take the clients BP D. Recognize the response is expected

B. Check the clients pedal pulses Rationale: These symptoms are associated with compromised arterial perfusion. A thrombus is a complication of a femoral arterial cardiac catheterization and must be suspected in the absence of a pedal pulse in the extremity below the entry site.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiological effect of nicotine should the nurse explain to the group? A. Constriction of the superficial vessels dilates the deep vessels B. Constriction of the peripheral vessels increases the force of flow C. Dilation of the superficial vessels causes constriction of collateral circulation D. Dilation of the peripheral vessels causes reflex constriction of visceral vessels

B. Constriction of the peripheral vessels increases the force of flow Rationale: Constriction of the peripheral blood vessels and the resulting increase in BP impair circulation and limit the amount of oxygen being delivered to body cells, particularly in the extremities.

A nurse is leading a discussion in a senior citizen venter about the risk factors for developing coronary heart disease for women VS men. What should the nurse response when asked to identify the most significant risk factor? A. Obesity B. Diabetes C. Elevated CRP levels D. High levels of HDL-C

B. Diabetes Rationale: Diabetes is twice as high a predictor of coronary heart disease in women than in men. Diabetes cancels the cardiac protection that estrogen provides premenopausal women

What specifically should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopridogel (Plavix)? A. Nausea B. Epistaxis C. Chest pain D. Elevated temperature

B. Epistaxis Rationale: the high vascularity of the nose, combined with its susceptibility to trauma (e.g., sneezing, nose blowing) makes it a frequent site of hemorrhage

What should the nurse identify as the primary cause of the pain experienced by a client with coronary occlusion? A. Arterial Spasm B. Heart muscle ischemia C. Blocking of the coronary veins D. Irritation of nerve endings in the cardiac plexus

B. Heart muscle ischemia Rationale: Ischemia causes tissue injury to and the release of chemicals, such as bradykinin, that stimulate sensory nerve and produce pain

A client admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased BP, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client's physiological response? A. Parasympathetic reflexes from the infarcted myocardium cause diaphoresis B. Inflammation in the myocardium causes a rise in the systemic body temperature C. Catecholamines released at the site of the infarction cause intermittent localized pain D. Constriction of central and peripheral blood vessels causes a decrease in blood pressure

B. Inflammation in the myocardium causes a rise in the systemic body temperature Rationale: Temperature may increase within the first 24 hours as a rest of the inflammatory response to tissue destruction and persia as long as a week.

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? A. Elevate the legs and tell the client to drink more fluids B. Instruct the client to remain in bed and notify the health care provider C. Rub the client's legs to stimulate circulation and cover the client with a blanket D. Tell the client about the dangers of prolonged bed rest and encourage ambulation

B. Instruct the client to remain in bed and notify the health care provider Rationale: Localized sensory changes may indicate nerve damage, impaired circulation or thrombophlebitis. Activity should be limited and the health care provider notified.

What nursing intervention is anticipated for a client with Guillain-Barre syndrome? A. Providing a straw to stimulate the facial muscles B. Maintaining ventilator settings to support respiration C. Encouraging aerobic exercises to avoid muscle atrophy D. Administering Abx medication to prevent pneumonia

B. Maintaining ventilator settings to support respiration Rationale: Guillain-Barre is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected

A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do? A. Keep both legs dependent B. Notify the healthcare provider C. Apply a wam soak to the calf D. Administer the prescribed analgesic

B. Notify the healthcare provider Rationale: The clinical findings indicate a possible thrombophlebitis. Bed rest with the legs elevated should be maintained and the health care provider notified immediately. A thrombus may progress to a pulmonary embolus.

Atherosclerosis impedes coronary blood flow by which of the following mechanisms? A. Plaques obstruct the vein B. Plaques obstruct the artery C. Blood clots form outside the vessel wall D. Hardened vessels dilate to allow blood to flow through

B. Plaques obstruct the artery Rationale: Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atherosclerosis is a direct result of plaque formation in the artery. Hardened vessels can't dilate properly and, therefore, constrict blood flow.

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness. A. Hepatitis A B. Rheumatic Fever C. Spinal Meningitis D. Rheumatic Arthritis

B. Rheumatic Fever Rationale: Antibodies produced against group A beta-hemolytic streptococci sometimes interact with antigens in the hearts valves, causing damage and symptoms of rheumatic heart disease; early recognition and treatment of strep infections have limited the occurrence of rheumatic heart disease

Which of the following groups of symptoms indicated a ruptured abdominal aneurysm? A. Lower back pain, increased BP, decreased RBC, increased WBC B. Severe lower back pain, decreased BP, decreased RBC, increased WBC C. Severe lower back pain, decreased BP, decreased RBC, decreased WBC D. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC

B. Severe lower back pain, decreased BP, decreased RBC, increased WBC Rationale: Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can't be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn't increase. For the same reason, the RBC count is decreased - not increase. The WBC count increases as cells migrate to the site of injury.

A nurse is caring for a client with the diagnosis of Guillain-Barre syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? A. Auscultate for breath sounds B. Suction the client's oropharynx C. Administer oxygen via NC D. Place the client in the orthopneic position

B. Suction the client's oropharynx Rationale: A patent airway is priority. The client does not have the ability to deep breath and cough

What instructions about the use of nitroglycerin should the nurse provide to a client with angina? A. "Identify when pain occurs, and place 2 tablets under the tongue." B. "Place 1 tablet under the tongue, and swallow another when pain is intense." C. "Before physical activity place 1 tablet under the tongue, and repeats the dose in 5 minutes if pain occurs." D. Place 1 tablet under the tongue when pain occurs, and use an addition tablet after the attack to prevent recurrence."

C. "Before physical activity place 1 tablet under the tongue, and repeats the dose in 5 minutes if pain occurs." Rationale: Anginal pain, which can be anticipated during certain activities, may be prevented by dilating the coronary arteries immediately before engaging in the activity

The most important assessment for the nurse to make after a client has had a femoropopliteal bypass for peripheral vascular disease would be: A. Incisional pain B. Pedal pulse rate C. Capillary refill time D. Degree of hair growth

C. Capillary refill time Rationale: Checking capillary refill provides data about current perfusion of the extremity. While the presence and quality of the pedal pulse provide data about peripheral circulation, it is not necessary to count the rate.

Which nursing action is most important when caring for a patient after cardiac catheterization? A. Provide for rest B. Administration of oxygen C. Check a pulse distal to the insertion D. Assess the electrocardiogram every fifteen minutes

C. Check a pulse distal to the insertion Rationale: the pulse should be assessed b/c the trauma at the insertion site may interfere with blood flow distal to the site. There is also danger of bleeding.

A patient is admitted with fever, hematuria, and new onset of a cardiac murmur. The patient has a history of intravenous drug abuse and complains of tender spots on the pads of her fingers. She has a low-grade fever, and the nurse notes an enlarged spleen on physical examination. What is the priority nursing diagnosis? A. Risk for infection related to invasive procedures B. Risk for anxiety related to lack of availability of narcotics C. Decreased cardiac output related to alteration in contractility D. Knowledge deficit related to discharge plans

C. Decreased cardiac output related to alteration in contractility Rationale: Because the patient is experiencing endocarditis, the most important nursing diagnosis is decreased cardiac output related to alteration in contractility.Infection and anxiety are only potential problems, and although knowledge deficit is important, it is not the priority on admission.

When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated? A. Right upper quadrant B. Directly over the umbilicus C. Middle lower abdomen to the left of the midline D. Midline lower abdomen to the right of the midline

C. Middle lower abdomen to the left of the midline Rationale: The aorta lies directly left of the umbilicus; therefore, any other region is inappropriate for palpation

A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary artery pressure monitoring, including pulmonary capillary wedge pressures. The purpose of this is to help assess the: A. Degree of coronary artery stenosis B. Peripheral arterial pressure C. Pressure from fluid within the left ventricle D. Oxygen and carbon dioxide concentration is the blood

C. Pressure from fluid within the left ventricle Rationale: The pulmonary artery pressures are used to assess the heart's ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricle end-diastolic pressure and guides the physician in determining fluid management for the client. The degree of coronary artery stenosis is assessed during a cardiac catherization. The peripheral arterial pressure is assessed with an arterial line.

During a cardiac catheterization blood samples from the right atrium, right ventricle, and pulmonary artery are analyzed for their oxygen content. Normally: A. All contain less CO2 than does pulmonary vein blood B. All contain more oxygen than does pulmonary vein blood C. The samples of blood all contain about the same amount of oxygen D. Pulmonary artery blood contains more oxygen than the other samples

C. The samples of blood all contain about the same amount of oxygen Rationale: Blood samples from the right atrium, right ventricle, and pulmonary artery would all be about the same with regard to oxygen concentration. Such blood contains slightly less oxygen than does systemic arterial blood.

A client with Guillain-Barre syndrome has been hospitalized for 3 days. Which assessment finding indicates a need for more frequent monitoring? A. Localized seizures B. Skin desquamation C. Hyperactive reflexes D. Ascending weakness

D. Ascending weakness Rationale: The classic symptom of Guillain-Barre syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face. more frequent assessment, especially of respiratory status is needed.

A client is returned to the surgical unit immediately after plaint of a coronary artery stent that was accomplished via access through the femoral artery. What response should the nurse consider the priority when assessing this client? A. Acute pain B. Impaired mobility C. Impaired swallowing D. Hematoma formation

D. Hematoma formation Rationale: Because the femoral artery is large, it has the potential for hematoma formation and hemorrhage after surgery

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: A. Stroke volume B. Cardiac output C. Venous pressure D. Left ventricular functioning

D. Left ventricular functioning Rationale: The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.

A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? A. Stroke volume B. Venous pressure C. Coronary artery patency D. Left ventricular functioning

D. Left ventricular functioning Rationale: the catheter is placed in the pulmonary after. Information regarding left ventricular function is obtained when the catheter balloon is inflated.

A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG) surgery 2 days ago. Which of the following surgical complications should the nurse suspect? A. Left-sided heart failure B. Aortic regurgitation C. Complete heart block D. Pericardial tamponade

D. Pericardial tamponade Rationale: A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Left-sided heart failure can cause pulsus alternans (pulse amplitude alternation from beat to beat, with a regular rhythm). Aortic regurgitation may cause bisferious pulse (an increased arterial pulse with a double systolic peak). Complete heart block may cause a bounding pulse (a strong pulse with increased pulse pressure).

A client os receiving coumadin (warfarin). The nurse explains the need for careful regulation of dietary intake of vitamin K. What physiologic process does vitamin K promote that makes this instruction essential? A. Platelet aggregation B. Ionization of blood calcium C. Fibrinogen formation by the liver D. Prothrombin formation by the liver

D. Prothrombin formation by the liver Rationale: Vitamin K promotes the livers synthesis of prothrombin, an important blood clotting factor, and will reverse the effects of warfarin

What should the nurse teach a client to expect when preparing for discharge after surgery for a coronary artery bypass graft? A. Mild fever and extreme fatigue for several weeks after surgery B. Cessation of drainage from the incisions after hospitalization C. Mild incisional pain and tenderness up to three weeks after surgery D. Some edema in the led used for the donor graft is expected with activity

D. Some edema in the led used for the donor graft is expected with activity Rationale: The client is up more at home, so dependent edema usually increases

A client has contrast medium injected into the brachial artery so that a cerebral angiogram can be performed. What nursing assessment is most essential immediately after the procedure? A. Stability of gait B. Presence of a gag reflex C. BP in both arms D. Symmetry of the radial pulse

D. Symmetry of the radial pulse Rationale: Trauma to the artery can interfere with circulation to the accessed extremity. This is most easily assessed by checking the pulses bilaterally.

A nurse is caring for a client with chronic occlusive arterial disease. What precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions? A. Emotional stress, which is short-lived B. Poor hygiene and limited protein intake C. Stimulants such as coffee, tea, or cola drinks D. Trauma from mechanical, chemical, or thermal sources

D. Trauma from mechanical, chemical, or thermal sources Rationale: Diminished sensation decreases awareness of injury. Injured tissue cannot heal properly b/c of cellular deprivation of oxygen and nutrients; ulceration and gangrene may result

A nurse has difficult palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? A. Count the pulse at another site B. Notify the HCP C. Lower the legs to increase blood flow D. Verify the pulse by using a doppler

D. Verify the pulse by using a doppler Rationale: Clients with venous insufficiency often have edema, which may make palpation of an arterial pulse difficult. A doppler uses sound waves so that the pulse can be heard.

After cardiac catheterization, which of the following findings should the nurse report to the physician? a) pain on the groin when changing positions b) the client denies tingling sensation in the extremity c) the client verbalizes that she experienced flushing sensation during the procedure d) the toenail blanches on compression and pinkish color returns after 1 to 3 seconds

a) pain on the groin when changing positions Rationale: pain in the groin after cardiac catheterization may indicate hematoma at the site. This indicates bleeding at the site and compression of blood vessels by the hematoma may occur. his in turn, may cause circulatory impairment in the area.

At 10:00 AM, a patient receives a new order for transesophageal echocardiography (TEE) ass soon as possible. Which action will you take first? a. Make the patient NPO. b. Teach the patient about the procedure. c. Start an intravenous line. d. Attach the patient to a cardiac monitor

a. Make the patient NPO. Rationale: Because TEE is performed after the throat is numbed using a topical anesthetic and possibly intravenous sedation, it is important that the patient be NPO for at least 4 to 6 hours prior to the test. The other actions also will need to be accomplished for the TEE, but will not affect how quickly the examination can be scheduled. Focus: Prioritization

You are teamed with an LPN/LVN in caring for a group of patients on the cardiac unit. Which action by the LPN/LVN indicates you need to intervene immediately? a. The LPN/LVN assists the patient to the bathroom 30 minutes after the patient has returned from a coronary arteriogram. b. The LPN/LVN checks a patient's blood pressure before administering nitroglycerin (Nitro-Stat) 0.4 mg SL. c. The LPN/LVN returns a patient to bed after the patient's heart rate increases from 72 to 96 while ambulating in the hall. d. The LPN/LVN brings breakfast to a patient who is scheduled for an echocardiogram later in the morning.

a. The LPN/LVN assists the patient to the bathroom 30 minutes after the patient has returned from a coronary arteriogram. Rationale: Because the femoral artery is usually used as the access site during a coronary arteriogram, patients are required to remain on bedrest (with the head only slightly elevated) for several hours after the procedure to avoid arterial bleeding at the site. Even if another arterial site is used, getting patients out of bed only 30 minutes after the procedure would be avoided. The other patient care provided by the LPN/LVN is appropriate. Blood pressure should be checked prior to administration of nitroglycerin. A heart rate increase of more than 20 beats/minute indicates poor cardiac compensation for exercise. Since echocardiography is noninvasive, there is no need to withhold meals before this procedure

During the initial post-operative assessment of a patient who has just transferred to the post-anesthesia care unit (PACU) after repair of an abdominal aortic aneurysm, you obtain all of these data. Which has the most immediate implications for the patient's care? a. The arterial line indicates a blood pressure of 190/112. b. The monitor shows sinus rhythm with frequent PACs. c. The patient does not respond to verbal stimulation d. The patient's urine output is 100 mL of amber urine.

a. The arterial line indicates a blood pressure of 190/112. Elevated blood pressure in the immediate post-operative period puts stress on the graft rupture and/or hemorrhage, so it is important to lower the blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions, but do not post an immediate threat to patient's hemodynamic stability.

A client who recently experienced a myocardial infarction is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). The nurse plans to teach the client that, during this procedure, a balloon-tipped catheter will: a) inflate a meshlike device that will spring open b) be used to compress the plaque against the coronary blood vessel wall c) cut away the plaque from the coronary vessel wall using a cutting blade d) be positioned in coronary artery to take pressure measurements in the vessel

b) be used to compress the plaque against the coronary blood vessel wall In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option C describes coronary atherectomy, option A describes placement of a coronary stent, and option D describes part of the process used in cardiac catheterization.

You have just received change-of-shift report about these patients on the coronary step down unit. Which one will you assess first? a. A 26-year-old with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today b. A 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change c. A 56-year-old who had a coronary angioplasty and stent placement yesterday and has complained of occasional chest pain since the procedure d. A 44-year-old who transferred from intensive care 2 days ago after coronary artery bypass grafting and has a temperature of 100.6o F

b. A 45-year-old with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change The patient's symptoms indicate acute hypoxia, so immediate further assessments (such as oxygen saturation, neurologic status monitoring, and breath sounds) are indicated. The other patients also should be assessed soon, because they are likely to require nursing actions such as medication administration and teaching but are not as acutely ill as the dyspneic patient.

A patient with Guillain-Barré syndrome asks the nurse what has caused the disease. In responding to the patient, the nurse explains that Guillain-Barré syndrome a. results from an acute infection and inflammation of the peripheral nerves. b. is due to an immune reaction that attacks the covering of the peripheral nerves. c. is caused by destruction of the peripheral nerves after exposure to a viral infection. d. results from degeneration of the peripheral nerve caused by viral attacks.

b. is due to an immune reaction that attacks the covering of the peripheral nerves. Rationale: Guillain-Barré syndrome is believed to result from an immunologic reaction that damages the myelin sheath of the peripheral nerves. Acute infection or inflammation of the nerves is not a cause. The peripheral nerves are not destroyed and do not degenerate.

A clinic nurse reviews the record of a child just seen by a physician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? a) pallor b) hyperactivity c) exercise intolerance d) gastrointestinal disturbances

c) exercise intolerance Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time. Pallor may be noted but is not specific to this type of disorder alone. Options B and D are not related to this disorder.

After cardiac catheterization that involves femoral artery, which of the following actions by the RN needs intervention by the charge nurse? a) the RN monitors the client's vital signs b) the RN applies small ice pack over the puncture site c) the RN elevates the head of the bed to sitting position as requested by the client d) the RN immobilizes the affected extremity in extension

c) the RN elevates the head of the bed to sitting position as requested by the client Rationale: avoid acute hip flexion after cardiac catheterization involving the femoral artery to prevent circulatory impairment. HOB may be elevated only up to 30 deg for the first 6 to 8 hours

The echocardiogram indicates a large thrombus in the left atrium of a patient admitted with heart failure. During the night, the patient complains of severe, sudden onset left foot pain. You note that no pulse is palpable in the left foot and that this it is cold and pale. Which action should you take next? a. Lower the patient's left foot below heart level. b. Administer oxygen at 4L/minute to the patient. c. Notify the patient's physician about the assessment data. d. Check the patient's vital signs and oximetry.

c. Notify the patient's physician about the assessment data. Rationale: The patient's symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the physician should be notified immediately so that interventions such as fibrinolytic therapy, balloon angioplasty, or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. The patient's vital signs are not

the nurse who is caring for a client scheduled to undergo a cardiac catheterization for the first time. The nurse tells the client that the: a) procedure is performed in the operating room b) initial catheter insertion is quite painful; after that, there is little or no pain c) client may feel fatigue and have various aches, because it is necessary to lie quietly on a hard x-ray table for about 4 hours d) client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations

d) client may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations Rationale: Pre-procedure teaching points include that the procedure is done in a darkened cardiac catheterization room and that ECG leads are attached to the client. A local anesthetic is used so there is little to no pain with catheter insertion. The X-ray table is hard and may be tilted periodically. The procedure may take up to 2 hours, and the client may feel various sensations with catheter passage and dye injection.

A patient who has numbness and weakness of both feet is hospitalized with Guillain-Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include a. intubation and mechanical ventilation. b. insertion of a nasogastric (NG) feeding tube. c. administration of methylprednisolone (Solu-Medrol). d. IV infusion of immunoglobulin (Sandoglobulin).

d. IV infusion of immunoglobulin (Sandoglobulin). Rationale: Because the Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and tube feedings may be used later in the progression of the syndrome but are not needed now. Corticosteroid use is not helpful in reducing the duration or symptoms of the syndrome.

Which of these nursing actions for a patient with Guillain-Barré syndrome is most appropriate for the nurse to delegate to an experienced nursing assistant? a. Nasogastric tube feeding q4hr b. Artificial tear administration q2hr c. Assessment for bladder distension q2hr d. Passive range of motion to extremities q8hr

d. Passive range of motion to extremities q8hr Rationale: Assisting a patient with movement is included in nursing assistant education and scope of practice. Administration of tube feedings, administration of ordered medications, and assessment are skills requiring more education and scope of practice, and the RN should perform these skills.

At 9:00 PM, you admit a 63-year-old with a diagnosis of acute myocardial infarction (AMI) to the ED. The physician is considering the use of fibrinolytic therapy with tissue plasminogen activator (tPA, alteplase [Activasel]). Which information is most important to communicate to the physician? a. The patient was treated with alteplase about 8 months ago. b. The patient takes famotidine (Pepcid) for esophageal reflux. c. The patient has T wave inversions on the 12-lead ECG. d. The patient has had continuous chest pain since 1:00 PM.

d. The patient has had continuous chest pain since 1:00 PM. Rationale: Because continuous chest pain lasting for more than 6 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic therapy is usually not utilized for patients with chest pain that has lasted for more than 6 hours (in some centers, 12 hours). The other information is also important to communicate, but would not impact the decision about alteplase use. Focus: Prioritization

A 24-year-old patient is hospitalized with the onset of Guillain-Barré syndrome. During this phase of the patient's illness, the most essential assessment for the nurse to carry out is a. monitoring the cardiac rhythm continuously. b. determining the level of consciousness q2hr. c. evaluating sensation and strength of the extremities. d. performing constant evaluation of respiratory function.

d. performing constant evaluation of respiratory function Rationale: The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously. The other assessments will also be included in nursing care, but they are not as important as respiratory assessment.