6 NCLEX PN

The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence? 1. Weigh self every morning before breakfast. 2. Sleep with the head elevated on only one pillow. 3. Adjust diuretic dose based on severity of peripheral edema. 4. Take additional digoxin (Lanoxin) if respiratory distress occurs.

1. Weigh self every morning before breakfast. Rationale: A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. The client should weigh himself or herself daily as a means of determining fluid balance and possible overload. The client should sleep with the head elevated as high as needed to prevent pulmonary congestion during sleep. The client should not self-adjust any medication dosages.

The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development? 1. Hypokalemia 2. Hypernatremia 3. Hypochloremia 4. Hypercalcemia

1. Hypokalemia Rationale: The nurse assesses the client's serum laboratory results for hypokalemia. The client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The electrolyte imbalances mentioned in the other options do not have this effect.

The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? 1. "I will walk for one-half hour daily." 2. "As long as I exercise I can eat anything I wish." 3. "My weight has nothing to do with this disease." 4. "It doesn't matter if my father had high cholesterol."

1. "I will walk for one-half hour daily." Rationale: Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Options 2 and 4 are incorrect because obesity and a diet high in fat can contribute to CAD. Option 4 is incorrect because genetic factors also contribute to CAD.

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? 1. Administer another nitroglycerin tablet. 2. Apply 1 to 3 L/minute of oxygen via nasal cannula. 3. Call for a 12-lead electrocardiogram (ECG) to be performed. 4. Wait an additional 5 minutes, then give a second nitroglycerin tablet.

1. Administer another nitroglycerin tablet. Rationale: In the hospitalized client, nitroglycerin tablets usually are prescribed 1 every 5 minutes as needed (PRN) for chest pain up to a total dose of 3 tablets. The nurse in this question should administer the second tablet. The client with known angina pectoris should have low-flow oxygen at a rate of 1 to 3 L/minute via nasal cannula, if pain is not relieved. A 12-lead ECG would be done if prescribed by standing protocol or by individual health care provider prescription.

A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action? 1. Assist the client to get back into bed. 2. Report the chest pain episode to the health care provider. 3. Tell the client to stand still, and take the client's blood pressure. 4. Give a nitroglycerin (Nitrostat) tablet, and assist the client to the bathroom.

1. Assist the client to get back into bed. Rationale: The client is assisted back to bed to put the client at rest. The nurse can then measure vital signs and administer nitroglycerin that is prescribed for as-needed (PRN) use. The nurse should then report the chest pain episode to the health care provider. The nurse should not continue to assist the client into the bathroom because it places the client in danger because of continued myocardial oxygen demands.

The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? 1. Bilberry 2. Ginseng 3. Feverfew 4. Evening primrose

1. Bilberry Rationale: Bilberry is an herbal supplement that has been used to treat varicose veins. This supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease. Ginseng has been used to improve memory performance and decrease blood glucose levels in type 2 diabetes mellitus. Feverfew is used to prevent migraine headaches and to treat rheumatoid arthritis. Evening primrose is used to treat eczema and skin irritation.

A client is scheduled for a dipyridamole thallium scan. The nurse should check to make sure that the client has not consumed which substance before the procedure? 1. Caffeine 2. Fatty meal 3. Excess sugar 4. Milk products

1. Caffeine Rationale: This test is an alternative to the exercise stress test. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline forms of medication. Aminophylline is the antagonist to dipyridamole.

The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided? 1. Catsup 2. Sherbet 3. Cooked cereal 4. Leafy green vegetables

1. Catsup Rationale: Catsup is high in sodium. Leafy green vegetables, cooked cereal, and sherbet all are low in sodium. Clients with heart failure should monitor sodium intake.

A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? 1. Chest pain 2. Urge to cough 3. Warm, flushed feeling 4. Pressure at the insertion site

1. Chest pain Rationale: The client is taught before cardiac catheterization to immediately report chest pain or any unusual sensations. The client is taught that a warm, flushed feeling may accompany dye injection, occasional palpitations may occur, and the urge to cough may occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site.

A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure? 1. Lung crackles, peripheral edema, and weight gain 2. Confusion, decreasing level of consciousness, and aphasia 3. Respiratory distress, chest pain, and the use of accessory muscles 4. Flank pain with radiation to the groin, accompanied by hematuria

1. Lung crackles, peripheral edema, and weight gain Rationale: The client with infective endocarditis may experience both left- and right-sided heart failure, and thus the nurse monitors the client for both pulmonary and peripheral symptoms, such as lung crackles, peripheral edema, and weight gain. Options 2 and 4 relate to disorders of the brain and kidney, respectively. Option 3 contains symptoms that occur with pulmonary embolism, which is not related to the subject of the question.

The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 3. Take a calcium supplement to lower blood pressure. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important

1. Monitor the blood pressure at home. 2. Restrict sodium intake as prescribed. 4. Eye examinations with an ophthalmoscope should be routine. 5. Follow-up appointments for blood pressure checks are important Rationale: Primary hypertension is a condition that increases the risk of cardiovascular disease and renal disease. Home self-measure blood pressure monitoring should be done as prescribed to monitor the client's response to prescribed treatment. Follow-up appointments for blood pressure checks are also important to monitor the client's response to treatment. Sodium should be restricted as prescribed to prevent elevations in the blood pressure. Regular ophthalmoscopic examination is needed to detect retinal changes seen in hypertensive clients. The use of calcium supplements to lower blood pressure is not known and therefore is not recommended.

The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? 1. Pedal edema that is 3+ 2. Slight residual calf tenderness 3. Skin warm, equal temperature both legs 4. Calf girth ⅛ inch larger than unaffected limb

1. Pedal edema that is 3+ Rationale: Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain. Option 3 indicates full resolution of the problem, whereas options 2 and 4 indicate partial resolution. Option 1 is the correct option because it indicates the least degree of symptom reversal.

The nurse is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply. 1. Pink-tinged frothy sputum 2. Increase in respiratory rate 3. Ankle and lower leg swelling 4. Paroxysmal nocturnal dyspnea 5. Auscultation of crackles throughout the lungs

1. Pink-tinged frothy sputum 2. Increase in respiratory rate 5. Auscultation of crackles throughout the lungs Rationale: Left-sided heart failure can lead to pulmonary edema or acute decompensated heart failure (ADHF). Pink-tinged frothy sputum, an increase in respiratory rate (tachypnea), and auscultation of crackles throughout the lungs are signs of pulmonary edema caused by excess fluid accumulation in the alveoli. These signs need to be communicated to the health care provider because pulmonary edema requires immediate emergency treatment. Ankle and lower leg swelling and paroxysmal nocturnal dyspnea are clinical signs of chronic heart failure.

The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? 1. Provide a quiet and low-stimulus environment. 2. Encourage the family to come visit very frequently. 3. Encourage the client to call friends and relatives each day. 4. Recommend that the client watch TV as a constant diversion.

1. Provide a quiet and low-stimulus environment. Rationale: Chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain, such as emotional excitement. Each of the incorrect options increases the amount of client stimulation, which increases the risk of an anginal episode.

A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe? 1. Restricting the client's potassium intake 2. Encouraging the client to rest after meals 3. Administering the heparin with a 25-gauge needle 4. Holding the digoxin for a heart rate less than 60 beats per minute

1. Restricting the client's potassium intake Rationale: Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity. Digoxin should be held and the health care provider notified when the client's heart rate is less than 60 beats per minute, unless otherwise prescribed. Heparin should be administered with a 25- or 27-gauge needle to reduce tissue trauma. Resting after meals decreases the demands placed on the heart and should be encouraged.

The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason? 1. The client requires prophylactic antibiotics before treatment. 2. The dentist should use a low-speed drill to avoid dysrhythmias. 3. The dentist should use a lidocaine solution without epinephrine. 4. The client is at risk for episodes of heart failure triggered by stressful events.

1. The client requires prophylactic antibiotics before treatment. Rationale: The client with a history of rheumatic fever is at risk for developing infective endocarditis. The client should tell all health care providers and dentists about this problem so that prophylactic antibiotic therapy can be given before any procedure that is invasive or carries a risk of bleeding. Options 2, 3, and 4 are unrelated to rheumatic heart disease.

Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin? 1. To prevent the formation of clots 2. To relieve pain at the injection site 3. To prevent a fever after the procedure 4. To prevent inflammation of the injection site

1. To prevent the formation of clots Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure. Options 2, 3, and 4 are unrelated to the purpose of administering aspirin to this client.

A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. 1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry. 5. Select whole milk products.

1. Use liquid vegetable oil. 2. Increase intake of fruits. 3. Choose whole grain foods. 4. Remove skin from poultry. Rationale: Hyperlipidemia is a modifiable risk factor for the development of coronary heart disease. Reducing the amount of dietary saturated fat and cholesterol helps lower the risk for coronary heart disease. Dietary modifications such as the using liquid vegetable oil, eating fresh fruits and whole grain foods, and removing the skin from poultry will lower dietary fat. The client should also use low-fat or fat-free (skim) milk in place of whole milk products to lower dietary fat.

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which? 1. Vagus nerve to slow the heart rate 2. Vagus nerve to increase the heart rate 3. Diaphragmatic nerve to slow the heart rate 4. Diaphragmatic nerve to increase the heart rate

1. Vagus nerve to slow the heart rate Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

The nurse determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement? 1. "I will watch my weight gain." 2. "I will avoid walking for exercise." 3. "I will monitor my cholesterol intake." 4. "I will follow a low-fat, low-salt diet."

2. "I will avoid walking for exercise." Rationale: Lack of physical exercise contributes to the development of coronary artery disease, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Walking should be encouraged for 30 minutes a day. Watching weight gain, monitoring cholesterol and following a low-fat, low-salt diet are accurate statements

The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question? 1. "Are you having any nausea?" 2. "Where is the pain located?" 3. "Are you allergic to any medications?" 4. "Do you have your nitroglycerin with you?"

2. "Where is the pain located?" Rationale: If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, precipitating factors, location, radiation, and quality. Although options 1, 3, and 4 may be components of the assessment, these would not be the initial assessment questions in this situation.

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action? 1. Monitor oxygen saturation levels. 2. Place the client on a cardiac monitor. 3. Measure blood pressure every 4 hours. 4. Check capillary refill at least once per shift.

2. Place the client on a cardiac monitor. Rationale: The client with decreased cardiac output should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed. Other cardiovascular data should be collected at least every 2 hours initially.

A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted? 1. Increased pulse rate 2. Relief of apprehension 3. Decreased urine output 4. Increased blood pressure

2. Relief of apprehension Rationale: Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressures, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when administered intravenously. Options 1, 3, and 4 are unrelated to the action of morphine sulfate.

The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe? 1. One half pound per day 2. Two pounds per week 3. Four pounds per week 4. Six pounds per week

2. Two pounds per week Rationale: Most people, including the mildly and moderately obese, can lose only about 2 pounds per week of weight from fat loss. Weight loss beyond that level is probably due to protein and water loss alone.

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 1. Viral infection 2. Yeast infection 3. Streptococcal infection 4. Staphylococcal infection

3. Streptococcal infection Rationale: Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis. Options 1, 2, and 4 are incorrect.

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere, anytime."

4. "The best thing about this is that I can use it anywhere, anytime." Rationale: Guided imagery involves the client's creation of an image in the mind, concentrating on the image, and gradually become less aware of the offending stimulus. It does not require any adjuncts and does not need to be done in a quiet area only, although some clients may use other relaxation techniques or play music with it.

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first? 1. "Do you exercise regularly?" 2. "Would you consider losing weight?" 3. "Is there a history of diabetes mellitus in your family?" 4. "When was the last time you had your blood pressure checked?"

4. "When was the last time you had your blood pressure checked? Rationale: The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 1. Intake and output 2. Height and weight 3. Peripheral pulse rates 4. Prior reaction to contrast media

4. Prior reaction to contrast media Rationale: This procedure requires a signed informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. Although intake and output, height and weight, and presence of peripheral pulses may be components of data collection, they are not the most critical items.

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? 1. The boot has not yet dried. 2. The boot is controlling leg edema. 3. The boot is impairing venous return. 4. The boot has been applied too tightly.

4. The boot has been applied too tightly. Rationale: An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home? 1. The client can get the prescriptions filled. 2. The client can be self-sufficient at home without any help. 3. The client can independently dress and put on support hose. 4. The client can verbally describe the daily medications, doses, and times to be administered.

4. The client can verbally describe the daily medications, doses, and times to be administered. Rationale: Medication therapy is an essential part of the therapeutic regimen for treating heart failure. The client must have a clear understanding of which medications to take and when. Options 1 and 3 can be carried out with the assistance of someone else. Option 2 may not be realistic for this client.

The nurse is caring for a client in the cardiac care unit with heart disease. The nurse knows that the direction of blood flows through the heart and lungs in which order? Please arrange the blood flow in the direction of flow. All options must be used Blood flows to the right atrium from the superior and inferior vena cavae. Blood flows from the right atrium to the right ventricle via the tricuspid valve. Blood flows from the right ventricle to the lungs for oxygenation. Blood flows from the lungs to the left atrium. Blood flows from the left atrium via the mitral valve to the left ventricle. Blood flows from the left ventricle to the aorta and then to the systemic circulation.

1 Blood flows to the right atrium from the superior and inferior vena cavae. 2 Blood flows from the right atrium to the right ventricle via the tricuspid valve. 3 Blood flows from the right ventricle to the lungs for oxygenation. 4 Blood flows from the lungs to the left atrium. 5 Blood flows from the left atrium via the mitral valve to the left ventricle. 6 Blood flows from the left ventricle to the aorta and then to the systemic circulation. Rationale: Nurses need to be aware of how the blood flows through the heart in order to know how any alterations in this pathway can affect the many functions of the heart. Blood returns to the heart via the superior and inferior vena cavae and then progresses through the right atrium to the lungs for oxygenation and then returns and progresses to the left side of the heart and then out through the aorta to the systemic circulation.

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic? 1. Dark, pink base 2. Deep and painful 3. Accompanied by very slight pain 4. Brown pigmentation of surrounding skin

2. Deep and painful Rationale: Arterial leg ulcers tend to be deep and painful. The client usually has rest pain, and the ulcer site is painful. Surrounding skin has coloration consistent with peripheral arterial disease. Options 1, 3, and 4 are not characteristics of an arterial leg ulcer.

The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement? 1. "A smoker has twice the risk of having a heart attack as a nonsmoker." 2. "I may try just cutting down first, because the damage has already been done." 3. "I don't think I want to quit because none of the effects are reversible anyway." 4. "I'm never going to start again because I can cut my risk of cardiovascular disease to zero within a year."

1. "A smoker has twice the risk of having a heart attack as a nonsmoker." Rationale: Cigarette smokers have twice the risk of having a myocardial infarction as a nonsmoker and have two to four times the risk of having sudden cardiac death. Smoking cessation will reduce its damaging effects on the cardiovascular system; however, its cessation will not cut the risk to zero in 1 year.

The nurse is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement? 1. "I will take this medication every day." 2. "I will take this medication every other day." 3. "I will take this medication until I feel better." 4. "I will take this medication only when I have pain."

1. "I will take this medication every day." Rationale: A single daily dose of 1 baby aspirin (low-dose aspirin) may be a component of the standard treatment regimen for the client after an MI. Aspirin helps prevent clotting and may prevent a thrombosis that could cause a second MI. If the client cannot tolerate aspirin, then another antiplatelet medication may be prescribed. The other three options are unacceptable because the benefit comes in taking the medication on a daily basis.

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level? 1. 90 mg/dL 2. 190 mg/dL 3. 290 mg/dL 4. 390 mg/dL

1. 90 mg/dL Rationale: The normal fibrinogen level is 180 to 340 mg/dL for men and 190 to 420 mg/dL for women. A critical value is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. For these reasons, the nurse should become most concerned with the level of 90 mg/dL.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high-Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to accurately measure output. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful.

A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check which? 1. Blood pressure 2. Cardiac rhythm 3. Respiratory rate 4. Peripheral pulses

1. Blood pressure Rationale: Assessing the blood pressure is a priority before administering nitroglycerin to determine the vasodilating effect of the medication and to monitor for a drop in blood pressure. Cardiac rhythm and respiratory rate are also important to assess after checking the blood pressure. Peripheral pulses do not need to be checked before administering this medication.

A client brings the following medications to the clinic for a yearly physical. The nurse realizes which medication has been prescribed to treat heart failure? 1. Digoxin (Lanoxin) 2. Warfarin (Coumadin) 3. Amiodarone (Cordarone) 4. Potassium chloride (K-Dur)

1. Digoxin (Lanoxin) Rationale: Digoxin strengthens the heartbeat and decreases the heart rate. It is used in the treatment of heart failure. Potassium chloride increases the potassium level. Although digoxin does lower the potassium level, potassium chloride is not specifically administered for heart failure. Warfarin and amiodarone do not treat heart failure.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? 1. Flat 2. Semi-Fowler's 3. Trendelenburg's 4. Reverse Trendelenburg's

1. Flat Rationale: To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate? 1. Headache is a common side effect of nitrates. 2. Fever usually accompanies coronary artery disease. 3. Acetaminophen potentiates the therapeutic effects of nitrates. 4. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.

1. Headache is a common side effect of nitrates. Rationale: Headache occurs as a side effect of nitrates. Acetaminophen may be given before nitrates to prevent headaches or to minimize the discomfort from the headaches. Option 2 is incorrect. Options 3 and 4 are unrelated to the data in the question.

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply. R 1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke. 4. Cigars or pipes are healthier than cigarette smoking. 5. Tobacco smoking increases a female's level of estrogen.

1. Nicotine decreases oxygen to the heart. 2. Hypnosis may be helpful to stop smoking. 3. Avoid exposure to environmental tobacco smoke. ationale: Tobacco use is a major risk factor for the development of coronary heart disease. Nicotine vasoconstricts the arteries causing a decrease in myocardial oxygen supply and an increase in demand. To successfully quit smoking, it is necessary to combine multiple strategies. Hypnosis is a complementary/alternative therapy smoking cessation strategy. Exposure to environmental tobacco (secondhand) smoke does increase the risk for the development of coronary heart disease. Cigar or pipe smokers have an increased risk for the development of coronary heart disease similar to environmental tobacco smoke. Tobacco smoking decreases estrogen levels in premenopausal women, increasing their risk of coronary heart disease.

The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply. 1. Obtain annual influenza vaccination. 2. Restrict fluid intake to 1000 mL per day. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week. 5. Take an extra dose of prescribed diuretic for swollen ankles.

1. Obtain annual influenza vaccination. 3. Avoid adding salt to foods or in cooking. 4. Report a weight gain of 3 or more pounds in a week. Rationale: Heart failure is a chronic illness and requires lifelong treatment with a focus on health maintenance. Annual influenza vaccination is recommended to prevent the flu. Avoiding dietary sodium will decrease intravascular volume. A weight gain of 3 or more pounds in a week most likely indicates fluid retention and needs to be reported to the health care provider. Fluid restrictions are not commonly prescribed for chronic heart failure although the client may be advised to monitor intake. The client should not change the dose of any medicine without talking with the health care provider.

The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? 1. Reviews the intake and output records for the last 2 days 2. Prescribes daily weights starting on the following morning 3. Changes the time of diuretic administration from morning to evening 4. Requests a sodium restriction of 1 g/day from the health care provider

1. Reviews the intake and output records for the last 2 days Rationale: Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition? 1. Shock 2. Kidney dysfunction 3. Respiratory insufficiency 4. Increased intracranial pressure

1. Shock Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock. The remaining conditions would not benefit from and, in some cases, would worsen because of this position.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? 1. Smoking history 2. Recent exposure to allergens 3. History of recent insect bites 4. Familial tendency toward peripheral vascular disease

1. Smoking history Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing which type of angina? 1. Stable 2. Variant 3. Unstable 4. Intractable

1. Stable Rationale: Stable angina, also known as exertional angina, is triggered by a predictable amount of effort or emotion. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and incapacitating, and is refractory to medical therapy.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? 1. Surgical tourniquet 2. Dry sterile dressings 3. Incentive spirometer 4. Over-the-bed trapeze

1. Surgical tourniquet Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client? 1. Take daily weights and monitor trends. 2. Encourage fluids to improve hydration. 3. Elevate the legs above the level of the heart. 4. Position supine with the head of the bed at 30 degrees.

1. Take daily weights and monitor trends. Rationale: BNP levels greater than 500 pg/mL indicate that heart failure is probable. Nursing measures are geared toward decreasing intravascular volume, decreasing preload, and decreasing afterload. Option 2 increases intravascular volume, and options 3 and 4 increase preload.

The nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia? 1. Tall, peaked T waves 2. ST segment depressions 3. Shortened P-R intervals 4. Shortening of the QRS complex

1. Tall, peaked T waves Rationale: The symptoms of hyperkalemia relate to its effect on the myocardial muscle. These include changes noted on the ECG, such as tall, peaked T waves, prolonged P-R interval, widening of the QRS complex, shortening of the Q-T interval, and disappearance of the P wave. Other cardiac symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in hypokalemia.

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which description best describes the client's response? 1. Angry 2. Denial 3. Phobic 4. Obsessive-compulsive

2. Denial Rationale: Denial is the most common reaction when a client has a myocardial infarction or anginal pain. No angry behavior was identified in the question. Phobias and obsessive-compulsive disorders are mental health diagnoses.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds

2. Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? 1. "I need to avoid pregnancy by taking oral contraceptives." 2. "I should avoid sitting in one position for long periods of time." 3. "I can finally stop wearing these support stockings that you gave me." 4. "I will be sure to maintain my fluid intake to at least four glasses daily."

2. "I should avoid sitting in one position for long periods of time." Rationale: Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching? 1. "I will avoid using table salt with meals." 2. "It is best to exercise once a week for an hour." 3. "I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations."

2. "It is best to exercise once a week for an hour." Rationale: Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthy habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that causes pain, and to take the medication at the first sign of chest discomfort.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? 1. "Smoking cessation is very important." 2. "Moving to a warmer climate should help." 3. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."

2. "Moving to a warmer climate should help." Rationale: Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response? 1. "There is nothing to worry about." 2. "You are concerned about losing your leg?" 3. "There are many people with the same problem, and they are doing just fine." 4. "You have the best health care provider in the city, and your health care provider will not let anything happen to you."

2. "You are concerned about losing your leg?" Rationale: The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client's concern and provides an opportunity for the client to further discuss the concern. Options 1, 3, and 4 are inappropriate because they provide false reassurance and do not address the client's concern.

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

2. Acute kidney injury Rationale: The client who undergoes cardiac surgery is at risk for acute kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Kidney injury is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first? 1. Check the client's vital signs. 2. Assist the client to sit or lie down. 3. Administer sublingual nitroglycerin. 4. Apply nasal oxygen at a rate of 2 L/min.

2. Assist the client to sit or lie down. Rationale: Chest pain is caused by an imbalance between myocardial oxygen supply and demand. During episodes of pain, the nurse first limits the client's activity and assists the client to a position of comfort, checks the vital signs, administers oxygen and medication according to protocol, and obtains a 12-lead electrocardiogram.

The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure. 1. Normal sinus 2. Atrial fibrillation 3. Sinus bradycardia 4. Ventricular fibrillation

2. Atrial fibrillation Rationale: Atrial fibrillation is characterized by no distinct P waves and an irregular ventricular response. In sinus bradycardia and normal sinus rhythm there will be clear distinct P waves and a regular ventricular rhythm. In ventricular fibrillation there are no clear P waves or QRS complexes.

The nurse is reinforcing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of taking which measure? Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output. 1. Saving all chores for the end of the day 2. Avoiding exposure to either very hot or very cold weather 3. Eating large meals to reduce the work of the gastrointestinal tract 4. Keeping items stored above shoulder level to encourage exercise

2. Avoiding exposure to either very hot or very cold weather Rationale: The client should avoid extreme hot or cold temperatures to avoid placing undue stress on the cardiovascular system. The client should space activities throughout the day rather than save them for the end of the day when the client is more fatigued. The client should eat smaller meals so less blood flow is diverted for the work of digestion. Exercise is important, but the client should keep most items stored at heart level, to prevent straining and increased intrathoracic pressure, which can decrease cardiac output.

The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner choice from the daily menu? 1. Beef ravioli, spinach soufflé, and Italian bread 2. Baked pollock, mashed potatoes, and carrot-raisin salad 3. Roasted chicken breast, brown rice, and stewed tomatoes 4. Beef vegetable soup, macaroni and cheese, and a dinner roll

2. Baked pollock, mashed potatoes, and carrot-raisin salad Rationale: Furosemide depletes potassium, and a client on digoxin and furosemide needs to maintain normal potassium levels and moderate salt intake. Hypokalemia may make the client more susceptible to digoxin toxicity. The recommended daily intake for potassium is 2000 mg. Option 4 is not the best choice because beef vegetable soup contains a high amount of sodium and a minimal amount of potassium. Macaroni and cheese is also high in sodium and contains no potassium. Option 1 is not the best choice because beef ravioli is high in sodium and contains no potassium. Spinach soufflé is a good source of potassium but also contains sodium. Option 3 is not the best choice because roasted chicken breast, brown rice, and stewed tomatoes contain a minimal amount of potassium. Option 2 is the best choice because all three foods are high in potassium and low in sodium.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1. Strict bed rest for 24 hours 2. Bathroom privileges and self-care activities 3. Unrestricted activities because the client is monitored 4. Unsupervised hallway ambulation with distances less than 200 feet

2. Bathroom privileges and self-care activities Rationale: Upon transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1. Wear elastic stockings. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease, but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active? 1. Presence of ascites 2. Bilateral lung crackles 3. Jugular vein distention 4. Pedal edema bilaterally

2. Bilateral lung crackles Rationale: The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Breath sounds are an accurate indicator of left-sided heart function. Peripheral edema, jugular vein distention, and ascites can be present as a result of insufficiency of the pumping action of the right side of the heart.

A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication? 1. Stroke 2. Cardiac arrest 3. High blood pressure 4. Urinary stone formation

2. Cardiac arrest Rationale: The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization, and move back during repolarization. Depolarization is responsible for cardiac contraction. Options 1, 3, and 4 are not associated with a low calcium level.

A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse's response is based on which fact? 1. Most people love high-fat diets. 2. Denial is a common occurrence early after MI. 3. The client probably wants to belittle the opinion of the staff. 4. The client is not motivated to learn about heart disease at this time.

2. Denial is a common occurrence early after MI. Rationale: An early initial coping response following MI is denial. The nurse uses this knowledge of this common response in planning care for the client. Option 1 is an opinion and not based on information in the question. There is no evidence in the question to support options 3 and 4.

The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply. 1. Defibrillation 2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion 5. Amiodarone (Cordarone)

2. Digoxin (Lanoxin) 3. Warfarin (Coumadin) 4. Electrical cardioversion Rationale: The three goals of treatment for atrial fibrillation are ventricular rate control, prevention of embolic stroke, and restoration and maintenance of normal sinus rhythm. Digoxin (Lanoxin) is used for ventricular rate control. Warfarin (Coumadin) is used to decrease the risk of embolic stroke. Electrical cardioversion is used to restore normal sinus rhythm. Amiodarone (Cordarone) is used to treat ventricular tachycardia or ventricular fibrillation. Defibrillation is the treatment of choice for ventricular fibrillation.

A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client? 1. Providing a walker to aid in ambulation 2. Elevating the head of the bed to at least 45 degrees 3. Performing continuous monitoring of oxygen saturation 4. Placing an oxygen cannula at the bedside for use if needed

2. Elevating the head of the bed to at least 45 degrees Rationale: The management of dyspnea generally is directed toward alleviation of the cause. Symptom relief may be achieved or at least aided by placing the client at rest with the head of the bed elevated. Supplemental oxygen may be used but placing equipment at the bedside is not directly helpful. Monitoring of oxygen saturation detects early complications but does not help the client. Likewise, placing an oxygen cannula at the bedside for use would not help the client.

The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care? 1. Place the client's bed in the Fowler's position. 2. Encourage the client to increase fluid intake. 3. Instruct the client to perform range-of-motion exercises of the extremities. 4. Hold regularly scheduled medications for 24 hours following the procedure.

2. Encourage the client to increase fluid intake. Rationale: Immediately following a cardiac catheterization using the femoral approach, the client should not flex or hyperextend the affected leg. Placing the client in the Fowler's position increases the risk of hemorrhage. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus were developing. Flexion or hyperextension and range-of-motion exercises of the extremity are contraindicated. The regularly scheduled medications are needed to treat acute and chronic conditions.

The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next? 1. Ask whether the client wants to see a psychiatrist. 2. Explore with the client the sources of stress in life. 3. Reassure the client that everybody seems stressed these days. 4. Ask the client to write down a list of stressors to be evaluated at a later time.

2. Explore with the client the sources of stress in life. Rationale: The nurse should encourage the client to explore and verbalize stressors. Later, the nurse can teach the client strategies for coping with stress, such as the basic relaxation techniques of deep breathing, progressive muscle relaxation, and visualization. Option 1 could be construed as excessive or insulting and puts the client's feelings on hold. Option 3 ignores the client's concerns. Option 4 places further data collection of this area on hold.

The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client? 1. Shaves the front of the client's chest 2. Gives the client a device holder to wear around the waist 3. Teaches the client to rest as much as possible during the next 24 hours 4. Tells the client to cover the monitor in plastic wrap before taking a bath

2. Gives the client a device holder to wear around the waist Rationale: The nurse applies electrocardiographic (ECG) monitoring leads to the chest in the usual fashion and gives the client a sling or holder to carry the transistor-sized monitor, which is worn around the chest or waist. The nurse would remind the client to maintain a normal schedule and to keep a diary of all activity and symptoms. The client should avoid activities that could interfere with the ECG recorder, such as using heavy machinery, electric shavers, hair dryers, or bathing or showering. Therefore, options 1, 3, and 4 are incorrect.

A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action? 1. Get a prescription for pain medication. 2. Have the client stop and lie back down in bed. 3. Report the complaint to the health care provider. 4. Have the client continue to get out of bed and into a chair.

2. Have the client stop and lie back down in bed. Rationale: The pain associated with coronary artery disease is called angina pectoris, and it occurs because of myocardial tissue ischemia from insufficient blood flow to the heart. The nurse should first have the client stop the activity and lie back down to decrease the workload and oxygen demand on the heart. Options 1 and 3 can be done after ensuring that the client is resting. The pain medication that is likely to be prescribed is nitroglycerin, which is a coronary vasodilator. Option 4 is contraindicated and will worsen the pain and possibly lead to myocardial infarction.

The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen

2. Hyperactive bowel sounds in the area Rationale: Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm.

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? 1. I should take daily medication for life. 2. I should eat a diet that is low in fat and cholesterol. 3. I should continue to smoke to keep the metabolic rate high. 4. I should begin to exercise if diet is not sufficient to achieve weight loss.

2. I should eat a diet that is low in fat and cholesterol. Rationale: A diet that is low in fat and cholesterol helps slow the progression of CAD. This must be accompanied by regular exercise and cessation of smoking. If these measures are effective, the client may not need daily medication.

The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which? 1. Bend the leg at the hip. 2. Keep the ankles uncrossed. 3. Place two pillows under the knees. 4. Use the knee gatch on the bed controls.

2. Keep the ankles uncrossed. Rationale: A graft can become clotted from any form of pressure, which results in impaired blood flow through the graft. Positions and movements to be avoided include bending at the hip or knee, crossing the knees or ankles, or the use of a knee gatch or pillows under the knees.

The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm

2. Limiting movement and abduction of the right arm Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment? 1. No stimulus, no stress 2. Low stimulus, low stress 3. High stimulus, low stress 4. Moderate stimulus, low stress

2. Low stimulus, low stress Rationale: An environment that is low stimulus and low stress is needed to decrease anxiety and metabolic demands for the client after MI. Nursing care is directed at promoting rest and assisting with activities of daily living. Option 1 cannot be provided, and options 3 and 4 are too high in stimulus to be therapeutic.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? 1. Moderately impaired, and the surgeon should be called 2. Normal, caused by increased blood flow through the leg 3. Slightly deteriorating, and should be monitored for another hour 4. Adequate from an arterial approach, but venous complications are arising

2. Normal, caused by increased blood flow through the leg Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration

2. Pericardial friction rub Rationale: A pericardial friction rub is heard when there is inflammation of the pericardial sac during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints that could accompany a wide variety of disorders.

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action? 1. Suction the client vigorously. 2. Place the client in high-Fowler's position. 3. Begin assembling medications that are anticipated to be given. 4. Call the respiratory therapy department to request a ventilator.

2. Place the client in high-Fowler's position. Rationale: The client in pulmonary edema is placed in high-Fowler's position if the blood pressure is adequate. Vigorous suctioning may deplete the client of vital oxygen at a time when the respiratory system is compromised. Assembling medications is useful but not critical to the immediate well-being of the client. The client may or may not need mechanical ventilation.

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia? 1. Tall, peaked T waves 2. ST-segment depression 3. Prolonged P-R interval 4. Widening of the QRS complex

2. ST-segment depression Rationale: In the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client may also exhibit a flat T wave. Options 1, 3, and 4 are cardiac findings noted in the client with hyperkalemia.

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

2. Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority.

The nurse has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client's long-term cardiac health? 1. Knowledge of when it is safe to resume sexual activity 2. The ability to take an accurate pulse in either the wrist or neck 3. An understanding of the importance of proper microwave oven usage 4. An understanding of why vigorous arm and shoulder movement must be avoided initially

2. The ability to take an accurate pulse in either the wrist or neck Rationale: Clients with permanent pacemakers must be able to accurately take their pulse in the wrist and/or neck. The client needs to identify any variation in the pulse rate or rhythm and immediately report the variation to the health care provider. Clients can safely operate microwave ovens, radios, electric blankets, lawn mowers, leaf blowers, and cars (proper grounding must be ensured if the client is to operate electrical items). Sexual activity is not resumed until 6 weeks after surgery. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. The remaining options do not have the same impact on long-term cardiac health as does the correct option.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the nurse best describe this type of anginal pain? 1. Stable angina 2. Variant angina 3. Unstable angina 4. Nonanginal pain

2. Variant angina Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. The data in the question is characteristic of a type of angina pain, and therefore, nonanginal pain is incorrect.

A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? 1. Prone with the head on a pillow 2. With the foot of the bed elevated 3. Reverse Trendelenburg's position 4. With the residual limb flat on the bed

2. With the foot of the bed elevated Rationale: During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem? 1. "Can you describe the pain to me?" 2. "Have you ever had this pain before?" 3. "Does the pain get worse when you breathe in?" 4. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

3. "Does the pain get worse when you breathe in?" Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Describing the pain, asking if it has occurred in the past, and rating the pain using a pain scale may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

The nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. "I need to substitute eggs and milk for meat." 2. "I will eliminate all cholesterol and fat from my diet." 3. "I should routinely use polyunsaturated oils in my diet." 4. "I need to seriously consider becoming a strict vegetarian."

3. "I should routinely use polyunsaturated oils in my diet." Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hyperlipidemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.

While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? 1. "Your doctor expects me to prepare you for this procedure." 2. "That's fine, if that's what you want. I'll call your health care provider." 3. "So you're saying that you want to talk to your health care provider?" 4. "I'm concerned with the way you've dismissed me. I know what I am doing."

3. "So you're saying that you want to talk to your health care provider?" Rationale: In option 3, the nurse uses the therapeutic communication technique of reflection to redirect the client's feelings back for validation. Option 1 is nontherapeutic and addresses the legal issue of performing a procedure when in fact the client is refusing. Although option 2 may seem appropriate, it does not reflect the client's feelings and doesn't provide an opportunity for the client to express feelings. Option 4 is clearly nontherapeutic because it focuses on the nurse's feelings rather than the client's feelings.

The nurse finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse's best response when the client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning!"? 1. "Would you like a mild sedative to help you relax?" 2. "Oh, don't worry, the weather is supposed to be sunny and clear today." 3. "Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" 4. "I can appreciate your concerns. Your family can stay with you tonight if you want them to."

3. "Yes, this equipment is a little scary. Can we talk about how the cardiac monitor works?" Rationale: The nurse should initially respond to validate the client's concern and then should determine the client's knowledge level of the cardiac monitor. This gives the nurse an opportunity to do client education if necessary. Bringing in the family, friends, or chaplain as an alternate resource may provide the client with additional psychological support. Pharmacological interventions should be considered only if necessary. Minimizing the client's concern is a communication block.

A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? 1. Bed rest 2. Restricting fluids 3. Antihypertensives 4. Maintaining a low-fiber diet

3. Antihypertensives Rationale: The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low-fiber diet is not helpful and will cause constipation.

The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu? 1. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet 2. Pork chop, baked potato, cauliflower in cheese sauce, ice cream 3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries 4. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk)

3. Baked haddock, steamed broccoli, herbed rice, sliced strawberries Rationale: A client trying to lower fat and cholesterol in the diet should decrease the use of fatty cuts of meats such as beef, lamb or pork, organ meats, sausage, hot dogs, bacon, and sardines; avoid vegetables prepared in butter, cream, or other sauces; use low-fat milk products instead of whole milk products and cream; and decrease the amount of commercially prepared baked goods. Option 3 is the only option that identifies low-fat and low-cholesterol foods.

A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? 1. Bed rest, with bathroom privileges only 2. Bed rest, keeping the affected extremity flat 3. Bed rest, with elevation of the affected extremity 4. Bed rest, with the affected extremity in a dependent position

3. Bed rest, with elevation of the affected extremity Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated and bed rest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in the remaining options are incorrect.

A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first? 1. Call a code blue. 2. Call the health care provider. 3. Check the client status and lead placement. 4. Press the recorder button on the ECG console.

3. Check the client status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission? 1. NPH insulin 2. Regular insulin 3. Chlorpropamide 4. Acarbose (Precose)

3. Chlorpropamide Rationale: Chlorpropamide is an oral hypoglycemic agent that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. It is a first-generation sulfonylurea. Insulin does not cause or aggravate fluid retention. Acarbose is a miscellaneous oral hypoglycemic agent.

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving if which breath sounds are noted? 1. Rhonchi 2. Wheezes 3. Crackles in the lung bases 4. Crackles throughout the lung fields

3. Crackles in the lung bases Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client's condition improves, the amount of fluid in the alveoli decreases and may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.) Wheezes and rhonchi are not associated with pulmonary edema.

The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which information? 1. Oxygen assists in calming the client. 2. Oxygen prevents the development of any thrombus formation. 3. Deficient oxygenation to heart cells results in angina pectoris pain. 4. Oxygen dilates the blood vessels, supplying more nutrients to the heart muscle.

3. Deficient oxygenation to heart cells results in angina pectoris pain. Rationale: The pain associated with angina is derived from ischemic myocardial cells. The pain is often associated with activity that places more oxygen demand on heart muscle. Supplemental oxygen helps meet the added demands on the heart muscle. Oxygen does not dilate blood vessels, prevent thrombus formation, or directly calm the client.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1. Dyspnea 2. Hacking cough 3. Dependent edema 4. Crackles on lung auscultation

3. Dependent edema Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A female client complains of an "odd, left-sided, twinge-like pain" along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action? 1. Administer naproxen (Naprosyn). 2. Listen to the client's heart and lungs. 3. Determine if the pain is cardiac in origin. 4. Ask the client about previous cardiac disease.

3. Determine if the pain is cardiac in origin. Rationale: The best initial action is to rule out chest pain of cardiac origin to eliminate a cardiovascular etiology related to the client's complaint. If the pain is left untreated and the pain is caused by myocardial ischemia or infarction (MI), the client could suffer a devastating cardiac injury. Furthermore, the nurse does this because a female presenting with an MI is more likely to display atypical clinical indicators, including fatigue and dyspnea. After instituting measures to rule out a cardiac problem, the nurse completes the client assessment by auscultating the heart and lungs and by reviewing the medical record. After a cardiac problem is ruled out, the nurse can administer an analgesic if prescribed.

The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding? 1. Decreased, indicating a decreased risk of coronary artery disease 2. Elevated, but would not present a risk for coronary artery disease 3. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease 4. Normal, indicating adequate blood glucose control with no risk for coronary artery disease

3. Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease Rationale: A fasting blood glucose of 200 mg/dL signals the presence of diabetes mellitus. Diabetes mellitus predisposes a client to coronary artery disease. Options 1, 2, and 4 are inaccurate interpretations.

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client? 1. Checking vital signs 2. Reviewing serum electrolytes 3. Evaluating total body fluid 4. Monitoring electrocardiogram

3. Evaluating total body fluid Rationale: Fluid overload can cause complications for the client with heart failure. Therefore, the nurse evaluates the client's fluid balance to forestall activation of harmful compensatory mechanisms and deterioration of other organ systems that increasing total body fluid can cause. This is the nurse's priority because balancing the client's fluid status has the broadest range of potential benefits for the client, including improving oxygenation. The vital signs, serum electrolytes, and electrocardiogram are important assessments, yet remain secondary in importance to fluid status because they are items that are affected by fluid balance.

A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time? 1. Tell the client that his fears are not rational. 2. Tell the client that his life has not changed. 3. Explore the specific concerns with the client. 4. Tell the client to talk it out with the significant other.

3. Explore the specific concerns with the client. Rationale: The therapeutic action by the nurse is one that gathers more data. This then allows the nurse to formulate the appropriate response. Each of the incorrect options is nontherapeutic because they place the client's feelings on hold and do not address them.

A client is admitted to the hospital with possible rheumatic heart disease. The nurse collects data from the client and checks the client for which signs/symptoms? 1. Skin scratches 2. Vaginal itching 3. Fever and sore throat 4. Burning on urination

3. Fever and sore throat Rationale: Rheumatic heart disease can occur as a result of infection with group A beta-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis, which is assessed by noting for the presence of sore throat and fever. The other options are unrelated to this problem and indicate possible yeast infection, skin lesions, and urinary tract infection, respectively.

The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities? 1. Deep breathing and coughing 2. Repositioning self from side to side 3. Isometric exercises of the arms and legs 4. Ankle circles, plantar, and dorsiflexion exercises

3. Isometric exercises of the arms and legs Rationale: The client with myocardial infarction should avoid activities that tense the muscles, such as isometric exercises. These increase intra-abdominal and intrathoracic pressures and can decrease the cardiac output. They also can trigger vagal stimulation, causing bradycardia. The exercises in options 1, 2, and 4 are acceptable.

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? 1. Having the client void before surgery 2. Completing a preoperative checklist 3. Marking the location of the pedal pulses on the right leg 4. Checking the results of any baseline coagulation studies

3. Marking the location of the pedal pulses on the right leg Rationale: A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.

The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? 1. Pain with diaphoresis 2. Discomfort in one digit 3. Numbness and tingling in the legs 4. Cramping in the foot while resting

3. Numbness and tingling in the legs Rationale: Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. Options 1, 2, and 4 are not complications of this disorder. The finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs.

The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside? 1. Bedside commode 2. Rolling shower chair 3. Oxygen tubing and flowmeter 4. Twelve-lead electrocardiogram (ECG) machine

3. Oxygen tubing and flowmeter Rationale: CAD causes obstruction to blood flow through one or more major coronary arteries, cutting off oxygen and nutrients to the cardiac cells, and resulting in chest pain. Providing oxygen to the client is important to help decrease pain and prevent its recurrence. A bedside commode and ECG machine may be helpful but are not the priority. A rolling shower chair has no value for this client because the client should be able to walk and shower if pain free and an activity prescription allows it.

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 1. Provide the client with a walker. 2. Remove the telemetry equipment. 3. Encourage the client to cough and deep breathe. 4. Premedicate the client with an analgesic before ambulating.

4. Premedicate the client with an analgesic before ambulating. Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way? 1. Result in hypoglycemia 2. Give the client insomnia 3. Precipitate rebound hypertension 4. Cause enhanced side effects of other prescribed medications

3. Precipitate rebound hypertension Rationale: Beta-adrenergic blocking agents should be tapered slowly. This will avoid abrupt withdrawal syndrome, characterized by headache, malaise, palpitations, tremors, sweating, rebound hypertension, dysrhythmias, and possibly myocardial infarction (in clients with cardiac disorders, including angina pectoris). Options 1, 2, and 4 are incorrect.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction

3. Pulmonary embolism Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)? 1. Mental status 2. Urinary output 3. Respirations and blood pressure 4. Temperature and blood pressure

3. Respirations and blood pressure Rationale: Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client who experienced an MI. Although monitoring mental status is a component of the nurse's assessment, it is not the priority following administration of morphine sulfate. The nurse should monitor the client's respirations and blood pressure. Signs of morphine toxicity include respiratory depression and hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature is also not associated with the use of this medication.

A client's blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia? 1. Supine 2. Left lateral 3. Semi-Fowler's 4. Trendelenburg's

3. Semi-Fowler's Rationale: Coolness, pallor, and tachycardia are consistent with clinical indicators of hypoxia related to inadequate cardiac output. To reduce the myocardial workload, improve cardiac output, and promote tissue oxygenation, the nurse positions the client in the semi-Fowler's position to maintain perfusion to vital organs and promote chest expansion (option 3) so long as the client's neurological status is stable. The supine position removes the strain on the heart of pumping blood against gravity into the cerebral vasculature effectively; however, a flat position can lead to excessive preload and increase the cardiac workload (option 1). Left-lateral position could be satisfactory (option 2), but until the client is stable and unless the client is at risk for aspiration, semi-Fowler's position is a better choice. Trendelenburg's position is used when the client experiences profound hypotension or shock (option 4).

The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client's care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply. 1. Lying supine 2. Right side-lying 3. Sitting up and leaning forward 4. Semi-Fowler's with knees bent 5. Head of bed elevated to 45 degrees

3. Sitting up and leaning forward 5. Head of bed elevated to 45 degrees Rationale: Acute pericarditis refers to inflammation of the pericardial sac. A common symptom is chest pain. Chest pain is often relieved when the client sits up and leans forward or with the head of bed elevated to 45 degrees. Lying supine makes the pain worse. Right side-lying and semi-Fowler's with knees bent does not relieve the chest pain associated with acute pericarditis.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? 1. Legs are unsightly in appearance and distress the client. 2. The client complains of aching and feelings of heaviness in the legs. 3. The client complains of leg edema, and skin breakdown has started. 4. The health care provider finds that the legs become distended when the tourniquet is released during the Trendelenburg's test.

3. The client complains of leg edema, and skin breakdown has started. Rationale: Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse? 1. The client is not experiencing nausea or vomiting. 2. The pain is described as substernal and radiating to the left arm. 3. The pain has not been unrelieved by rest and nitroglycerin tablets. 4. The client says the pain began while trying to open a stuck dresser drawer.

3. The pain has not been unrelieved by rest and nitroglycerin tablets. Rationale: The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may also radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and is frequently accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief.

A client, who is 36 hours post-myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made? 1. The skin is cool but slightly diaphoretic. 2. Dyspnea is noted only at the end of the exercise. 3. The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute. 4. The preactivity blood pressure (BP) is 140/84 mm Hg; the postactivity BP is 110/72 mm Hg.

3. The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute. Rationale: The nurse checks vital signs and the level of fatigue with each activity. The client is not tolerating the activity if systolic BP drops more than 20 mm Hg, pulse rate increases more than 20 beats per minute, or if the client experiences dyspnea or chest pain. In addition, a significant drop in BP can indicate orthostatic hypotension, which is an abnormal condition. Cool, diaphoretic skin is a sign of some degree of cardiovascular compromise.

For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal? 1. Elevating the legs when in bed 2. Sleeping in the supine position 3. Using a bedside commode for stools 4. Seasoning beef with a meat tenderizer

3. Using a bedside commode for stools Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client's legs would increase venous return to the heart and result in an increase in cardiac workload. The supine position can increase respiratory effort and decrease oxygenation, which increases cardiac workload. Meat tenderizers are high in sodium. Sodium contributes to hypertension, which increases cardiac workload.

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect? 1. Decrease in pedal edema 2. High urine output during the day 3. Weight gain of 2 to 3 pounds in a few days 4. Cough accompanied by other signs of respiratory infection

3. Weight gain of 2 to 3 pounds in a few days Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in daytime voiding is expected while on diuretic therapy (Lasix). A cough as a result of respiratory infection does not necessarily indicate that heart failure is exacerbating.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the health care provider to write a prescription for the client to remain on bed rest. In which position should the bed be positioned? 1. In the high-Fowler's position 2. With the head of bed elevated at least 60 degrees 3. With the head of bed elevated no more than 30 degrees 4. With the foot of bed elevated as much as tolerated by the client

3. With the head of bed elevated no more than 30 degrees Rationale: Following cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours or per agency procedure. The client may turn from side to side. The affected leg is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position? 1. In semi-Fowler's position 2. With the head of the bed elevated 45 degrees 3. With the head of the bed elevated no more than 15 degrees 4. With the foot of the bed elevated as much as tolerated by the client

3. With the head of the bed elevated no more than 15 degrees Rationale: Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 4 to 6 hours. The client may turn from side to side. The head of the bed is not elevated more than 30 degrees to prevent kinking of the blood vessel at the groin and possible arterial occlusion.

The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement? 1. "Recuperation after cardiac surgery is generally slower for older people." 2. "It's important to get out of bed every day, even if tired or weak at first." 3. "Fatigue, discomfort, and lack of appetite occur more commonly with older people and may last for 2 to 5 weeks." 4. "A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control."

4. "A daily half-mile-long brisk walk generally helps people bounce back more quickly and provides more of a sense of control." Rationale: Clients generally increase activity by beginning a simple walking program, starting with distances of 400 feet twice daily and gradually increasing the distance until able to walk 1¼ mile (usually at the end of the second week). Exercise has physiological and psychological benefits. The statements made in options 1, 2, and 3 are correct.

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? 1. "I am considering cutting my workload." 2. "I need to cut down on cigarette smoking." 3. "I am so relieved that my heart is repaired." 4. "I need to adhere to my dietary restrictions."

4. "I need to adhere to my dietary restrictions." Rationale: Following the angioplasty, the client needs to be instructed about specific dietary restrictions that must be followed. Following the recommended dietary and lifestyle changes helps prevent further atherosclerosis. Abrupt closure of the artery can occur if the recommended dietary and lifestyle changes are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking? 1. "Since the damage has already been done, it will be all right to cut down a little at a time." 2. "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 3. "If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

4. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale: The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is comparable to that of a person who never smoked. Therefore, options 1, 2, and 3 are incorrect.

The clinic nurse is obtaining cardiovascular data on a client. The nurse prepares to check the client's apical pulse and places the stethoscope in which position? 1. Midsternum equal with the nipple line 2. At the midaxillary line on the left side of the chest 3. At the midline of the chest just below the xiphoid process 4. At the midclavicular line at the fifth left intercostal space

4. At the midclavicular line at the fifth left intercostal space Rationale: The heart is located in the mediastinum. Its apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the heart's apex.

The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted? 1. Mild dyspnea after walking 10 feet 2. Minimal chest pain rated 1 on a 1-to-10 pain scale 3. Pulse rate that increases from 68 to 94 beats per minute 4. Blood pressure that increases from 114/82 to 118/86 mm Hg

4. Blood pressure that increases from 114/82 to 118/86 mm Hg Rationale: General indicators that a client is tolerating exercise include an absence of chest pain or dyspnea, a pulse rate increase of less than 20 beats per minute, and a blood pressure change of less than 10 mm Hg.

The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal? 1. Sausage, pancakes, and toast 2. Broccoli, buttered rice, and grilled chicken 3. Hamburger, baked apples, and avocado salad 4. Fresh strawberries, steamed vegetables, and baked fish

4. Fresh strawberries, steamed vegetables, and baked fish Rationale: Diets high in saturated fats raise the serum lipid level, which, in turn, raises the blood cholesterol. Over time, high blood cholesterol levels lead to the development of atherosclerosis and diseases such as coronary artery disease. A diet that is low in saturated fats is helpful in reducing the progression of atherosclerosis. Meats and dairy products tend to be higher in fat than other food groups.

The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next? 1. Do a repeat 12-lead ECG. 2. Wait to see whether the pain resolves. 3. Report the episode of chest pain to the health care provider. 4. Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions.

4. Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions. Rationale: After completing the stat ECG, the nurse should administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. The nurse should not wait to see whether pain resolves on its own but should determine whether the pain is relieved with nitroglycerin. The nurse should do a repeat ECG if it is prescribed. The nurse should report the episode of pain to the health care provider but should administer the nitroglycerin before doing so.

The nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse should plan to maintain bed rest for this client in which position? 1. High-Fowler's position 2. Lateral (side-lying) position 3. Head elevation of 45 degrees 4. Head elevation of no more than 30 degrees

4. Head elevation of no more than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. The client may turn from side to side. The client is placed in the supine position and the head of the bed is not elevated to more than 30 degrees to keep the affected leg straight at the groin and prevent arterial occlusion. Bathroom privileges are not allowed during the immediate postcatheterization period. For the high-Fowler's position, the head of the bed is elevated 90 degrees.

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? 1. Exposure to heat 2. Being in a relaxed environment 3. Prolonged episodes of inactivity 4. Ingestion of coffee or chocolate

4. Ingestion of coffee or chocolate Rationale: Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? 1. Tell the client that this is not allowed. 2. Tell the family member not to take the client outdoors. 3. Give the client a cup of hot coffee before going outside. 4. Instruct the family member to dress the client warmly before going outside.

4. Instruct the family member to dress the client warmly before going outside. Rationale: The nurse should meet both the physiological and psychosocial needs of the client in a holistic manner by asking the family member to be sure that the client is dressed warmly before going outside. Option 4 is correct because dressing the client warmly will decrease the chance of vasoconstriction, which may lead to an angina attack. Options 1 and 2 ignore the psychosocial needs. Option 3 is detrimental to physiological needs because, in addition to the cold weather, caffeine places an additional burden on the heart.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu? 1. Tea 2. Cola 3. Coffee 4. Lemonade

4. Lemonade Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client? 1. Prinzmetal's angina is effectively managed by beta-blocking agents. 2. Prinzmetal's angina improves with a low-sodium, high-potassium diet. 3. Prinzmetal's angina has the same risk factors as stable and unstable angina. 4. Prinzmetal's angina is generally treated with calcium channel blocking agents.

4. Prinzmetal's angina is generally treated with calcium channel blocking agents. Rationale: Prinzmetal's angina results from spasm of the coronary arteries and is generally treated with calcium channel blocking agents. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Beta-blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not specifically indicated although a healthy diet consuming foods low in fat and sodium is advocated in cardiac disease.

When preparing a client for a pericardiocentesis, which position does the nurse place the client in? 1. Supine with slight lowering of the head 2. Lying on the right side with a pillow under the head 3. Lying on the left side with a pillow under the chest wall 4. Supine with the head of bed elevated at a 45- to 60-degree angle

4. Supine with the head of bed elevated at a 45- to 60-degree angle Rationale: The client undergoing pericardiocentesis is positioned supine with the head of bed elevated to a 45- to 60-degree angle. This places the heart in proximity to the chest wall for easier insertion of the needle into the pericardial sac. The remaining options are incorrect positions for this procedure.

The nurse is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client? 1. Increase fluids to 3000 mL per day to promote renal perfusion. 2. Consume 1 to 2 oz of liquor each night to promote vasodilation. 3. Try to engage in vigorous activity to strengthen cardiac reserve. 4. Take in adequate daily fiber to prevent straining during a bowel movement.

4. Take in adequate daily fiber to prevent straining during a bowel movement. Rationale: Standard instructions for a client with cardiac disease include, among others, lifestyle changes such as decreasing alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen program to prevent straining and constipation, and maintaining fluid and electrolyte balance. Increasing fluids to 3000 mL could lead to increased blood volume and an increased workload on the heart in the client with cardiac disease.

A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client? 1. Reports the client to the police for illegal drug use 2. Explains to the client the damage that cocaine does to the heart 3. Tells the client it is imperative to stop before myocardial infarction occurs 4. Teaches about the effects of cocaine on the heart and offers referral for further help

4. Teaches about the effects of cocaine on the heart and offers referral for further help Rationale: To provide the most holistic care, the nurse should meet the information needs of the client about the effects of cocaine on the heart and offer referral for further help with this possible addiction. Option 1 is partially correct but does not meet the holistic needs of the client. Option 2 is not indicated and breaches the client's right to confidentiality. Option 3 is incorrect because it "preaches" to the client.

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? 1. The ulcer has a pale-colored base. 2. The ulcer is deep, with even edges. 3. The ulcer has little granulation tissue. 4. The ulcer has a brownish or "brawny" appearance.

4. The ulcer has a brownish or "brawny" appearance. Rationale: Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema. Therefore, options 1, 2, and 3 are incorrect descriptions.