pearson perf
c (Rationale: Strenuous exertion is restricted because it may precipitate dysrhythmias and sudden death. Sodium in the diet is decreased. The client should report decreased urine output to the physician. Medications for this disorder are taken as prescribed, usually daily. )
A 17-year-old client diagnosed with hypertrophic cardiomyopathy is about to be discharged from the hospital. The nurse-led topic is priority teaching for the client and parents? a Increase sodium in the diet. b Report excess urine to the physician. c Restrict strenuous physical exertion. d Take medications when feeling pain.
a (Rationale: The symptoms and age of the client lead the nurse to conclude that the client may be experiencing a myocardial infarction or, since the client has had surgery, a pulmonary embolus. The chest x-ray is done to detect the embolus, and an ECG is done to rule out a myocardial infarction. An MRI is not done for either condition and, in any case, would take about 2 hours to complete; this client's symptoms indicate an emergency. Electrolyte panels and a complete blood count will not diagnose a pulmonary embolus or myocardial infarction.)
A 65-year-old client begins to have chest pain, decreasing oxygen saturation, and dyspnea after surgery. The nurse expects the physician to order which diagnostic test for a definitive diagnosis of pulmonary embolism? a Chest x-ray and ECG b Electrolyte panel c MRI d Complete blood count
a (Rationale: The client is showing signs of increased intracranial pressure, and infusion of fluids exacerbates the increasing pressure. Asking how the client feels is a psychosocial assessment, and the primary need is physiological integrity. Offering fluids is inappropriate since the client should have fluids restricted. There is no evidence that the client had seizures and was receiving phenytoin. )
A 76-year-old client has been brought to the emergency department by ambulance with a suspected stroke. Initial vital signs are BP 150/100, pulse 90, and respirations 20. After 30 minutes, vital signs have changed to BP 170/90, pulse 78 and respirations of 24. Which action should the nurse initiate next? a Get an order to decrease IV fluids. b Offer the client clear liquids to prevent dehydration. c Ask how the client feels. d Check the client's phenytoin (Dilantin) level.
a (Rationale: As hematocrit increases, the blood becomes more viscous, which leads to slowing blood flow and the development of clots. The cupping will also cause slight bruising and increase the formation of clots. The child with polycythemia does not need monitoring for pulmonary hypertension, anemia, or alveolar hypoxia. )
A Hispanic infant with a congenital heart defect experiences chronic hypoxemia and has developed polycythemia. The mother is reluctant to admit the infant because the curandera has been performing cupping on the infant. The nurse monitors the infant for which of the following? a Thromboembolism b Alveolar hypoxia c Anemia d Pulmonary hypertension
a (Rationale: Right-sided chest pain and shortness of breath indicate the development of a pulmonary embolism. Oxygen is started to support gas exchange and tissue oxygenation. While elevating the head of the bed may support ventilation, it may be contraindicated by the type of skeletal traction. Homan's sign will provide information about venous thrombosis but is not the priority at this time. The analgesic is of lower priority than the oxygen and it may depress respirations. )
A client in skeletal traction suddenly develops right-sided chest pain and shortness of breath. Which intervention is priority for the nurse? a Start oxygen per nasal cannula. b Administer the prescribed analgesic. c Check for Homan's sign. d Elevate the head of the bed 45 degrees.
c (Rationale The nurse needs to question the health care provider about the beta-blocker, for this medication should be used with caution in clients with dilated cardiomyopathy. Anticoagulants, antidysrhythmics, and diuretics are often used in the treatment of dilated cardiomyopathy, and the nurse would not question these prescribed medication)
A client is diagnosed with dilated cardiomyopathy. Which scheduled medication should the nurse clarify with the health care provider before administering it? a Anticoagulant b Antidysrhythmic c Beta-blocker d Diuretic
c (Rationale: All cardiomyopathies have similar symptoms, but only dilated cardiomyopathy presents with orthopnea, nocturnal dyspnea, peripheral edema, and ascites. Hypertrophic and restrictive cardiomyopathy usually present with dyspnea on exertion. Hypotrophic cardiomyopathy is not a cardiomyopathy classification. )
A client presents to the emergency department with symptoms of orthopnea, paroxysmal nocturnal dyspnea, peripheral edema, and ascites. The physician suspects cardiomyopathy. The nurse suspects the client is experiencing which type of myopathy? a Restrictive cardiomyopathy b Hypertrophic cardiomyopathy c Dilated cardiomyopathy d Hypotrophic cardiomyopathy
c (Rationale: Prinzmetal's or variant angina is atypical angina that occurs unpredictably (unrelated to activity) and often at night. It is caused by coronary artery spasm with or without an atherosclerotic lesion. This client is at risk for silent ischemia and is associated with a higher relative risk of serious or fatal cardiac events. Stable angina occurs with exertion and is relieved with rest and nitroglycerin tablets. Unstable angina occurs with increasing frequency, severity, and duration. Pain is unpredictable, occurs with decreasing levels of activity or stress, and may occur at rest. It is a precursor to myocardial infarction. The client has classic symptoms of variant angina and so is not experiencing nonanginal pain. Variant angina is prolonged, severe, and occurs at the same time every day, usually in the morning. )
A client tells the nurse that the anginal pain is unpredictable but usually occurs at night. The nurse questions the client and family further about precipitating factors at home; however, there does not appear to be any environmental or emotional cause for the pain. The nurse concludes that the client should contact the physician to facilitate admission to the hospital, because the client has which type of angina? a Nonanginal pain b Stable angina c Variant angina d Unstable angina
a (Rationale: Sinus bradycardia may be well tolerated in some clients. Further assessment is important before treating. If decreased mental status and low blood pressure are present, then treatment is indicated. Mental status and blood pressure take precedence over peripheral pulse assessment. Determining apical-radial pulse deficit is not indicated for this type of dysrhythmia. It is not appropriate to give medication before assessing the effect of the bradycardia on the client. )
A client walks into the clinic with a family member. The family member says the client has been "acting strange" and on several occasions has complained of being "light-headed and dizzy". During the assessment, the nurse auscultated a heart rate of 45 bpm. What should the nurse do next? a Assess mental status and blood pressure. b Determine whether an apical-radial pulse deficit is present. c Prepare to administer IV atropine. d Assess peripheral pulses on all four extremities.
b (Rationale: Direct pressure to the wound is the best initial method to manage uncontrolled bleeding. If this method is ineffective, then clamping a vessel, applying a tourniquet, and elevating the limb can be tried)
A client who was in an automobile accident is in shock. Which is the best measure for the nurse to initiate to control bleeding? a Clamp a visible vessel. b Apply direct pressure. c Apply a tourniquet. d Elevate the injured part.
c (Rationale: Nausea and anorexia are symptoms of digoxin toxicity. Abnormal sodium or potassium levels or abnormal PT/INR would not explain the client's symptoms and, therefore, are not priorities to assess before notifying the physician.)
A client with coronary artery disease (CAD) has had bypass surgery and is about to be discharged home on several new medications, including digoxin (Lanoxin) and furosemide (Lasix). The client complains of nausea and anorexia. Which action will the nurse do first? a Check the PT/INR. b Check the sodium level. c Check the digoxin level. d Call the physician.
a (Rationale: For the client awaiting a heart transplant, there are ventricular assistive devices, implantable cardioverter-defibrillator devices, and pacemakers that can be used to increase survival rates. Aortic valve surgery does not help dilated cardiomyopathy but is a treatment for obstructive hypertrophic cardiomyopathy. A myocardial biopsy and coronary angiography are tests for diagnosing heart disease. )
A client with dilated cardiomyopathy has made the decision to undergo heart transplant. The client is concerned that severe ventricular dysrhythmias will affect the chances of surviving until a heart becomes available. What is the nurse's best response to the client about how the physician will support survival to transplant? a "Prior to transplant you will have an implantation of a ventricular assistive device." b "Your physician will perform a myocardial biopsy while you are waiting on the heart." "c A coronary angiography will be performed prior to heart transplantation." d "Prior to transplant you will have an aortic valve surgery."
a (Rationale: Prostaglandins maintain the patency of the truncus arteriosus, allowing mixing to keep the infant partially oxygenated until definitive repair can be done. Cardiac glycosides would be used to improve myocardial contractility. Diuretics decrease preload by working on the kidney. Medications are used to decrease plasma aldosterone in the treatment of congenital heart defects not increase plasma aldosterone which is beneficial in decreasing afterload.)
A newborn diagnosed with truncus arteriosus is prescribed prostaglandin E1(PGE1). The newborn's parents ask how this medication will help their newborn. The nurse bases the response on which rationale? a Maintains patency b Increases plasma aldosterone c Improves myocardial contractility d Decreases preload
d (Rationale: Re-establishing blood flow and cardiac tissue perfusion during an acute episode of CAD is imperative to minimize damage to the myocardium. Anxiety and Ineffective Health Maintenance are appropriate nursing diagnoses but do not take precedence over cardiac tissue perfusion. Decreased Cardiac Output results in decreased peripheral tissue perfusion and is a high priority but not as high as establishing perfusion to the heart. )
A nurse caring for a client with acute coronary artery disease (CAD) identifies which priority nursing diagnosis? a neffective Health Maintenance b Anxiety c Decreased Cardiac Output d Ineffective Tissue Perfusion
d ( Feedback Rationale: In DIC, the lungs, as well as the rest of the body, have microclots in the capillaries and arterioles, which prevent normal gas exchange. Irregular respirations are an ineffective breathing pattern. Mechanical ventilation and oxygen administration are treatments for impaired gas exchange. )
A nurse caring for a client with disseminated intravascular coagulopathy (DIC) plans care for the client with nursing diagnosis of impaired gas exchange. Which assessment is the appropriate finding for this client? a The client is on 50% oxygen. b The client is mechanically ventilated. c The client has irregular respirations. d The client has microclots in the pulmonary vasculature.
a,e (Rationale During Stage I cardiogenic shock, the body alters capillary hydrostatic pressures in order to maintain fluid volume and preserve cardiac output. Decreases in MAP decrease capillary hydrostatic pressures. Also, when these pressures are decreased, fluid shifts from the interstitial space into the capillaries. The other answer choices are incorrect.)
A nurse is caring for a client in Stage I cardiogenic shock. The nurse understands that capillary hydrostatic pressures may be altered during this stage of shock. What is true regarding capillary hydrostatic pressures in Stage I shock? (Select all that apply.) a Decreases as mean arterial pressure (MAP) decreases b Increases as mean arterial pressure (MAP) decreases c When increased, causes fluid shifts from interstitial space into the capillaries d When decreased, causes fluid shifts from capillaries into the interstitial space e When decreased, causes fluid shifts from interstitial space into the capillaries
a,d,e (Rationale A pulmonary angiography involves an IV injection of contrast dye, which is injected into the pulmonary arteries and is illuminated on x-ray. The ventilation part of the ventilation-perfusion (V/Q) lung scan involves the inhalation of a radio-tagged gas that measures ventilation.)
A nurse is caring for a client suspected of having a pulmonary embolism. The client's health care provider has ordered the client to have a pulmonary angiogram. Which statements will the nurse include in teaching the client about this procedure? (Select all that apply.) a "Part of this procedure involves the placement of an IV." b "Part of this procedure involves inhaling a gas that measures ventilation." c "Part of this procedure uses radioisotopes to help diagnose pulmonary embolism." d "Part of this procedure involves the use of x-ray." e "Part of this procedure involves contrast injected into the pulmonary arteries."
a (Rationale The V/Q scan is a nuclear medicine procedure that uses radioisotopes to visualize an embolism. The D- dimer blood test is elevated with the presence of an embolism. The primary diagnostic test for pulmonary embolism is the CT scan with contrast, which involves injection of contrast to visualize the embolism.)
A nurse is caring for a client with a pulmonary embolism (PE) who is scheduled to have a lung scan (V/Q scan). When teaching the client about this procedure, which statement will the nurse include? a "This is a nuclear medicine procedure that uses radioisotopes to visualize an embolism." b "This is a blood test that scans the blood for an embolism." c "This is the primary diagnostic test for pulmonary embolism (PE)." d "This procedure involves injection of IV contrast to visualize the embolism."
a (Rationale This client is likely in Stage I shock. During this stage, the sympathetic nervous system (SNS) is stimulated as a compensatory mechanism. The result is tachycardia and hypertension. Early shock often shows no symptoms. Stage II shock occurs with prolonged vasoconstriction, eventually leading to decreased BP. Stage III is irreversible shock, which is identified with a complete lack of cardiac output (CO), despite treatment. Tachycardia and hypertension do not occur during this stage.)
A nurse is caring for a client with hypovolemic shock secondary to a gunshot wound to the abdomen. The nurse notes the client's heart rate is 120 and blood pressure is 150/90. Which stage of shock does the nurse determine this client is experiencing? a Stage I b Stage II c Stage III d Early
c (Rationale: The P wave is an indication of atrial contraction and absence of this wave would mean that the atria either are not contracting or are fibrillating and the fibrillation wave is so small as to not be seen on that particular lead. The QRS reflects ventricular contraction, which ejects blood to the body. )
A nurse is observing the client's rhythm strip on the cardiorespiratory monitor when the P wave suddenly disappears. What does the nurse interpret the cardiac strip to mean? a The ventricle is no longer contracting. b Only the left ventricle is contracting. c The atria are not contracting. d The client's heart is no longer ejecting blood.
a,c,d (Rationale Current medications, history of DVT, and recent surgical history are factors assessed during the health history portion of the nursing assessment. The degree of edema and apical pulse quality are assessed during the physical exam portion of the nursing assessment.)
A nurse is performing a nursing assessment on a client with a pulmonary embolism (PE). Which assessments will the nurse anticipate during the health history portion of the nursing assessment? (Select all that apply.) a Current medications b Quality of apical pulse c Recent surgeries d History of DVT e Degree of edema
d (Rationale To prevent anxiety in a client with PE, the nurse should explain all procedures and therapies. The nurse may also administer antianxiety medications as ordered; however, this is a collaborative nursing intervention, not an independent intervention. Placing the client away from the nurses' station and discouraging visitors is nontherapeutic for a client with anxiety related to PE.)
A nurse is planning care for a client with a pulmonary embolism (PE) who is scheduled to have a vena caval filter placed. What independent nursing intervention will the nurse implement to decrease the client's feelings of anxiety? a Administering antianxiety medications as ordered b Placing client away from the nurses' station to provide privacy c Discouraging visitors to maintain a therapeutic environment d Explaining all procedures and therapies ordered
a (Rationale: Strategies for promoting mobility in the toddler while on oxygen are important for growth and development. Bed rest and drawing blood gases are unnecessary. Signs of toxicity are not a priority based on the information in the question.)
A toddler requires supplemental oxygen therapy for a cyanotic heart defect. In planning for home care, the nurse discusses which scenario with the parents? a Promoting mobility while on oxygen b Symptoms of oxygen toxicity c Maintaining the child on bed rest d Method for drawing blood for ABGs
a (Rationale: In hypertrophic cardiomyopathy, symptoms may not develop until the demand for oxygen increases as with exercising. This type of cardiomyopathy is not a problem with filling the heart, but rather an obstruction of blood being ejected from the heart to meet the body's oxygen demand. It is not likely that the child had symptoms. The ventricle does not rupture due to scarring. )
A young athlete collapsed and died due to hypertrophic cardiomyopathy. The parents ask the nurse how it is possible that their child had no symptoms of this disorder before experiencing sudden cardiac death. What is the most appropriate response made by the nurse? a "Exercise causes the heart to contract more forcefully and can lead to changes in the heart's rhythm or outflow of blood." b "It is likely that your child had symptoms of the disorder but may not have thought them important." c "During exercise, the heart may not be able to meet the body's demands for blood and oxygen." d "Cardiomyopathy results in destruction and scarring of cardiac muscle cells. As a result, the ventricle may rupture, causing sudden death."
d (Rationale: The catheter used to place the stent is usually inserted in the femoral artery. The affected leg is maintained in extension to prevent bleeding and hematoma formation. Chest tubes are not needed for this surgery and would not be secured to bed linens in any case. IV lines would be maintained as a saline lock in the event a line is needed for IV medications. Because the stent re-establishes blood flow to the myocardium, narcotic analgesics are rarely needed)
An African American male client with a history of diabetes and stroke returns from coronary angioplasty with stent placement. Which priority action will the nurse perform at this time? a Securing chest tubes to the bedding b Treating chest pain with intravenous morphine as needed c Discontinuing intravenous lines when taking oral fluids d Maintaining leg extension on the affected side
a (Rationale: The nurse should prepare the infant for an atrial septostomy. This procedure involves threading a balloon into a vein up to the right atrium during a cardiac catheterization. The balloon is then inflated at the foramen ovale, creating a wider opening, promoting mixing to maintain some oxygenated blood to the systematic circulation. The nurse should not prepare the client for an electrocardiogram, stent, or transcatheter closure.)
An infant diagnosed with transposition of the great arteries is scheduled for a cardiac catheterization. The nurse prepares the infant for which procedure where a balloon is inserted to make the foramen ovale wider? a Atrial septostomy b Transcatheter closure c Electrocardiogram d Stent
d ( Feedback Rationale: Although any of these problems could lead to decreased urine output in this infant, the most likely cause is decreased renal perfusion and circulating blood volume secondary to decreased cardiac output)
An infant is recovering from cardiac surgery. The nurse notes decreased urine output and suspects the most likely cause is: a infection. b renal artery infarction. c pneumonia. d decreased cardiac output.
d (Rationale: Early signs of heart failure would include tachycardia, tachypnea, scalp sweating, sudden weight gain, and respiratory distress. Dyspnea on exertion is not seen in infants. Cyanosis and pallor are late signs of heart failure.)
An infant with a congenital heart defect is being stabilized prior to surgery. The nurse monitors the infant for which early sign of heart failure? a Cyanosis b Dyspnea on exertion c Pallor d Tachycardia
c,e (Rationale: Prostaglandin E1 provides for oxygenation and cardiac output by keeping the PDA open so there is a mixing of oxygenated and unoxygenated blood. If the PDA is closed, there is no means of oxygenating blood because there is no communication between the systemic and pulmonary circulations. The vessels do not move. Hypercyanotic spells are the spells seen in infants with tetralogy of Fallot. Calcium levels are not affected by prostaglandins.)
An infant with transposition of the great vessels is placed on an IV drip of prostaglandin E1. The nurse teaches the parents that this medication is necessary because it: (Select all that apply.) a prevents hypercyanotic spells. b maintains the position of the vessels c provides for oxygenation and adequate cardiac output. d maintains calcium levels. e keeps the patent ductus arteriosus (PDA) open.
a (Rationale: Symptoms of pulmonary embolism have a sudden onset, and the dyspnea causes apprehension in the client. Increase in heart and respiratory rates with PE is abrupt, not slow. Cyanosis of the upper torso is associated with embolism of a central vein rather than the pulmonary vasculature. Bilateral wheezing is associated with asthma. )
For the client at risk for pulmonary embolism (PE), which assessment finding would indicate to the nurse that the client has a pulmonary embolism? a Abrupt onset of dyspnea and apprehension. b Slow increase in heart and respiratory rates. c Cyanosis of the upper torso. d Significant bilateral wheezing.
d (Rationale Immediately after the birth of an infant, profound cyanosis that does not respond to oxygen is a manifestation of a heart defect associated with decreased pulmonary blood flow. Fatigue, clubbing of fingers and toes, and poor feeding are manifestations of a heart defect associated with decreased pulmonary blood flow; however, these defects are not seen immediately after birth. These manifestations are considered chronic signs and symptoms that may occur if the disorder remains undiagnosed.)
Immediately after the birth of an infant, the nurse is completing a physical assessment. Which manifestation indicates the infant may have a heart defect associated with decreased pulmonary blood flow? a Clubbing of fingers and toes b Poor feeding c Fatigue d Profound cyanosis that does not respond to oxygen
b (Rationale: Interdisciplinary goals for the client with heart failure are to reduce cardiac workload and improve pump effectiveness. Loss of fluid, as indicated by weight loss, reduces cardiac workload. Decrease in heart rate and reduced pulmonary congestion indicate improved pump effectiveness. The client's condition has improved and there is not a need for more aggressive treatment. However, the heart rate remains higher than normal, and there are still crackles in the lungs, indicating the need for continued treatment. )
In assessing a client admitted 24 hours ago with heart failure, the nurse notes that the client has lost 2.5 pounds, heart rate is down from 105 to 88, and there are fine crackles only in the bases of the lungs. The nurse correctly interprets these data as indicating: a The client's condition is unchanged. b The treatment regimen is achieving the desired effect. c A need for more aggressive treatment. d Heart failure has resolved.
b ( Feedback Rationale: Normal ejection fraction is 60%; 25% ejection indicates severe dysfunction. The percentage represents the amount of blood ejected from the ventricle, not the amount retained. Cardiac output is decreased in heart failure. )
In reviewing the physician's admitting notes for a client with heart failure, the nurse notes that the client has an ejection fraction of 25%. What is the appropriate interpretation of the nurse's findings? a 25% of the blood in the ventricle remains after systole. b Ventricular function is severely impaired. c Cardiac output is greater than normal. d The amount of blood ejected from the ventricles is within normal limits.
a,c,d (Rationale: Early ambulation and flexing the ankles or ROM exercises will help prevent venous stasis and pulmonary emboli. For some clients, the doctor may order external compression boots to promote circulation. While hydration is important, if the client is taking fluids well, there is no need to continue IV fluids for 4 days. Pulmonary artery wedge pressure monitoring is not a preventive measure, but a monitoring of the pressure in the lungs after an embolus has occurred. )
Prior to surgery, the nurse is teaching the client about pulmonary embolism. The nurse tells the client that the primary treatment is prevention. The client asks the nurse what steps can be taken to prevent this condition and the nurse responds with: (Select all that apply.) a early ambulation after surgery. b intravenous fluids for 4 days postoperatively. c external pneumatic compression boots. d flexing of ankles postoperatively. e pulmonary artery wedge pressure monitoring.
d ( Feedback Rationale: A platelet transfusion replaces platelets used in the abnormal clotting process of DIC. Platelets do not replace clotting factors or increase the oxygen carrying ability of the blood. Promotion of intravascular clotting is not a desired effect.)
The nurse administering platelets to a client with disseminated intravascular coagulation (DIC) understands that the intended effect of this treatment is to: a restore tissue oxygenation. b replace specific clotting factors. c promote intravascular clotting. d replace depleted platelets.
c (Rationale: Administration of anticoagulants is an effective means of preventing pulmonary embolism. Thrombolytic drugs such as streptokinase are used to dissolve already formed clots. Vitamin K and protamine sulfate are used to facilitate clotting and counteract the effects of anticoagulants. )
The nurse administers which medication as part of pharmacological treatment aimed at prevention of pulmonary embolism? a Aquamephyton (vitamin K) b Streptokinase c Enoxaparin (Lovenox) d Protamine sulfate
d (Rationale: Calibrating and leveling the system every shift ensures accuracy and consistency of measurements. The IV tubing is secured to the patient, not the bed linens. The arterial flush will not work with only gravity because it needs to be under pressure. Dampening of the waveform during measurement is the expected finding. )
The nurse caring for a client undergoing pulmonary artery pressure monitoring for heart failure provides appropriate care when the nurse: a secures IV tubing to the bed linens. b maintains flush solution flow by gravity. c reports waveform dampening during wedge pressure measurements. d calibrates and levels the system every shift.
d (Rationale: An increase of 30 mmHg systolic and 15 mmHg diastolic on two occasions is diagnostic for PIH. The other examples do not meet these criteria.)
The nurse concludes that a client is at risk for pregnancy-induced hypertension (PIH) when the vital signs taken during pregnancy show that the blood pressure increases from: a 90/56 to 110/70. b 134/80 to 140/88. c 122/80 to 138/86. d 100/60 to 130/76.
b (Rationale: Administer oxygen as prescribed. Administration of oxygen decreases the risk for hypoxia and hypercapnia, which can increase cerebral ischemia and intracranial pressure. The commode at the bedside, Metamucil, and hand weights are all appropriate for this client. )
The nurse concludes that further teaching is needed when visiting the home of a client who has recovered from a cerebrovascular accident (CVA). Which finding indicates the client is at risk of Ineffective Tissue Perfusion? a The commode is at the bedside. b Oxygen canister is in the closet. c Metamucil is on the kitchen counter. d Hand weights are next to the couch.
a,b,e (Rationale: Interventions for managing pain include using a standard pain scale to evaluate and monitor pain and analgesic effectiveness, handling extremities gently, and applying cool compresses to painful joints. Monitoring oxygen saturation and encouraging frequent turning and coughing will not assist the client with treatment of pain. These interventions are more appropriate for promoting effective tissue perfusion.)
The nurse has determined the client with DIC is experiencing pain. Which interventions will the nurse provide to support the client in pain? (Select all that apply.) a Using standard pain scale to evaluate and monitor pain and analgesic effectiveness b Applying cool compresses to painful joints c Encouraging frequent turning and coughing d Continuously monitoring oxygen saturation and oxygen administration as ordered e Handling extremities gently
c,d (Rationale: The client's edema is unlikely to be due to fluid retention if daily weights have been stable, so the nurse's interventions are aimed at promoting venous return to the heart by having the client elevate the legs and applying antiembolism stockings. While reviewing the diet and lab values is appropriate, it is unlikely the client is experiencing fluid retention if daily weights are not increasing. There is no need to increase the client's diuretic dosage. )
The nurse in a long-term care facility is talking with the family of a client diagnosed with heart failure, diabetes, hypertension, and chronic renal failure. The nurse notes mild edema of the ankles while the client is sitting in the chair. Breath sounds are clear, equal, and with good chest excursion, and the client denies any feeling of shortness of breath. The nurse reviews the medical record and sees no significant change in the client's daily weights over the last week. What are the nurse's priority interventions for this client? (Select all that apply.) a Call the doctor for an order to increase the client's diuretic. b Review the client's BUN and creatinine. c Apply antiembolism stockings. d Encourage the client to elevate feet when sitting. e Review the client's diet to determine sodium intake.
a (Rationale: Stable angina is predictable and is associated with increased activity, and is relieved by rest and nitrates. ECG changes, nocturnal pain, and weak peripheral pulses are not findings associated with stable angina)
The nurse in the clinic assesses a client with stable angina. What expectations does the nurse have for this client? a Correlation between activity level and pain b Persistent ECG changes c Increasing nocturnal pain d Weak peripheral pulses
c (Rationale: Clients with DIC should be protected from injury that will result in bleeding. An oral swab is the least likely to cause tissue injury to the oral cavity during oral care. Mouthwashes containing alcohol should be avoided because they may cause discomfort and they tend to dry the mucous membranes. Toothbrushes and flossing are both likely to cause bleeding. )
The nurse is administering oral care to a 72-year-old client, who was in an MVA and developed disseminated intravascular coagulation. What is the most appropriate nursing intervention for this client? a Use an alcohol-based solution to prevent infection. b Limit flossing to once a day. c Use swabs to administer oral care. d Encourage tooth brushing at least once a shift.
d (Rationale: Preventing hypoxia and hypercapnia through administration of oxygen will prevent further ischemia of cerebral tissues and ICP. Fluid in the lungs and pulmonary emboli are unrelated to stroke. Administering oxygen will not prevent rebleeding. )
The nurse is administering oxygen to a client experiencing a stroke in order to prevent hypoxia and hypercapnia. The nurse expects this treatment to decrease the risk for: a fluid accumulation in the lungs. b pulmonary emboli. c rebleeding. d increased intracranial pressure (ICP).
a,d,e (Rationale: Bleeding may result in multiple bruises on various skin surfaces and mucous membranes. Puncture sites such as those from injections or intravenous infusions may ooze blood when a client has DIC. Pale, cool extremities may be noted when a patient is bleeding as blood is diverted back to major organs to maintain oxygenation. History of a malignant tumor supports the diagnosis of chronic DIC. Thyroid disease is not a known risk factor for acute DIC.)
The nurse is assessing a client suspected of having developed Disseminated Intravascular Coagulation (DIC). Which assessment findings would support the diagnosis of acute DIC? (Select all that apply.) a Bleeding at the IV insertion site b A history of a malignant tumor c A history of thyroid disease d Multiple bruises on various skin surfaces e Pale, cool extremities
a (Rationale: The motor pathways of the nervous system cross at the medulla and spinal cord, so that damage to a cerebral vessel on one side will manifest neurologic deficits in the opposite, or contralateral, side. This client will exhibit deficits on the right side. )
The nurse is assigned to care for a client who has had an acute ischemic stroke of a left cerebral vessel. The chart reveals that the client has contralateral deficits. The nurse explains to the family that this means: a The client will have neurological deficits on the right side. b The client will have neurological deficits on the left side. c Both sides of the client's body are involved. d Deficits will be present below the level of the stroke.
d ( Feedback Rationale: Petechiae, oozing from injection sites and hematuria are signs of DIC. Pain and swelling in the leg indicate thrombophlebitis. The client's clotting times would be prolonged in DIC, and platelet levels would be decreased.)
The nurse is carefully monitoring a postpartum client who experienced abruptio placentae for which sign of disseminated intravascular coagulation (DIC)? a Increased platelet levels b Pain and swelling in the leg c Rapid clotting times d Petechiae, oozing from injection sites, and hematuria
a (Rationale: The open ductus arteriosus will allow a small amount of mixing of oxygenated and unoxygenated blood. Stress increases the workload of the heart. The next priorities are maintaining caloric intake and providing comfort for the family. Documenting vital signs is a routine activity and not a priority when compared to care activities. )
The nurse is caring for a 2-month-old infant with transposition of the great vessels. Which of the following interventions has the highest priority? a Reducing stressors for the infant b Maintaining proper caloric intake c Providing comfort for the family d Documenting vital signs
b,d,e (Rationale Medical conditions associated with atrial fibrillation include long-standing hypertension, mitral regurgitation, mitral stenosis, acute myocardial infarction, and heart failure. Mitral valve prolapse is associated with development of premature atrial contractions. Cor pulmonale is associated with development of premature atrial contractions and atrial flutter.)
The nurse is caring for a client being evaluated for atrial fibrillation. Which medical conditions should the nurse inquire about during the health history interview with the client? (Select all that apply.) a Cor pulmonale b Long-standing hypertension c Mitral valve prolapse d Heart failure e Mitral regurgitation
a (Rationale During the psychosocial portion of the nursing assessment the nurse will assess the coping skills of the parents. Information about the maternal prenatal history is included in the health history. The respiratory rate and blood pressure are assessed during the physical examination.)
The nurse is caring for a client diagnosed with a congenital heart defect. Which item will the nurse include in the psychosocial portion of the nursing assessment? a Parental coping skills b Respiratory rate c Blood pressure d Maternal prenatal history
a,b,d (Rationale Incidence of torsades de pointes is common in individuals who are on liquid protein diets, experiencing starvation, or taking prescribed diuretics. The incidence of asystole is associated with massive cardiac muscle damage. The incidence of pulseless electrical activity is associated with overdose of cardiac medication.)
The nurse is caring for a client diagnosed with torsades de pointes. Which information might the nurse anticipate finding in the client's admission history? (Select all that apply.) a Experiencing starvation b Currently on liquid protein diet c Overdose of cardiac medication d Taking prescribed diuretics e Massive cardiac muscle damage
a (Rationale: Widespread vasodilation can cause distributive shock as the blood pressure drops dangerously low due to decreased peripheral vascular resistance. Hypersensitivity causes anaphylactic shock. Blood loss is associated with hypovolemic shock and ineffective cardiac pumping causes cardiogenic shock.)
The nurse is caring for a client experiencing distributive shock. What does the nurse conclude as the cause of the client's shock? a Widespread vasodilation b Blood loss c Ineffective cardiac pumping d Hypersensitive reaction
a (Rationale: Paced beats shown on the monitor indicate the pacer is functioning. The client is not allowed to ambulate for 24 hours after implantation. Normal sinus rhythm, heart rate of 80 bpm, and blood pressure of 120/80 do not reflect pacemaker function. )
The nurse is caring for a client who had a permanent pacemaker inserted due to complete heart block. The nurse notes which outcome is indicative of a successful procedure? a Client's ECG monitor shows paced beats at a rate of 68 bpm. b Client's ECG monitor demonstrates normal sinus rhythm. c Client has heart rate of 80 bpm, blood pressure 120/80. d Client ambulates in the hall within 4 hours of the procedure without dyspnea or chest pain.
a (ationale: The endotoxins released by bacteria stimulate the release of vasoactive proteins causing peripheral vasodilation and decreased peripheral resistance. Cardiogenic, hypovolemic, and obstructive shock are not characterized by these symptoms. )
The nurse is caring for a client who is diagnosed with shock. Which type of shock will the nurse provide an intervention if the client presents with widespread vasodilation and decreased peripheral resistance? a Septic shock b Hypovolemic shock c Cardiogenic shock d Obstructive shock
a (Rationale: A basic preventive measure for the prevention of pulmonary emboli for the client on bed rest is to promote circulation by active ROM exercises. The nurse would keep the client well hydrated. Heat is not applied without a physician's order and placing a pillow under the knees promotes venous stasis and clot formation. )
The nurse is caring for a client who is placed on strict bed rest. When planning care, the nurse initiates which action to prevent pulmonary emboli? a Provide active ROM to the legs. b Restrict fluids. c Apply heating pad to both legs. d Place a pillow under the knees.
c (Rationale Cough is the most common manifestation of PE. Syncope, cyanosis, and hemoptysis may occur; however, these are less common.)
The nurse is caring for a client who is suspected of having a pulmonary embolism (PE). Which is the most common manifestation of PE that the nurse will recognize upon assessment? a Syncope b Cyanosis c Cough d Hemoptysis
a (Rationale: An electrocardiogram records electrical activity of the heart and would be the diagnostic tool of choice to determine why the client's heart rate is irregular. Echocardiograms demonstrate the internal structure of the heart. The thallium stress test measures areas of ischemia in the heart. Cardiac catheterization is the insertion of a catheter into the chambers of the heart and allows for visualization of the coronary arteries and measurement of pressures within the chambers of the heart. )
The nurse is caring for a client whose heart rate suddenly becomes irregular. When notifying the physician, the nurse anticipates an order for which diagnostic study? a Electrocardiogram b Echocardiogram c Thallium stress test d Cardiac catheterization
b (Rationale: Interventions to promote effective tissue perfusion include assessing extremities, level of consciousness and mental status; monitoring central and peripheral tissue perfusion; and gentle repositioning every 2 hours. Although the other choices may be needed for the care of a client with DIC, they do not support the promotion of tissue perfusion.)
The nurse is caring for a client with Disseminated Intravascular Coagulation (DIC) and has identified the need to promote tissue perfusion. What intervention would the nurse include in the plan of care? a Applying cool compresses to painful joints b Assessing level of consciousness c Using of a standard pain scale to evaluate and monitor pain d Providing emotional support
b ( Feedback Rationale: Renal failure is a common cause of hypocalcemia, and a value of 7.0 mg/dL is low, which can cause more cardiac dysrhythmias. The potassium, sodium, and digoxin levels are within normal limits)
The nurse is caring for a client with a nursing diagnosis of Ineffective Tissue Perfusion. The client also has a medical history of renal failure, new myocardial infarction, and dysrhythmias. With which priority lab result should the nurse contact the physician? a Sodium level of 145 mEq/L b Calcium level of 7.0 mg/DL c Digoxin/digitalis level of 0.8 ng/ML d Potassium of 5.0 mEq/L
c (Rationale Acute inflammatory responses, such as in anaphylactic shock, increase the levels of eosinophils in the client's serum. Decreased WBC, decreased hemoglobin and increased basophils are not found in anaphylactic shock.)
The nurse is caring for a client with anaphylactic shock after the client was exposed to latex at a dental appointment. Which diagnostic finding, unique to anaphylactic shock, will the nurse expect to find? a Decreased hemoglobin b Decreased WBC c Increased eosinophils d Increased basophils
d,e (Rationale Morphine sulfate, used to decrease pain, also decreases the client's anxiety and dilates the coronary arteries, improving perfusion to the myocardium. This medication does not improve gas exchange or myocardial contractility.)
The nurse is caring for a client with cardiogenic shock who appears anxious and short of breath. The healthcare provider orders morphine sulfate for the treatment of the client's symptoms. What is the nurse's best understanding about the reason for this order? (Select all that apply.) a This medication improves gas exchange. b This medication improves myocardial contractility. c This medication constricts the coronary arteries. d This medication increases perfusion to the myocardium. e This medication decreases anxiety.
d (Rationale: Increased pain is significant in that it shows that there are new areas of clots impeding circulation. If the client is resting comfortably and does not require increasing levels of analgesics, the goal has been met. Bleeding with suctioning, new petechiae, and increased oxygen need demonstrate that the client's condition is continuing to worsen.)
The nurse is caring for a client with disseminated intravascular coagulopathy (DIC) who is on the mechanical ventilator. Which outcome observed by the nurse determines that goals of care for the client have been met? a Has new petechiae b Has increased bleeding when suctioned c Requires an increase in oxygen d Has no increased symptoms of pain
b (Rationale: Pregnant women with severe preeclampsia may develop HELLP syndrome, which has a very poor prognosis. HELLP presents with nausea, vomiting, flu-like symptoms, and bleeding due to liver involvement and platelet aggregation. Eclampsia presents with seizures, blurred vision, and high blood pressure. Chronic and transient hypertension may lead to HELLP syndrome. )
The nurse is caring for a client with severe preeclampsia who is showing signs of bleeding and oozing from intravenous sites and who is bruising under the skin. The nurse suspects this is a sign of which clinical manifestation? a Eclampsia b Hemolysis, elevated liver enzymes, low platelet count syndrome (HELLP) c Chronic hypertensive disease d Transient hypertension
b (Rationale: Diminished reflexes signify magnesium toxicity. Slurred speech, decreased appetite, and awkward movements indicate a therapeutic magnesium level.)
The nurse is caring for a client with severe pregnancy-induced hypertension who is in the hospital on a magnesium sulfate drip. The nurse monitors the client for which sign of magnesium toxicity? a Slurring of speech b Diminished reflexes c Awkward movements d Decreased appetite
c (Rationale: Patients with chronic DIC may receive continuous heparin infusion by pump for long-term treatment. The administration of fresh frozen plasma, platelets, and oxygen are used for acute DIC.)
The nurse is caring for a patient with chronic DIC. Which order from the healthcare provider would the nurse expect? a Administer platelet infusion. b Administer fresh frozen plasma. c Administer heparin via continuous infusion pump. d Administer oxygen.
a,c (Rationale: The left lateral position reduces pressure on the vena cava, thereby increasing venous return. Hyperreflexia indicates central nervous involvement and is a sign of progression toward eclampsia. Blood pressure is assessed every 1-4 hours. Urine output is decreased in preeclampsia; the client is weighed daily for fluid status)
The nurse is caring for a pregnant woman who is admitted with preeclampsia. The nurse plans care based on the nursing diagnosis of deficient fluid volume related to fluid shifts from vasospasms. Which nursing intervention is a priority for this client? (Select all that apply.) a Assess deep tendon reflexes. b Assess blood pressure every 8 hours. c Place client in the left lateral recumbent position. d Monitor for increased urine output. e Weigh client weekly.
a (Rationale: The woman experiencing eclampsia is at great risk for seizures, and the highest priority of care is a patent airway. Checking blood pressure, fetal heart tones, and administering magnesium sulfate and oxygen are all components of care but are of lower priority than maintaining a patent airway. )
The nurse is caring for a woman who has been admitted with early pregnancy-induced hypertension (PIH) that has progressed to eclampsia. The priority intervention by the nurse is to: a maintain a patent airway. b prepare to administer magnesium sulfate. c administer oxygen. d check the blood pressure and fetal heart tones.
a,c,e (Rationale: Clinical manifestations of torsades de pointes include tachycardia, seizures, and hypotension. Epistaxis and bradypnea are not assessment findings that support this client's diagnosis.)
The nurse is caring for an adolescent client who is brought to the emergency department (ED) experiencing torsades de pointes. Which clinical manifestations found during the nursing assessment support this diagnosis? (Select all that apply.) a Seizures b Bradypnea c Tachycardia d Epistaxis e Hypotension
b,d,e (Rationale Assessment findings of syncope, dizziness, shortness of breath, angina, and generalized weakness are indicative of decreased cardiac output related to the cardiac dysrhythmia. You would speak honestly and sensitively to the client and family. You would tell them that healthcare providers must immediately intervene because decreased cardiac output can be life threatening. Nausea and vomiting are not clinical manifestations associated with decreased cardiac output related to sinus dysrhythmia. Seizures are a clinical manifestation in clients with ventricular dysrhythmia, particularly with torsades de pointes, ventricular fibrillation, and pulseless electrical activity)
The nurse is caring for an older adult client who presents with her family at the emergency department (ED) and is diagnosed with a sinus dysrhythmia. Which assessment findings related to decreased cardiac output would require immediate intervention? (Select all that apply.) a Seizures b Dizziness c Nausea and vomiting d Syncope e Shortness of breath
c (Rationale: Observing for signs of decreased perfusion is the intervention the nurse needs to implement after cardiac catheterization. During the procedure, the catheter can trigger arteriospasm and vasoconstriction, leading to loss of perfusion to the extremity. The child should avoid hip flexion to prevent bleeding; therefore, the nurse should keep the child on supine bed rest for 4 to 6 hours, not just 2 hours, after cardiac catheterization. The child needs to maintain quiet, low exertion activity for 24 hours, not just 12 hours, to prevent bleeding following cardiac catheterization. The nurse should encourage fluids, not restrict oral fluids, because the child is at risk for dehydration after cardiac catheterization.)
The nurse is caring for a school-age client who has undergone cardiac catheterization for repair of an atrial septal defect. Which intervention should the nurse implement? a Keep on bed rest for 2 hours b Maintain quiet, low exertion activity for 12 hours c Observe for signs of decreased perfusion d Restrict oral fluids
a,b,c,e ( Rationale Pregnancy, fracture of long bones (especially the femur), reproductive surgery, and MI are all factors that increase the risk of the development of DVT or PE. Asthma alone is not a risk factor for these conditions.)
The nurse is caring for four clients on the medical-surgical unit. Which clients will the nurse recognize as having the greatest risk of deep vein thrombosis (DVT) or pulmonary embolism (PE)? (Select all that apply.) a 24-year-old male in traction device after femur fracture b 65-year-old male recovering from an MI c 19-year-old pregnant female with gestational diabetes d 32-year-old female with an asthma exacerbation. e 55-year-old female scheduled for a hysterectomy
c (Rationale: Chest pain and hemoptysis are classic symptoms of pulmonary embolism, a serious complication of atrial fibrillation. Irregular pulse is expected with atrial fibrillation. Fatigue may also be an expected outcome for some individuals with atrial fibrillation. Fever is not associated with atrial fibrillation.)
The nurse is discharging a client to home with a new diagnosis of atrial fibrillation. The nurse explains that which symptom is the most important to report to the physician? a Fever b Fatigue c Hemoptysis d Irregular pulse
c
The nurse is discussing care with the parents of a 19-year-old client who has been diagnosed with end stage cardiomyopathy. The parents ask the nurse if it is helpful for family members and the client if the family is allowed to be present during resuscitation efforts. What is the best response by the nurse? a "The family can help until medical personnel arrive." b "It is not allowed in this facility." c "The family presence is a means of preserving the wholeness and integrity of the family unit." d "There are no benefits to the client or the family; it is a traumatic experience."
c (Rationale: The client who admits fear but is willing to seek help and to talk about those fears has met the goal of verbalizing feelings about impending death. The client who verbalizes not being ready to die is not accepting the inevitable. Worrying about the family and stating that this is not possible are forms of denial that avoid discussion of fears and feelings. )
The nurse is discussing treatment options and evaluating the goals of a client diagnosed with cardiomyopathy. Which client statement helps the nurse determine that teaching has been successful? a "I just can't die yet; I am not ready." b "This is just not possible; I am too young to die." c "I am afraid to die and would like to talk about it with my pastor." d "How will my family survive without me?"
d (Rationale: The nurse should include information about chromosomal abnormalities such as Down, Marfan, and DiGeorge syndromes, which place the child at a greater risk for being born with a congenital heart disorder. Fetal exposure to a bacterial infection does not place the child at a greater risk for developing a congenital heart disorder because most disorders result from viral infections and metabolic disorders. A mother infected with gonorrhea does not place the child at a greater risk for developing a congenital heart disorder. A mother's young age does not place the child at a greater risk for developing a congenital heart disorder.)
The nurse is educating a women's community group about congenital heart disorders. Which factor should the nurse identify as placing a child at a greater risk for being born with a congenital heart disorder? a Young age of mother b Mother infected with gonorrhea c Fetal exposure to a bacterial infection d Chromosomal abnormality such as Down syndrome
d (Rationale: Headache and blurred vision are symptoms of the disorder, indicating that the PIH has not resolved. Baseline blood pressure and increasing urine output are signs that PIH is resolving. Perineal pain is unrelated to PIH.)
The nurse is evaluating a woman at 48 hours postpartum who experienced pregnancy-induced hypertension (PIH). Which assessment would lead the nurse to conclude that the PIH has not resolved? a Urine output is increasing. b Client complains of perineal pain. c Blood pressure is returned to baseline. d Client complains of headache and blurred vision.
a,b,e (Rationale: Laboratory findings that support a diagnosis of DIC include the presence of schistocytes, a decreased platelet count, and an increase in fibrin degradation products or fibrin split products. The client with DIC would not have an elevated hemoglobin or shortened prothrombin time, thromboplastin time, and thrombin time.)
The nurse is evaluating the lab results for a client suspected of having DIC. Which laboratory findings would support the diagnosis? (Select all that apply.) a Decreased platelet count b Increased fibrin degradation products or fibrin split products c Shortened prothrombin time, thromboplastin time, and thrombin time d Elevated hemoglobin e The presence of fragmented red blood cells called schistocytes
c (Rationale: Peptic ulcer disease does not exacerbate heart failure. Respiratory infections, nutritional anemia, atrial fibrillation, stress, pregnancy, and thyroid disorders are among disorders and conditions that will exacerbate heart failure)
The nurse is examining a client in the clinic for follow-up care for heart failure. Which factor, if reported by the client, would not be associated with exacerbating heart failure? a Recent upper respiratory infection b Nutritional anemia c Peptic ulcer disease d Atrial fibrillation
d (Rationale: The fetus is affected by PIH due to maternal vasospasms that decrease blood flow and nutrients to the fetus, which may cause the baby to die if PIH worsens. Back pain and increased appetite are not signs of worsening PIH. Edema increases as PIH progresses. )
The nurse is instructing a client with mild pregnancy-induced hypertension (PIH) who is about to be discharged home. The nurse teaches the client's spouse to call the physician if the client experiences which symptom? a Back pain increases. b Appetite increases. c Edema decreases. d Fetal movement slows or stops.
c (Rationale: Clients with diseases that slow the body's ability to clot, such as hemophilia, are at increased risk for hemorrhagic shock. Hypertension, renal insufficiency, and tachycardia do not interfere with the client's ability to clot. )
The nurse is monitoring a client in shock who is receiving a blood transfusion. Which diagnosis needs to be determined prior to the transfusion to decrease the client's chance of going further into shock? a Renal insufficiency b Hypertension c Hemophilia d Tachycardia
d (Rationale: The blood gas is near normal and would be the goal that signifies the client is improving. The findings described for hemoglobin and hematocrit, RBC and platelets, and PT and INR are abnormal.)
The nurse is monitoring a client who is experiencing septic shock with a nursing diagnosis of Ineffective Tissue Perfusion. Which finding by the nurse indicates the client is improving? a RBC 15,000 cells/mcL and platelets 100,000/mm3 b PT 30 seconds, INR 2.5 c Hemoglobin 8.1 g/100mL and Hematocrit 26% d Blood gas pH 7.34, PaO2 77, PcO2 38, and bicarb 22
d
The nurse is performing a routine prenatal assessment of a 36-year-old renal client at 23 weeks' gestation, with suspected pregnancy-induced hypertension (PIH). Which factor is indicative of PIH? a Complaints of low back pain b Glucose in the urine c A baseline blood pressure of 122/80 d Proteinuria
a,c,e (Rationale Presence of trauma, burns, and recent surgical history are factors assessed during the health portion of the nursing assessment. The recent vital signs and CVP are assessed during the physical exam portion of the nursing assessment.)
The nurse is performing an assessment on a client with hypovolemic shock. Which assessments will the nurse anticipate during the health history portion of the nursing assessment? (Select all that apply.) a Presence of burns b Recent vital signs c Presence of trauma d Recent CVP measurement e Recent surgeries
a,c (Rationale: Any type of cardiomyopathy has a very poor prognosis, so the client and family will likely experience anticipatory grieving of the loss of a loved one. The client will likely experience fear in confronting death. Risk for bleeding, decisional conflict, and risk for electrolyte imbalance are not priorities for this client. )
The nurse is planning care for a client with cardiomyopathy. Which nursing diagnoses are appropriate for the client? (Select all that apply.) a Fear b Decisional Conflict c Anticipatory Grieving d Risk for Electrolyte Imbalance e Risk for Bleeding
d
The nurse is planning care for a client with septic shock who is scheduled to have a central line placed. Which independent nursing intervention will the nurse implement to decrease the client's feelings of anxiety? a Administering antianxiety medications as ordered b Placing client away from nurse's station to provide for privacy c Discouraging visitors to maintain therapeutic environment d Explaining all procedures and therapies ordered
b ( Feedback Rationale: Nitroglycerin is ordered to be taken every 5 minutes 3 times for pain. Waiting 10 minutes between doses is not appropriate if the client is in pain. Ten liters of oxygen is an unsafe dose. The nurse instructs the client to call 911 if the pain does not subside after 3 doses. )
The nurse is planning discharge instructions for a client diagnosed with coronary artery disease (CAD). The client, who is to take nitroglycerin at home for substernal chest pain, asks the nurse what to do if there is still pain after taking the medication. What is the appropriate response made by the nurse? a "Apply oxygen at 10 liters per minute." b "Take another nitroglycerin tablet." c "Take an aspirin and call 911." d "Wait for 10 minutes before taking a second pill."
b (Rationale Countershock delivers a direct current charge that depolarizes all cardiac cells at the same time. This may stop a tachydysrhythmia and allow the SA node to regain control of impulse formation. A pacemaker is a pulse generator that provides electrical stimulus to the heart when it does not provide its own stimulus sufficient to maintain cardiac output. An ECG is a diagnostic test that measures the electrical activity of the heart, not a therapy. Medical teams use cardiac mapping and cardiac ablation to locate and destroy an ectopic focus.)
The nurse is providing care for a client who demonstrates a tachydysrhythmia. Which treatment option does the nurse anticipate for this client? a Cardiac ablation b Countershock c Pacemaker d ECG
d (Rationale Cardiomyopathy is a disease process in which the heart is weakened, which interferes with its ability to pump blood through the body. The other statements do not accurately describe cardiomyopathy.)
The nurse is providing education to a client newly diagnosed with cardiomyopathy. Which statement should the nurse use to best describe cardiomyopathy to the client? a Cardiomyopathy is an abnormal heart rate. b Cardiomyopathy is another term for high blood pressure. c Cardiomyopathy develops when the kidneys cannot regulate the blood pressure. d Cardiomyopathy causes ineffective pumping pumping of the heart.
d (Rationale The nurse needs to include heart failure as a risk factor associated with cardiomyopathy. Alcoholism, not smoking, is a risk factor for cardiomyopathy. Hypertension, not hypotension, is a risk factor. Hyperthyroidism is not a risk factor for cardiomyopathy.)
The nurse is providing education to a community group about cardiac disorders. When discussing cardiomyopathy, which risk factor should the nurse discuss? a Hypotension b Hyperthyroidism c Smoking d Heart failure
a (Rationale: In DIC, there is abnormal initiation and formation of blood clots. As clots are formed and then begin to dissolve, more end products of fibrinogen and fibrin are also formed. These are called FDP or fibrin split products. Although PT and PTT are prolonged and the platelet count is decreased in DIC, they could also be indications of other coagulation disorders. Only an increase in FDP is associated with DIC. )
The nurse is reviewing laboratory results of a client with suspected disseminated intravascular coagulation (DIC). The nurse looks to the results of which test as the more specific marker for DIC? a Fibrin degradation products (FDP) b Partial thromboplastin time (PTT) c Partial thromboplastin time (PTT) d Platelet count
a (Rationale A cardiac catheterization evaluates the client's coronary artery perfusion. An echocardiogram detects cardiac enlargement. A myocardial biopsy examines heart cells for infiltration, fibrosis, or inflammation. Radionuclear scans identify changes in ventricular volume and mass.)
The nurse is reviewing the diagnostic tests for a client admitted for possible cardiomyopathy. Which test will evaluate coronary artery perfusion? a Cardiac catheterization b Echocardiogram c Myocardial biopsy d Radionuclear scan
c (Rationale: The client in hypovolemic shock requires blood replacement and plasma expanders to keep the hematocrit and hemoglobin at acceptable levels. Narcotic analgesics would be given every 1-2 hours, but may be withheld until the client's blood pressure is stable. Normal saline and dextrose solutions cannot replace lost hemoglobin or plasma factors and would not be given until the client is stabilized)
The nurse is reviewing the orders for a client who is experiencing hypovolemic shock. Which action should the nurse expect to note in the client's chart? a Intravenous normal saline run wide open b Narcotic analgesics for pain every 6 hours c Packed red blood cells and albumin 25% d D10 half normal saline
d (Rationale: Tissue plasminogen activator (TPA) is given within the first 3 hours after the ischemic stroke to cause fibrinolysis of the clot. It does not affect vasospasm, infection, or platelet aggregation. )
The nurse is reviewing the orders of a client experiencing a thrombotic stroke and notes an order for the administration of tissue plasminogen within the first 3 hours after the stroke. The nurse concludes that the reason for this order is to: a Increase platelet aggregation. b Reduce the risk of vasospasm. c Decrease the risk of infection. d Cause fibrinolysis of the clot.
d (Rationale: The client who abuses alcohol or cocaine is at risk for developing dilated cardiomyopathy that is reversible if the abuse is stopped. Alcoholism does not present a particular risk of valve disorders (stenosis, regurgitation) or restrictive cardiomyopathy. )
The nurse is teaching a client about to be discharged after undergoing detoxification from chronic alcohol abuse. The client asks the nurse about complications or risk for any heart problems related to alcoholism. The nurse teaches the client that which heart disease is likely for an alcoholic client? a Mitral regurgitation, irreversible b Valve stenosis c Restrictive cardiomyopathy d Dilated cardiomyopathy, reversible
a (Rationale: Since enoxaprin is an anticoagulant, the client is taught to use an electric razor, use a soft toothbrush, and not to floss to prevent the chance of excess bleeding. Aspirin will increase bleeding potential. Blurred vision is not associated with anticoagulants. )
The nurse is teaching a client who will be discharged home on enoxaprin (Lovenox) about self-care at home. Which statement by the client indicates understanding? a "I will use an electric razor." b "I will use a hard toothbrush and floss twice daily." c I will take aspirin for pain." d I will report blurred vision."
c (Rationale: Ultimately, shock is a systemic imbalance between oxygen supply and demand. Sufficient cardiac output is not shock, insufficient cardiac output is. Hemorrhage is a cause of one type of shock, it does not define shock. Abnormal blood pressure is not a definition of shock; blood pressure can be either high or low depending on the stage of shock. )
The nurse is teaching the parents of a child who have asked the nurse to define shock. The nurse knows the parents understand what shock is by which statement? a "Shock is the same as a hemorrhage." b "Shock is sufficient cardiac output." c "Shock is a systemic imbalance between oxygen supply and demand." d "Shock is the result of an abnormal blood pressure."
c (Rationale To monitor fluid volume, the nurse needs to monitor the client's weight daily. Auscultating heart sounds and administering supplemental oxygen will assist in monitoring cardiac output. Encouraging rest periods throughout the day will assist in monitoring the client's activity.)
The nurse needs to monitor fluid volume for a client diagnosed with cardiomyopathy. What intervention should the nurse include in the client's plan of care? a Auscultate heart sounds b Encourage rest periods throughout the day c Monitor the client's weight daily d Administer supplemental oxygen
a,c,e (Rationale: The client undergoing angiography has a large-bore catheter inserted through the femoral artery, so the priority of care is to monitor and prevent bleeding. The client will lie flat for several hours and the groin will be checked regularly. A sandbag may be placed to maintain constant pressure on the arterial puncture site. Elevating the foot of the bed would increase pressure and blood flow to the groin and increase the risk of bleeding, as would applying heat to the leg. )
The nurse receives an 82-year-old client with a history of A-fib from the angiography department. What priority actions will the nurse do next? (Select all that apply.) a Check the groin for bleeding or hematoma. b Elevate the foot of the bed or place pillows under the legs. c Place the client supine for several hours. d Apply heat to the calf of the leg. e Place a sandbag on the femoral site.
c (Rationale: Mobitz type 11 AV block is associated with a large anterior myocardial infarction and a high mortality rate. Pacemaker therapy may be necessary to maintain ventricular function and cardiac output. Recording findings on the chart is not the priority when the client is experiencing heart block. Heart block is not a dysrhythmia and is not treated with medication as the myocardium is no longer functioning. Placing the client in Fowler's position will not change heart block.)
The nurse recognizes from the cardiac strip, that a 78-year-old client is in second-degree AV block, type 11 (Mobitz 11). What is the appropriate intervention for this client? a Recording the finding on the chart b Administering a class 1B antidysrhythmic drug c Preparing for temporary pacemaker insertion d Placing the client in Fowler's position
b (Rationale: The client with decreased cardiac output has compromised perfusion to all bodily organs. The signs and symptoms would include decreasing urine output, absent or weak pedal pulses, absence or weak bowel sounds, and a decreasing level of consciousness. )
The nurse selects the nursing diagnosis of decreased cardiac output for a client with a pulmonary embolism based on which findings? a Bounding pedal pulses b Decreasing urine output c Client is alert and oriented. d Positive bowel sounds
d (Rationale: Clients with trauma, such as burns and gunshot wounds, are at risk for DIC. Urinary tract infection, cellulitis, and otitis media are not considered risks for DIC unless the client develops sepsis from one of these.)
The nurse will explain the risk factors for disseminated intravascular coagulation (DIC) to the family of the client who has experienced which clinical manifestation? a Cellulitis b Otitis media c Urinary tract infection d Trauma
a (Rationale Chronic use of digoxin is a risk factor for developing a second-degree heart block.Chronic use of amiodarone, beta-blockers, and calcium-channel blockers is a risk factor for developing a third-degree heart block, not a second-degree heart block.)
The nursing team is caring for a client diagnosed with a second-degree heart block. Which prescribed medication found in the client's medical record may have caused this diagnosis? a Digoxin b A calcium channel blocker c A beta-blocker d Amiodarone
c (Rationale: In DIC, there is an initial enhanced coagulation mechanism with resulting increase in fibrin and platelet deposition in capillaries and arterioles, resulting in thrombosis. Use of heparin is aimed at preventing the formation of additional thrombi. Explaining the use of the medication is far more therapeutic than saying that the doctors know what they are doing or that the nurse might have misread the order. It is not an option for the nurse to send the partner to the physician as the nurse should understand the disease and the reason for treatment. )
The partner of a client with disseminated intravascular coagulopathy (DIC) approaches the nurse with concern because the client has been placed on heparin therapy. The partner states, "I thought the problem was too much bleeding. Doesn't heparin make a person bleed more?" The best response by the nurse is which of the following? a "Let me make sure I have not misread the doctor's orders." b "I understand your concern but the doctors know what they are doing." c "The drug is being used to stop abnormal clotting in the capillaries and arterioles." d "Please talk to the physician about why this drug is being used."
a ( Feedback Rationale: Oxygen is prescribed to maintain adequate oxygenation for times when the child is likely to be under stress. Drawing blood is a painful procedure for the child. Feeding, holding, and assessment are not activities that should stress the infant.)
The physician has ordered oxygen as needed for an infant diagnosed with tetralogy of Fallot. Which situation is the most appropriate for the nurse to administer the ordered oxygen? a During laboratory blood draws b When someone is feeding the child c When the child is being held d During assessments of the infant
b (Rationale: Morphine is given IV to relieve anxiety; it also is a venous dilator, which reduces the workload on the heart. The amount and time interval are as needed or PRN. There is no evidence that this client has respiratory distress. The drug may be given for chest pain, but it is also given for anxiety. )
The physician orders morphine 2 mg to 5 mg IV as needed for pain and dyspnea for an 80-year-old client with pulmonary edema from heart failure. The nurse appropriately: a questions the order because the order does not have a time interval. b administers the drug as ordered, monitoring respiratory function. c withholds the medication until respiratory status improves. d administers the drug only when the client complains of chest pain.
d (Rationale: When the body is exposed to stress, the adrenal glands secrete epinephrine and norepinephrine. These hormones cause vasoconstriction and increase the work of the heart, making the risk of heart disease greater. Doctors do not typically think that problems are caused by stress. Stress increases blood sugar eventually. Chemicals released in stress do not cause kidney destruction. )
The provider has told the client that the amount of stress must be reduced because it is having a negative effect on the client's heart. When the provider leaves the room, the client asks the nurse why stress would affect the heart. What is the best response made by the nurse? a "Doctors always think problems are caused by stress." "b Stress causes the release of chemicals that destroy the kidneys." c "Stress lowers blood sugar, which puts you at increased risk of heart disease." d "Stress causes a release of chemicals that cause blood vessels to narrow and the heart rate to increase."
a,c,d (Rationale: PDA, ASD, and AV canal all cause increased pulmonary blood flow. Pulmonic stenosis decreases pulmonary blood flow because the pulmonary valve is stenosed. Coarctation of the aorta obstructs systemic blood flow to the lower extremities and does not directly affect pulmonary blood flow.)
There are a number of infants in the cardiac unit with congenital defects. The nurse realizes that the congenital defects that can cause increased pulmonary blood flow are which of the following? (Select all that apply.) a Patent ductus arteriosus (PDA) b Pulmonic stenosis c Atrial septal defect (ASD) d Atrioventricular canal defect (AV canal) e Coarctation of the aorta
a (Rationale: Left-sided failure results in backflow of blood from the pulmonary system resulting in pulmonary edema and shortness of breath. Edema of the feet and ankles and liver enlargement would be seen in clients with right-sided failure, due to backup of blood return from the body. Abdominal distention is not usually a symptom of heart failure. )
When assessing a client diagnosed with left-sided heart failure, the nurse anticipates which finding? a Shortness of breath b Liver enlargement c Edema of the feet and ankles d Abdominal distention
b (Rationale: Numbness and tingling at the mouth that disappears within minutes or hours is a manifestation of temporary occlusion of the middle cerebral artery. Sudden eye pain, paralysis, and loss of sensation are manifestations of stroke. )
Which clinical manifestation would alert the nurse that the client has experienced a transient ischemic attack (TIA)? a Sudden severe pain over the left eye b Numbness and tingling at the corner of the mouth c Complete paralysis of the right arm and leg d Loss of sensation and reflexes in both legs
b (Rationale The clinical problem that the nurse should include when planning care for a client with cardiomyopathy is diminished cardiac output. Excess fluid volume is a problem for a client with cardiomyopathy, not fluid volume deficit. Chronic pain and impaired gas exchange are not problems associated with cardiomyopathy.)
Which clinical problem should the nurse include when planning care for a client with cardiomyopathy? a Chronic pain b Diminished cardiac output c Fluid volume deficit d Impaired gas exchange
c (Rationale: The client at risk for DIC will be have coagulation studies drawn to monitor the prothrombin time, thromboplastin time, and thrombin time. Electrolyte panels, x-rays, and CT scans are not useful in the diagnosis of DIC.)
Which diagnostic test does the nurse anticipate will be required for a client at risk for developing Disseminated Intravascular Coagulation (DIC)? a CT scan b X-rays c Coagulation studies d Electrolyte panel
c (Rationale: Restlessness is an early sign of impending hypovolemic shock. Bowel sounds are not expected 2 hours after surgery. A blood pressure of 110/70 is a normal postoperative finding. A negative Homan's sign indicates the client has not formed a thrombosis in the legs. )
he nurse is caring for an 82-year-old client 2 hours after abdominal surgery. The nurse monitors for signs of complications and would notify the physician upon assessing which sign and/or symptom? a Absent bowel sounds in all four quadrants b Blood pressure of 110/70 c Restlessness d Negative Homan's sign
