Cardiac Disorders1

The client is diagnosed with a pulmonary embolus and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour?______

880 units. If there are 20,000 units of heparin in 500 mL of D5W, then there are 40 units in each mL. 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour. 40 × 22 = 880

70. The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery.

*1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.* 2. Occupational therapy addresses activities of daily living. The client should be referred to physical therapy to develop a realistic and progressive plan of activity. 3. The client with pericarditis is not usually prescribed oxygen and 2 L/min is a low dose of oxygen that is prescribed for a client with chronic obstructive pulmonary disease (COPD). 4. Endocarditis, not pericarditis, may lead to surgery for valve replacement.

4. Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure 2. Activity intolerance 3. Powerlessness 4. Anticipatory grieving

* 1. Medical client problems indicate the nurse and the physician must collaborate to care for the client; the client must have medications for heart failure.* 2. The nurse can instruct the client to pace activities and can teach about rest versus activity without a physician's order. 3. This is a psychosocial client problem that does not require a physician's order to effectively care for the client. 4. Anticipatory grieving involves the nurse addressing issues that will occur based on the knowledge of the poor prognosis of this disease.

The client diagnosed with a pulmonary embolus is being discharged. Which interven- tion should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) liters a day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines.

***1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. 2. Pulmonary emboli are not caused by athero- sclerosis; therefore, this is not an appro- priate discharge instruction for a client with pulmonary embolism. 3. Infection does not cause a PE;therefore, this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause pulmonary embolism.

86. The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients? 1. Perform a "down and dirty" assessment on each client soon after receiving report. 2. Determine which client should have a bath and inform the unlicensed assistive personnel. 3. Give all the clients a wet washcloth to wash the face and a toothbrush and toothpaste. 4. Pick up any paper on the floor and get the room ready for morning physician rounds.

*1. "Down and dirty" rounds include assessing each client for the main focus of the client's admission or any new issue that is reported from the shift report and assessing all lines and tubes going into or coming out of the client. Once this is done, the nurse knows then that the client is stable and a full head-to-toe assessment can be done at a later time.* 2. The UAP will determine when and how to accomplish the job; the nurse may assist the UAP by informing the UAP of situations which may impact the timing of the baths, but this is not the purpose of morning rounds. 3. This is the UAP's job. 4. This is not the purpose of morning rounds.

81. The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement *first*? 1. Notify the healthcare provider. 2. Assess what the client ate at the last meal. 3. Request a STAT 12 lead echocardiogram. 4. Administer furosemide IVP.

*1. "Has developed" indicates a new issue; the nurse should notify the HCP of the assessment findings, which indicates the patient is in heart failure.* 2. What the client ate has no bearing on the new development of the clinical manifestations of heart failure. 3. A 12-lead ECG will not treat heart failure. 4. A diuretic may need to be administered but notifying the HCP is first.

The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber. 2. Attach an hourly drainage collection bag to the unit and discard the drainage. 3. Replace the unit with a continuous passive motion unit and start it on low. 4. Have another nurse verify the unit number prior to reinfusing the blood.

*1. A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. The cells are washed with saline and reinfused through a filter into the client. The salvaged cells cannot be stored and must be used within four (4) hours or discarded because of bacterial growth.* 2. The cell saver has a measuring device; an hourly drainage bag is part of a urinary drainage system. A cell saver is a sterile system that should not be broken until ready to disconnect for reinfusion. 3. The post-anesthesia care unit nurse would not replace the cell saver; it is inserted into the surgical wound. A continuous passive motion (CPM) machine can be attached on the outside of the bandage and started if the surgeon so orders, but this has nothing to do with the blood. 4. The blood has not been crossmatched so there is not a crossmatch number.

54. The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion.

*1. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.* 2. The client will need a monthly INR to determine the therapeutic level for the anticoagulant warfarin (Coumadin); PTT levels are monitored for heparin. 3. A client with symptomatic sinus bradycardia, not a client with atrial fibrillation, may need a pacemaker. 4. Synchronized cardioversion may be prescribed for new-onset atrial fibrillation but not for chronic atrial fibrillation.

87. The nurse has received shift report. Which client should the nurse assess *first*? 1. The client diagnosed with coronary artery disease complaining of severe indigestion. 2. The client diagnosed with CHF who has 3+ pitting edema. 3. The client diagnosed with atrial fibrillation whose apical rate is 100 and irregular. 4. The client diagnosed with sinus bradycardia who is complaining of being constipated.

*1. A complaint of indigestion could be cardiac chest pain. The nurse should assess this client because of the diagnosis of CAD and the word "severe" in the option.* 2. Edema is expected for the client diagnosed with heart failure, and it is not life-threatening. 3. An irregular heart rate is not life-threatening, and 110 is abnormal but also not life-threatening. 4. Constipation is not life-threatening albeit uncomfortable.

84. The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? *Select all that apply:* 1. Request a dietary consult for a sodium-restricted diet. 2. Instruct the client to elevate the feet during the day. 3. Teach the client to weigh every morning wearing the same type of clothing. 4. Assess for edema in dependent areas of the body. 5. Encourage the client to drink at least 3,000 mL of fluid per day. 6. Have the client repeat back instructions to the nurse.

*1. A dietitian can assist the nurse in explaining the sodium restrictions to the client as well as hidden sources of sodium.* *2. This will help the client's body to return excess fluid to the heart for removal from the body by the kidneys.* *3. The client should weigh himself/herself every morning in the same type of clothing (gown, underwear, jeans, etc.) and report a weight gain of 3 pounds in a week to the HCP.* *4. The nurse should not assess for edema in the feet and lower legs; but if the client is in bed, the lowest part of the body may be in the sacral area. Whichever area is dependent is where the nurse should look for edema.* 5. The client should drink enough fluids to maintain body function, but 3,000 mL is excessive. *6. Whenever the nurse is instructing a client, the nurse should determine if the client heard and understood the instructions. Having the client repeat the instructions is one way of determining "hearing." Having the client return demonstrate is a method of determining understanding.*

30. Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? *Select all that apply.* 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to 2 g a day. 4. Refer to counselor for stress reduction techniques. 5. Increase fiber in the diet.

*1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries.* *2. Walking will help increase collateral circulation.* 3. Salt should be restricted in the diet of a client with hypertension, not coronary artery disease. *4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle.* *5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.*

66. The client diagnosed with pericarditis is experiencing cardiac tamponade. Which *collaborative* intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.

*1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade.* 2. Cardiac enzymes may be slightly elevated because of the inflammatory process, but evaluation of these would not be ordered to treat or evaluate cardiac tamponade. 3. A 12-lead ECG would not help treat the medical emergency of cardiac tamponade. 4. Assessment by the nurse is not collaborative; it is an independent nursing action.

Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client who has refused to turn for the last three (3) hours. 3. The client who had an open cholecystectomy who refuses to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge.

*1. A potentially life-threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a pulmonary embolus.* 2. An immobile client should be turned at least every two (2) hours, but a pressure area is not life threatening. 3. This is expected in a client who has a large upper abdominal incision. It hurts to breathe deeply. The nurse should address this but has some time. The life-threatening complication is priority. 4. Clients who have had inguinal hernia repair often have difficulty voiding afterward. This is expected.

62. The client is diagnosed with acute pericarditis. Which sign/symptom *warrants immediate* attention by the nurse? 1. Muffled heart sounds 2. Nondistended jugular veins 3. Bounding peripheral pulses 4. Pericardial friction rub

*1. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider.* 2. Distended, not nondistended, jugular veins would warrant immediate intervention. 3. Decreasing quality of peripheral pulses, not bounding peripheral pulses, would warrant immediate intervention. 4. A pericardial friction rub is a classic symptom of acute pericarditis, but it would not warrant immediate intervention.

80. The nurse is functioning in the role of medication nurse during a code. Which should the nurse implement when administering amiodarone for ventricular tachycardia? 1. Mix the medication in 100mL of fluid & administer rapidly. 2. Push the amiodarone directly into the nearest IV port and raise the arm. 3. Question the physicians order because it is not ACLS recommended. 4. Administer via an IV pump based on mg/kg/min. 1. Mix the medication in 100 mL of fluid & administer rapidly.

*1. Amiodarone is administered during a code rapidly after being mixed in 100 mL of fluid.* 2. Amiodarone is not pushed; lidocaine is administered by this method. Amiodarone is replacing the use of lidocaine during a code because of evidence-based practice. 3. Amiodarone is ACLS recommended. 4. Dopamine is administered via mg/kg/min. The time to calculate this kind of dosage is not taken until after the code is concluded and the client is placed on a vasopressor medication, such as dopamine.

8. The nurse on the telemetry unit has just received the A.M. shift report. Which client should the nurse assess *first*? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4 sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level.

*1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation.* 2. The nurse would expect a client with CHF to have sacral edema of 4; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.

20. The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses a S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.

*1. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction.* 2. Elevating the head of the bed will not do anything to help a failing heart. 3. This is not a normal finding; it indicates heart failure. 4. Morphine is administered for chest pain, not for heart failure, which is suggested by the S3 sound.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

*1. Assessment of the lung sounds could indicate that the client's lung has reexpanded because it has been three (3) ys since the chest tube has been inserted.* 2. This should be done to ensure that the lung has reexpanded, but it is not the first intervention. 3. The HCP will need to be notified so that the chest tube can be removed, but it is not the first intervention. 4. This situation needs to be documented, but it is not the first intervention.

6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation-perfusion (V/Q) scan.

*1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF.* 2. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme. 3. A positive D-dimer would indicate a pulmonary embolus. 4. A positive ventilation-perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus.

90. The nurse identifies the concept of tissue perfusion as a client problem. Which is an *antecedent* of tissue perfusion? 1. The client has a history of CAD 2. The client has a history of diabetes insidipidus 3. The client has a history of chronic obstructive pulmonary disease. 4. The client has multiple fractures from a motor-vehicle accident.

*1. CAD narrows the arteries of the heart, causing the tissues not to be perfused, especially when an embolus or thrombus occurs.* 2. DI is a disease of the pituitary gland or the kidneys; it is not a perfusion issue. 3. COPD is an oxygenation issue, not a perfusion one. 4. Multiple fractures do not cause perfusion issues unless an interrelated issue occurs.

20. The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. When the machine is activated, there is a pause. What action should the nurse take? 1. Wait until the machine discharges. 2. Shout "all clear" and don't touch the bed. 3. Make sure the client is all right. 4. Increase the joules and redischarge.

*1. Cardioversion involves the delivery of a timed electrical current. The electrical impulse discharges during ventricular depolarization and therefore there might be a short delay. The nurse should wait until it discharges.* 2. Calling "all clear" and not touching the bed should be done prior to discharging the electrical current. 3. A pause is an expected event, and asking if the client is all right may worry the client unnecessarily. 4. Increasing joules and redischarging is implemented during defibrillation, not during synchronized cardioversion.

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

*1. Checking to see if someone has increased the suction rate is the simplest action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.* 2. No fluctuation (tidaling) would cause the nurse to assess the tubing for a blood clot. 3. The tube is milked to help dislodge a blood clot that may be blocking the chest tube causing no fluctuation (tidaling) in the water- seal compartment. The chest tube is never stripped, which creates a negative air pressure and would suck lung tissue into the chest tube. 4. Encouraging the client to cough force fully will help dislodge a blood clot that may be blocking the chest tube, causing no fluctuation (tidaling) in the water-seal compartment.

37. A client is being seen in the clinic to R/O mitral valve stenosis. Which assessment data would be *most significant*? 1. The client complains of shortness of breath when walking. 2. The client has jugular vein distention and 3 pedal edema. 3. The client complains of chest pain after eating a large meal. 4. The client's liver is enlarged and the abdomen is edematous.

*1. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis.* 2. Jugular vein distension (JVD) and 3 pedal edema are signs/symptoms of right-sided heart failure and indicate worsening of the mitral valve stenosis. These signs would not be expected in a client with early manifestations of mitral valve stenosis. 3. Chest pain rarely occurs with mitral valve stenosis. 4. An enlarged liver and edematous abdomen are late signs of right-sided heart failure that can occur with long-term untreated mitral valve stenosis.

The nurse is assessing the client with a pneumothorax who has a closed-chest drainage system. Which data indicate the client's condition is *stable*? 1. There is fluctuation in the water-seal compartment. 2. There is blood in the drainage compartment. 3. The trachea deviates slightly to the left. 4. There is bubbling in the suction compartment.

*1. Fluctuation in the water-seal compartment with respirations indicates the system is working properly and the client is stable.* 2. Blood in the drainage compartment indicates there is a problem because the client is diagnosed with a pneumothorax and there should not be any bleeding. 3. Any deviation of the trachea indicates a tension pneumothorax, a potentially life-threatening complication. 4. Bubbling in the suction compartment does not indicate a stable or unstable client.

46. The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement? 1. Restrict the client's fluids as ordered. 2. Keep the client in the supine position. 3. Maintain oxygen saturation at 90%. 4. Monitor the total parenteral nutrition.

*1. Fluid intake may be restricted to reduce the cardiac workload and pressures within the heart and pulmonary circuit.* 2. The head of the bed should be elevated to help improve alveolar ventilation. 3. Oxygen saturation should be no less than 93%; 90% indicates an arterial oxygen saturation of around 60 (normal is 80-100) 4. Total parenteral nutrition would not be prescribed for a client with mitral valve replacement. It is ordered for clients with malnutrition, gastrointestinal disorders, or conditions in which increased calories are needed, such as burns.

Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.

*1. Heparin is administered during throm- bolytic therapy, and the antidote is prota- mine sulfate and should be available to reverse the effects of the anticoagulant.* 2. Firm pressure reduces the risk for bleeding into the tissues. *3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for.* *4. Invasive procedures increase the risk of tissue trauma and bleeding.* *5. Stool softeners help prevent constipation and straining, which may precipitate bleed- ing from hemorrhoids.*

51. The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to order for this client? 1. Lidocaine 2. Atropine 3. Digoxin 4. Adenosine

*1. Lidocaine suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.* 2. Atropine decreases vagal stimulation and is the drug of choice for asystole. 3. Digoxin slows heart rate and increases cardiac contractility and is the drug of choice for atrial fibrillation. 4. Adenosine is the drug of choice for supraventricular tachycardia.

4. Which medical client problem should the nurse include in the plan of care for a client diagnosed with cardiomyopathy? 1. Heart failure. 2. Activity intolerance. 3. Powerlessness. 4. Anticipatory grieving.

*1. Medical client problems indicate the nurse and the physician must collaborate to care for the client; the client must have medications for heart failure.* 2. The nurse can instruct the client to pace activities and can teach about rest versus activity without a physician's order. 3. This is a psychosocial client problem that does not require a physician's order to effectively care for the client. 4. Anticipatory grieving involves the nurse addressing issues that will occur based on the knowledge of the poor prognosis of this disease.

77. The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge? 1. Carry your nitroglycerin tablets in a brown bottle. 2. Swallow a nitroglycerin tablet at the first sign of angina. 3. If one nitroglycerin tablet does not work in 10 minutes, take another. 4. Nitroglycerin tablets have a fruity odor if they are potent.

*1. Nitroglycerin tablets are dispensed in small brown bottles to preserve the potency. The client should not change the tablets to another container.* 2. The tablets are placed under the tongue to dissolve and thereby work more rapidly. 3. The client is taught to take one (1) tablet every 5 minutes and if the angina is not relieved to call 911. 4. The tablets do not have a fruity odor; they sting when placed under the tongue if they are potent.

The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential unit of blood could be given to the client? 1. The O- unit. 2. The A+ unit. 3. The B+ unit. 4. Any Rh+ unit.

*1. O- blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB+ is considered the universal recipient because a person with this blood type has all the antigens on the blood.)* 2. A+ blood contains the antigen A that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 3. B+ blood contains the antigen B that the client will react to, causing the development of antibodies. The unit being Rh+ is compatible with the client. 4. This client does not have antigens A or B on the blood. Administration of these types would cause an antigen-antibody reaction within the client's body, resulting in massive hemolysis of the client's blood and death.

42. Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? *Select all that apply.* 1. Paroxysmal nocturnal dyspnea 2. Orthopnea 3. Cough 4. Pericardial friction rub 5. Pulsus paradoxus

*1. Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress usually occurring at night because of the reclining position and occurs in valvular disorders.* *2. This is an abnormal condition in which a client must sit or stand to breathe comfortably and occurs in valvular disorders.* *3. Coughing occurs when the client with long-term valvular disease has difficulty breathing when walking or performing any type of activity.* 4. Pericardial friction rub is a sound auscultated in clients with pericarditis, not valvular heart disease. 5. Pulsus paradoxus is a marked decrease in amplitude during inspiration. It is a sign of cardiac tamponade, not valvular heart disease.

34. The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove Holter monitor during A.M. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

*1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity.* 2. The Holter monitor should not be removed for any reason. 3. All medications should be taken as prescribed. 4. The client should perform all activity as usual while wearing the Holter monitor so the HCP can get an accurate account of heart function during a 24-hour period.

59. The client's telemetry reading shows a P-wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin po. 4. Assess the client's cardiac enzymes

*1. The P-wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.* 2. A 12-lead ECG should be requested for chest pain or abnormal dysrhythmias. 3. Digoxin is used to treat atrial fibrillation. 4. Cardiac enzymes are monitored to determine if the client has had a myocardial infarction. Nothing in the stem indicates the client has had an MI.

8. The client comes to the emergency department saying, "I am having a heart attack." Which question is *most pertinent* when assessing the client? 1. "Can you describe your chest pain?" 2. "What were you doing when the pain started?" 3. "Did you have a high-fat meal today?" 4. "Does the pain get worse when you lie down?"

*1. The chest pain for an MI usually is described as an elephant sitting on the chest or a belt squeezing the substernal mid-chest, often radiating to the jaw or left arm.* 2. This helps to identify if it is angina (resulting from activity) or MI (not necessarily brought on by activity). 3. Learning about a client's intake of a high-fat meal would help the nurse to identify a gallbladder attack. 4. This is a question that the nurse might ask the client with reflux esophagitis.

45. The client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is *most appropriate*? 1. "You are at risk of developing an infection in your heart." 2. "Your teeth will not bleed as much if you have antibiotics." 3. "This procedure may cause your valve to malfunction." 4. "Antibiotics will prevent vegetative growth on your valves."

*1. The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure.* 2. Antibiotics have nothing to do with how much the teeth bleed during a cleaning. 3. Teeth cleaning will not cause the valve to malfunction. 4. Vegetation develops on valves secondary to bacteria that cause endocarditis, but the client will not understand vegetative growth on the valves; therefore, this is not the most appropriate answer.

The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client's lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W.

*1. The client must give permission to receive blood or blood products because of the nature of potential complications.* 2. Most blood products require at least a 20-gauge IV because of the size of the cells. RBCs are best infused through an 18-gauge IV. If unable to achieve cannulation with an 18-gauge, a 20-gauge is the smallest acceptable IV. Smaller IVs damage the cell walls of the RBCs and reduce the life expectancy of the RBCs. *3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Additional assessment findings of jugular vein distention, peripheral edema, and liver engorgement indicate right-sided failure.* *4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration.* 5. A keep-open IV of 0.9% saline would be hung. D5W causes red blood cells to hemolyze in the tubing.

Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn't take deep breaths, he could die.

*1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from develop- ing pneumonia or atelectasis.* 2. The client must take deep breaths; shallow breaths could lead to complications. 3. Deep breaths must be taken to prevent complications. 4. This is a cruel intervention; the nurse can medicate the client and then encourage deep breathing.

75. The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? *Select all that apply:* 1. Monitor the clients blood pressure and apical rate every 4 hours. 2. Place the client on intake and output every shift. 3. Require the client to sleep with the head of the bed elevated. 4. Teach the patient to perform Buerger Allen exercises daily. 5. Determine if the client is on anti platelet or anticoagulant medication. 6. Assess the clients neurological status every shift and prn.

*1. The client should be monitored for any cardiovascular changes.* *2. The client should be monitored for the development of heart failure as a result of increased strain on the heart from the atria not functioning as it should.* 3. There is no evidence that the client requires to sleep in the orthopneic position. 4. Buerger Allen exercises are useful for clients who have peripheral artery disease but do not have an effect on atrial fibrillation. *5, 6. Clients diagnosed with afib are at risk for developing emboli from the stasis of blood in the atria. If an emboli breaks loose from the lining of the atria, it can travel to the lungs (right) or to the brain (left).*

1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4 pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and capillary refill time 3 seconds.

*1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.* 2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing. 3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing. 4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.

23. The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's *best* response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bed rest.Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

*1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.* 2. The nurse should talk to the client in layman's terms, not medical terms. Medical terminology is a foreign language to most clients. 3. This is not answering the client's question. The nurse should take any opportunity to teach the client. 4. This is a condescending response, and telling the client that he or she is not out of danger is not an appropriate response.

The nurse is initiating a blood transfusion. Which interventions should the nurse implement? *Select all that apply.* 1. Assess the client's lung fields. 2. Have the client sign a consent form. 3. Start an IV with a 22-gauge IV catheter. 4. Hang 250mL of D5W at a keep-open rate. 5. Check the chart for the HCP's order.

*1. The nurse must make a decision on the amount of blood to infuse per hour. If the client is showing any sign of heart of lung compromise, the nurse would infuse the blood at the slowest possible rate.* *2. Blood products require the client to give specific consent to receive blood.* 3. The IV should be started with an 18-gauge catheter if possible; the smallest possible catheter is a 20-gauge. Smaller gauge catheters break down the blood cells. 4. Blood is not compatablie with D5W; the nurse should hang 0.9% normal saline (NS) to keep open. *5. The nurse should verify the HCP's order before having the client sign the consent form.*

71. The client has just had a pericardiocentesis. Which interventions should the nurse implement? *Select all that apply.* 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position.

*1. The nurse should monitor the vital signs for any client who has just undergone surgery.* *2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds involves entering the pericardial sac and allows assessment for cardiac failure.* *3. The pericardial fluid is documented as output.* *4. Evaluating the client's cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardial centesis.* 5. The client should be in the semi-Fowler's position, not in a flat position, which increases the workload of the heart.

The client is suspected of having a pulmonary embolus. Which diagnostic test con- firms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging (MRI).

*1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis.* 2. ABGs evaluate oxygenation level, but they do not diagnose a pulmonary embolism. 3. ACXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. 4. MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a pulmonary embolus.

11. Which meal would indicate the client understands the discharge teaching concerning the recommended diet for coronary artery disease? 1. Baked fish, steamed broccoli, and garden salad 2. Enchilada dinner with fried rice and refried beans 3. Tuna salad sandwich on white bread and whole milk 4. Fried chicken, mashed potatoes, and gravy

*1. The recommended diet for CAD is low fat, low cholesterol, and high fiber. The diet described is a diet that is low in fat and cholesterol.* 2. This is a diet very high in fat and cholesterol. 3. The word "salad" implies something has been mixed with the tuna, usually mayonnaise, which is high in fat, but even if the test taker did not know this, white bread is low in fiber and whole milk is high in fat. 4. Meats should be baked, broiled, or grilled - not fried. Gravy is high in fat.

18. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur? 1. Second intercostal space, right sternal notch. 2. Erb's point. 3. Second intercostal space, left sternal notch. 4. Fourth intercostal space, left sternal border.

*1. The second intercostal space, right sternal notch, is the area on the chest where the aorta can best be heard opening and closing.* 2. Erb's point allows the nurse to hear the opening and closing of the tricuspid valve. 3. The second intercostal space, left sternal notch, is the area on the chest where the pulmonic valve can best be heard opening and closing. 4. The fourth intercostal space, left sternal border, is another area on the chest that can assess the tricuspid valve.

41. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's International Normalized Ratio (INR) is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (AquaMephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding

*1. The therapeutic range for most clients'INR is 2-3, but for a client with a mechanical valve replacement it is 2-3.5. The medication should be given as ordered and not withheld.* 2. Vitamin K is the antidote for an overdose of warfarin, but 2.7 is within therapeutic range. 3. This laboratory result is within the therapeutic range, INR 2-3, and the medication does not need to be withheld. 4. There is no need for the nurse to assess for bleeding because 2.7 is within therapeutic range.

The client on the telemetry unit diagnosed with a thromboembolism is complaining of chest pain and anxiety. Which action should the nurse implement *first*? 1. Stay with the client and call the Rapid Response Team (RRT). 2. Assess the client's vital signs. 3. Have the unlicensed assistive personnel (UAP) stay with the client. 4. Check the client's telemetry reading.

*1. These clinical manifestations could indicate a pulmonary embolus. The nurse should not leave the client but should get help as soon as possible. The rules of the RRT are that anyone can call an RRT if a concern is noted, and no one will suffer consequences because one was called and it was not determined that the client was not in serious danger.* 2. The nurse's first action is to stay with the client and call for help. 3. The UAP cannot be assigned an unstable client. 4. The telemetry reading is not important in regard to the current clinical manifestations.

25. The nurse is transcribing the doctor's orders for a client with congestive heart failure. The order reads 2.5 mg of Lanoxin daily. Which action should the nurse implement? 1. Discuss the order with the health-care provider. 2. Take the client's apical pulse rate before administering. 3. Check the client's potassium level before giving the medication. 4. Determine if a digoxin level has been drawn.

*1. This dosage is 10 times the normal dose for a client with CHF. This dose is potentially lethal.* 2, 3, 4. No other action can be taken because of the incorrect dose.

26. The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the *most appropriate response* by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."

*1. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.* 2. This is the explanation in medical terms that should not be used when explaining medical conditions to a client. 3. This explains congestive heart failure but does not explain why chest pain occurs. 4. Respiratory compromise occurs when the lungs cannot oxygenate the blood, such as occurs with altered level of consciousness, cyanosis, and increased respiratory rate.

The nurse is teaching the client in a cardiac rehabilitation unit. Which dietary information should the nurse discuss with the client? 1. No more than 30% of daily food intake should be fats. 2. Eighty percent of calories should come from carbohydrates. 3. Red meat should comprise at least 50% of daily intake. 4. Monounsaturated fat in the daily diet should be increased.

*1. This is a correct statement. The recommended portions of food are 50% carbohydrates, 30% or less from fat, and 20% protein.* 2. Only 50% of the calories should come from carbohydrates 3. Red meat is an excellent source of protein but should only comprise 20% of the diet, and red meat is very high in fat. 4. Polyunsaturated fats, not the monounsaturated fats, are the better fats.

22. The nurse assessing the client with pericardial effusion at 1600 notes the apical pulse is 72 and the BP is 138/94. At 1800, the client has neck vein distention, the apical pulse is 70, and the BP is 106/94. Which action would the nurse implement *first*? 1. Stay with the client and use a calm voice. 2. Notify the health-care provider immediately. 3. Place the client left lateral recumbent. 4. Administer morphine intravenous push slowly.

*1. This is a medical emergency; the nurse should stay with the client, keep him calm, and call the nurses' station to notify the health-care provider. Cardiac output declines with each contraction as the pericardial sac constricts the myocardium.* 2. The client's signs/symptoms would make the nurse suspect cardiac tamponade, a medical emergency. The pulse pressure is narrowing, and the client is experiencing severe rising central venous pressure exhibited by neck vein distention. Notifying the health-care provider is important, but the nurse should stay with the client first. 3. A left lateral recumbent position is used when administering enemas. 4. Morphine would be given to a client with pain from myocardial infarction; it is not a treatment option for cardiac tamponade.

16. Which data would cause the nurse to *question* administering digoxin to a client diagnosed with congestive heart failure? 1. The potassium level is 3.2 mEq/L. 2. The digoxin level is 1.2 mcg/mL. 3. The client's apical pulse is 64. 4. The client denies yellow haze.

*1. This potassium level is below normal levels; hypokalemia can potentiate digoxin toxicity and lead to cardiac dysrhythmias.* 2. This digoxin level is within therapeutic range, 0.5 to 2.0 mcg/mL. 3. The nurse would question the medication if the apical pulse were less than 60. 4. Yellow haze is a sign of digoxin toxicity.

57. The client is in ventricular fibrillation. Which interventions should the nurse implement? *Select all that apply.* 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP.

*1. Ventricular fibrillation indicates the client does not have a heartbeat. Therefore CPR should be instituted.* 2. Adenosine, an antidysrhythmic, is the drug of choice for supraventricular tachycardia, not for ventricular fibrillation. *3. Defibrillation is the treatment of choice for ventricular fibrillation.* *4. The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation.* *5. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias.*

The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplantation unit. Which nursing task should the nurse delegate? 1. Take the hourly vital signs on a client receiving blood transfusions. 2. Monitor the infusion of antineoplastic medications. 3. Transcribe the HCP's orders onto the Medication Administration Record. 4. Determine the client's response to the therapy.

*A. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the UAP to take the vital signs as long as the UAP has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse.* B. Antineoplastic medication infusions must be monitored by a chemotherapy-certified, competent nurse. C. This is the responsibility of the word secretary or the nurse, not the unlicensed personnel. D. This represents the evaluation portion of the nursing process and cannot be delegated.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a stat chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading.

1. A STAT chest x-ray would not be needed to determine why there is no fluctuation in the water-seal compartment. 2. Increasing the amount of wall suction does not address why there is no fluctuation in the water-seal compartment. *3. The key to the answer is "2 hours." The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop.* 4. The stem does not state that the client is in respiratory distress, and a pulse oximeter read- ing detects hypoxemia but does not address any fluctuation in the water-seal compartment.

23. The client is admitted to the emergency department, and the nurse suspects a cardiac problem. Which assessment interventions should the nurse implement? *Select all that apply.* 1. Obtain a mid-stream urine specimen. 2. Attach telemetry monitor to the client. 3. Start a saline lock in the right arm. 4. Draw a basic metabolic panel (BMP). 5. Request an order for a STAT 12-lead ECG.

1. A mid-stream urine specimen is ordered for a client with a possible urinary tract infection, not for a client with cardiac problems. *2. Any time a nurse suspects cardiac problems, the electrical conductivity of the heart should be assessed.* *3. Emergency medications for heart problems are primarily administered intravenously, so starting a saline lock in the right arm is appropriate.* 4. This serum blood test is not specific to assess cardiac problems. A BMP evaluates potassium, sodium, glucose, and more. *5. A 12-lead ECG evaluates the electrical conductivity of the heart from all planes.*

56. The client is in complete heart block. Which intervention should the nurse implement *first*? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.

1. A pacemaker will have to be inserted, but it is not the first intervention. *2. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention.* 3. A STAT ECG may be done, but the telemetry reading shows complete heart block, which is a life-threatening dysrhythmia and must be treated. 4. The HCP will need to be notified but not prior to administering a medication. The test taker must assume the nurse has the order to administer medication. Many telemetry departments have standing protocols.

63. The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to *support* this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family history of carditis?" 4. "What over-the-counter (OTC) medications do you take?"

1. A sore throat in the last month would not support the diagnosis of carditis. *2. Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of the people.* 3. Carditis is not a genetic or congenital disease process. 4. This is an appropriate question to ask any client, but OTC medications do not cause carditis.

The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client? 1. Prednisone, a glucocorticoid. 2. Zithromax, an antibiotic. 3. Ativan, a tranquilizer. ' 4. Epogen, a biologic response modifier.

1. A steroid could delay healing time after the surgery and has no effect on the production of red blood cells. 2. An antibiotic does not increase the production of red blood cells. Orthopedic surgeries frequently involve blood loss. The client is wishing to donate blood to himself or herself (autologous). 3. Tranquilizers do not affect the production of red blood cells. *4. Epogen and Procrit are forms of erythropoietin, the substance in the body that stimulates the bone marrow to produce red blood cells. A client may be prescribed iron preparations to prevent depletion of iron stores and erythropoietin to increase RBC production. A unit of blood can be withdrawn once a week beginning at six (6) weeks prior to surgery. No phlebotomy will be done within 72 hours of surgery.*

52. The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which *collaborative* treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular status. 3. Prepare for an insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion.

1. A thrombolytic medication is administered for a client experiencing a myocardial infarction. 2. Assessment is an independent nursing action, not a collaborative treatment. *3. The client is symptomatic and will require a pacemaker.* 4. Synchronized cardioversion is used for ventricular tachycardia with a pulse or atrial fibrillation.

35. Which statement by the client diagnosed with coronary artery disease indicates that the client *understands* the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."

1. According to the American Heart Association, the client should not eat more than 3 eggs a week, especially the egg yolk. *2. The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, boil, or grill any meat.* 3. The client should drink low-fat milk, not whole milk. 4. Pork products (bacon, sausage, ham) are high in sodium, which is prohibited in a low-salt diet, not a low-cholesterol, low-fat diet.

83. The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is *priority*? 1. Sleep, rest, activity 2. Comfort 3. Oxygenation 4. Perfusion

1. Activity intolerance is a result of lack of perfusion of the cardiac muscle, but the priority is to get the muscle perfused. 2. Pain does not kill anyone, but the reason behind the pain could. In the case of chest pain, the cardiace muslce is not being perfused, which causes the pain. 3. The problem is not having enough oxygen available to the body, but that the oxygen is not being perfused to the cardiac muscle. *4. The cardiac muscle is not perfused when there is a narrowing of the arteries caused by CAD or when an embolus or thrombosis occludes the artery. Adequate perfusion will supply oxygen to the cardiac muscle, allow for increased activity, and decrease pain.*

19. The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal angioplasty (PTCA), also known as balloon surgery. Which assessment data would require *immediate* intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3 and bounding.

1. After PTCA, the client must keep the right leg straight for at least six (6) to eight (8) hours to prevent any arterial bleeding from the insertion site in the right femoral artery. 2. A pressure dressing is applied to the insertion site to help prevent arterial bleeding. *3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.* 4. A bounding pedal pulse indicates that adequate circulation is getting to the right foot; therefore, this would not require immediate intervention.

9. The nurse and an unlicensed nursing assistant are caring for four clients on a telemetry unit. Which nursing task would be *best* for the nurse delegate to the unlicensed nursing assistant? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the Intensive Care Unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done

1. Allowing the unlicensed assistive personnel (UAP) to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking. 2. The client going to the ICU would be unstable, and the nurse should not delegate to an UAP any nursing task that involves an unstable client. 3. The nurse cannot delegate teaching. *4. The UAP can assist the x-ray technician in positioning the client for the portable xray. This does not require judgment.*

74. The 45-year old male client diagnosed with essential hypertension had decided not to take his medications. The client's BP is 178/94 indicating a perfusion issue. Which question should the nurse ask the client *first*? 1. "Do you have the money to buy your medication?" 2. "Does the medication give unwanted side effects?" 3. "Did you quit taking the medications because you don't feel bad?" 4. Can you tell me why you stopped taking the medication?"

1. Although this might be the cause of noncompliance, actual side effects of antihypertensive medications may be more likely. Evidence indicates that the side effects of erectile dysfunction is a major reason of noncompliance for males. *2. This is a mild way of introducing the subject of side effects to a client not wishing to admit medication causes unwanted effects. It opens the door to more probing assessment questions. The nurse should bring up the subject to allow the client to be forthcoming with the issues why he is not taking his medication.* 3. This would be the 2nd question to ask if the client denies any problems with side effects. 4. Although in this case the nurse can ask "why" because it is an interview question and not therapeutic conversation being requested in the stem, a more direct question will open the conversation up better.

2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be *best* for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care.

1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. *2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure that could be life threatening.* 3. This is a nursing intervention, not a short-term goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output.

The nurse is preparing to administer medications to the following clients. Which medication would the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hanging the heparin bag to a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.

1. An INR of 2-3 is therapeutic; therefore, the nurse would administer this medication. 2. This is an elevated blood glucose level; there- fore, the nurse should administer the insulin. *3. A normal PTT is 39 seconds; therefore, 58-78 is 1.5 to 2 times the normal value and is within the therapeutic range. A PTT of 98 means the client is not clotting and the medication should be held.* 4. This is a normal blood pressure and the nurse should administer the medication.

43. The client is being evaluated for valvular heart disease. Which information would be *most significant*? 1. The client has a history of coronary artery disease. 2. There is a family history of valvular heart disease. 3. The client has a history of smoking for ten (10) years. 4. The client has a history of rheumatic heart disease.

1. An acute myocardial infarction can damage heart valves, causing tearing, ischemia, or damage to heart muscles that affects valve leaflet function, but coronary heart disease does not cause valvular heart disease. 2. Valvular heart disease does not show a genetic etiology. 3. Smoking can cause coronary artery disease, but it does not cause valvular heart disease. *4. Rheumatic heart disease is the most common cause of valvular heart disease.*

40. The nurse is teaching a class on valve replacements. Which statement identifies a *disadvantage* of having a biologic tissue valve replacement? 1. The client must take lifetime anticoagulant therapy. 2. The client's infections are easier to treat. 3. There is a low incidence of thromboembolism. 4. The valve has to be replaced frequently.

1. An advantage of having a biologic valve replacement is that no anticoagulant therapy is needed. Anticoagulant therapy is needed with a mechanical valve replacement. 2. This is an advantage of having a biologic valve replacement; infections are harder to treat in clients with mechanical valve replacement. 3. This is an advantage of having a biologic valve replacement; there is a high incidence of thromboembolism in clients with mechanical valve replacement. *4. Biologic valves deteriorate and need to be replaced frequently; this is a disadvantage of them. Mechanical valves do not deteriorate and do not have to be replaced often.*

The telemetry nurse is monitoring the following clients. Which client should the telemetry nurse instruct the primary nurse to assess first? 1. The client who has occasional premature ventricular contractions (PVC's). 2. The client post-cardiac surgery who has three (3) unifocal PVC's in a minute. 3. The client with a myocardial infarction who had two (2) multifocal PVC's 4. The client diagnosed with atrial fibrillation who has an AP of 110 and no P wave.

1. An occasional PVC does not warrant intervention; it is normal for most clients. 2. Less than six (6) unifocal PVC's in one minute is not life threatening *3. Multifocal PVC's indicate the ventricle is irritable, and this client is at risk for a cardiac event such as ventricular fibrillation.* 4. Atrial fibrillation is not life threatening, and the nurse would expect the client not to have a P wave

69. Which nursing diagnosis would be *priority* for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function.

1. Anxiety is a psychosocial nursing diagnosis, which is not a priority over a physiological nursing diagnosis. 2. Antibiotic therapy does not result in injury to the client. 3. Myocarditis does not result in valve damage (endocarditis does), and there would be decreased, not increased, cardiac output. *4. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.*

The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases. 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.

1. Arterial blood gases would be included in the client problem "impaired gas exchange." *2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output.* 3. This would be appropriate for the client prob- lem "high risk for bleeding." 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing.

The client is diagnosed with aortic stenosis. Which assessment data indicate a *complication* is occurring? 1. Barrel chest and clubbing of the fingers. 2. Intermittent claudication and rest pain. 3. Pink, frothy sputum and dyspnea on exertion. 4. Bilateral wheezing and friction rub.

1. Barrel chest and clubbing of the fingers are signs of chronic lung disease. 2. Intermittent claudication and rest pain are signs of peripheral arterial disease. *3. Pink, frothy sputum and dyspnea on exertion are signs of congestive heart failure, which occurs when the heart can no longer compensate for the strain of an incompetent valve.* 4. Friction rub occurs with pericarditis, and bilateral wheezing occurs with asthma.

Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for >four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure.

1. Blood will coagulate if left out for an extended period, but blood is stored with a preservative that prevents this and prolongs the life of the blood. *2. Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia.* 3. Blood components are stable and do not break down after four (4) hours. 4. These are standard nursing and laboratory procedures to prevent the complication of septicemia.

31. The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?"

1. Bowel movements are important, but they are not pertinent to coronary artery disease. 2. Chest x-rays are usually done for respiratory problems, not for coronary artery disease. *3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity.* 4. Weight change is not significant in a client with coronary artery disease.

13. Which cardiac enzyme would the nurse expect to elevate *first* in a client diagnosed with a myocardial infarction? 1. Creatine phosphokinase (CPK-MB) 2. Lactate dehydrogenase (LDH) 3. Troponin 4. White blood cells (WBC)

1. CPK-MB elevates in 12 to 24 hours. 2. LDH elevates in 24 to 36 hours. *3. Troponin is the enzyme that elevates within 1 to 2 hours.* 4. WBC elevates as a result of necrotic tissue, but this is not a cardiac enzyme.

7. The telemetry nurse notes a peaked T-wave for the client diagnosed with congestive heart failure. Which laboratory data should the nurse assess? 1. CPK-M2 2. Troponin 3. BNP (beta-type natriuretic peptide) 4. Potassium

1. CPK-MB is assessed to determine if the client has had a myocardial infarction. The electrical activity of the heart will not be affected by elevation of this enzyme. 2. Troponin is assessed to determine if the client has had a myocardial infarction. The electrical activity of the heart will not be affected by elevation of this enzyme. 3. BNP is elevated in clients with congestive heart failure, but it does not affect the electrical activity of the heart. *4. Hyperkalemia will cause a peaked T-wave; therefore, the nurse should check this laboratory data.*

1. Which population is at a higher risk for dying from a myocardial infarction? 1. Caucasian males 2. Hispanic females 3. Asian males 4. African American females

1. Caucasian males have a high rate of coronary artery disease, but they do not delay seeking health care as long as some other ethnic groups. The average delay time is five (5) hours. 2. Hispanic females are at higher risk for diabetes than for dying from a myocardial infarction. 3. Asian males have fewer cardiovascular events, which is attributed to their diet, which is high in fiber and omega-3 fatty acids. *4. African American females are 35% more likely to die from coronary artery disease than any other population. This population has significantly higher rates of hypertension and it occurs at a younger age. The higher risk of death from an MI is also attributed to a delay in seeking emergency care—an average of 11 hours.*

5. The client has an implantable cardioverter defibrillator (ICD). Which discharge instructions should the nurse teach the client? 1. Do not lift or carry more than 23 kg. 2. Have someone drive the car for the rest of your life. 3. Carry the cell phone on the opposite side of the ICD. 4. Avoid using the microwave oven in the home.

1. Clients should not lift more than 5-10 pounds because it puts a strain on the heart, 23 kg is more than 50 pounds. 2. There may be driving restrictions, but the client should be able to drive independently. *3. Cell phones may interfere with the functioning of the ICD if they are placed too close to it.* 4. Microwave ovens should not cause problems with the ICD.

47. Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60-year-old female with congestive heart failure 2. A 23-year-old male with Marfan syndrome 3. An 80-year-old male with atrial fibrillation 4. A 33-year-old female with Down syndrome

1. Congestive heart failure does not predispose the female client to having a mitral valve prolapse. *2. Clients with Marfan syndrome have life-threatening cardiovascular problems, including mitral valve prolapse, progressive dilation of the aortic valve ring, and weakness of the arterial walls, and they usually do not live past the age of 40 because of dissection and rupture of the aorta.* 3. Atrial fibrillation does not predispose a client to mitral valve prolapse. 4. A client with Down syndrome may have congenital heart anomalies but not mitral valve prolapse.

10. Which client would most likely be *misdiagnosed* for having a myocardial infarction? 1. A 55-year-old Caucasian male with crushing chest pain and diaphoresis. 2. A 60-year-old Native American male with an elevated troponin level. 3. A 40-year-old Hispanic female with a normal electrocardiogram. 4. An 80-year-old Peruvian female with a normal CPK-MB at 12 hours.

1. Crushing pain and sweating are classic signs of an MI and should not be misdiagnosed. 2. An elevated troponin level is a benchmark in diagnosing an MI and should not be misdiagnosed. *3. The clients who are misdiagnosed concerning MIs usually present with atypical symptoms. They tend to be female, be younger than 55 years old, be members of a minority group, and have normal electrocardiograms.* 4. CPK-MB may not elevate until up to 24 hours after onset of chest pain.

89. The nurse is administering morning medications. Which medication should be administered *first*? 1. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet. 2. The sliding scale insulin to a client with a fasting BGL of 345 mg/dL who is demanding breakfast. 3. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,4000 mL. 4. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76.

1. Digoxin is a routine medication that will be administered at 0900 in most hospitals. *2. The client intends on eating breakfast and this is a scheduled medication for before meals.* 3. This client is showing that the diuretic is dong what it should do. This medication will be given at 0900. 4. This is a slightly abnormal blood pressure but is in acceptable range for someone prescribed an ARB, angiotensin receptor blocker. The medication can be administered at 0900.

15. What is the *priority* problem in the client diagnosed with congestive heart failure? 1. Fluid volume overload 2. Decreased cardiac output 3. Activity intolerance 4. Knowledge deficit

1. Fluid volume overload is a problem in clients with congestive heart failure, but it is not priority because if the cardiac output is improved, then the kidneys are perfused, which leads to elimination of excess fluid from the body. *2. Decreased cardiac output is responsible for all the signs/symptoms associated with CHF and eventually causes death, which is why it is the priority problem.* 3. Activity intolerance alters quality of life, but it is not life threatening. 4. Knowledge deficit is important, but it is not priority over a physiological problem.

Which question should the nurse ask the client who is being admitted to *rule out* infective endocarditis? 1. "Do you have a history of heart attack?" 2. "Have you had a cardiac valve replacement?" 3. "Is there a family history of rheumatic heart disease?" 4. "Do you take nonsteroidal anti-inflammatory medications?"

1. Having a history of MI is not a risk factor for developing infective endocarditis. *2. This is why clients must receive prophylactic antibiotic treatment before dental work and invasive procedures.* 3. A personal history of rheumatic fever, not a family history, increases the risk of developing infective endocarditis. 4. NSAIDs have no effect on the development of infective endocarditis

7. The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking medication with food.

1. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discontinue the medication. *2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored.* 3. ACE inhibitors may cause the client to retain potassium; therefore, the client should not increase potassium intake. 4. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication.

25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

1. If the tablets are not kept in a dark bottle, they will lose their potency. 2. The tablets should burn or sting when put under the tongue. 3. The client should keep the tablets with him in case of chest pain. *4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.*

32. The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk if it is less than 40F. 4. Wear open-toed shoes when ambulating

1. Isometric exercises are weight lifting-type exercises. A client with CAD should perform isotonic exercises, which increase muscle tone, not isometric exercises. 2. The client should walk at least 30 minutes a day to increase collateral circulation. *3. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.* 4. The client should wear good supportive tennis shoes when ambulating, not sandals or other open-toed shoes.

The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The client's chest tube is below the level of the chest. 2. The nursing assistant has the chest tube attached to suction. 3. The nursing assistant allowed the client out of the bed. 4. The nursing assistant uses a bedside commode for the client.

1. Keeping the drainage system lower than the chest promotes drainage and prevents reflux. *2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the nursing assistant.* 3. Ambulation facilitates lung ventilation and expansion; drainage systems are portable to allow ambulation while chest tubes are in place. 4. The client should ambulate, but getting up and using the bedside commode is better than stay- ing in the bed, so no action would be needed.

22. The client diagnosed with a myocardial infarction is on bed rest. The unlicensed nursing assistant is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the assistant to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the nursing assistant for encouraging the client to move legs. 4. Take no action concerning the nursing assistant's behavior.

1. Leg movement is an appropriate action, and the assistant should not be told to stop encouraging it. 2. This behavior is not unsafe or dangerous and should not be reported to the charge nurse. *3. The nurse should praise and encourage assistants to participate in the client's care. Clients on bed rest are at risk for deep vein thrombosis, and moving the legs will help prevent that.* 4. The nurse should praise subordinates for appropriate behavior, especially when it is helping to prevent life-threatening complications.

55. The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement *first*? 1. Administer lidocaine, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client at 200 joules. 3. Assess the client's apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation.

1. Lidocaine is the drug of choice for ventricular tachycardia, but it is not the first intervention. 2. Defibrillation may be needed, but it is not the first intervention. *3. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular defibrillation. If the client's heart is beating, the nurse would then administer lidocaine.* 4. CPR is only performed on a client who is not breathing and does not have a pulse. The nurse must establish if this is occurring first, prior to taking any other action.

12. The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods.

1. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. 2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity. 3. Daily weighing monitors fluid volume status, not activity tolerance. *4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.*

14. Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Mid-epigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema

1. Mid-epigastric pain would support a diagnosis of peptic ulcer disease; pyrosis is belching. *2. Sweating is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.* 3. Intermittent claudication is leg pain secondary to decreased oxygen to the muscle, and pallor is paleness of the skin as a result of decreased blood supply. Neither is an early sign of MI. 4. Jugular vein distension (JVD) and dependent edema are signs/symptoms of congestive heart failure, not of MI.

16. The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? *Select all that apply.* 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.

1. Morphine should be administered intravenously, not intramuscularly. *2. Aspirin is an antiplatelet medication and should be administered orally.* *3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.* 4. The supine position will increase respiratory effort, which will increase myocardial oxygen consumption; the client should be in a semi-Fowler's position. 5. Nitroglycerin, a coronary vasodilator, is administered sublingually, not subcutaneously.

3. Which intervention should the nurse implement with the client diagnosed with dilated cardiomyopathy? 1. Keep the client in the supine position with the legs elevated. 2. Discuss a heart transplant, which is the definitive treatment. 3. Prepare the client for coronary artery bypass graft. 4. Teach the client to take a calcium-channel blocker in the morning.

1. Most clients with dilated cardiomyopathy prefer to sit up with their legs in dependent position. This position causes pooling of blood in the periphery and reduces preload. *2. Without a heart transplant, this client will end up in end-stage heart failure. A transplant is the only treatment for a client with dilated cardiomyopathy.* 3. A bypass is the treatment of choice for a client with occluded coronary arteries. 4. Calcium-channel blockers are contraindicated in clients with dilated cardiomyopathy because they interfere with the contractility of the heart.

The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement *first*? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

1. No fluctuation in the water-seal chamber four hours postinsertion indicates the tubing is blocked; the nurse should not milk the chest tube. *2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle.* 3. Coughing may help push a clot in the tubing into the drainage bottle, but the first intervention is to check and see if the client is lying on the tubing or the tube is kinked somewhere. 4. The insertion site can be assessed, but it will not help determine why there is no fluctuation in the water-seal drainage compartment.

60. Which client problem has *priority* for the client with a cardiac dysrhythmia? 1. Alteration in comfort 2. Decreased cardiac output 3. Impaired gas exchange 4. Activity intolerance

1. Not every cardiac dysrhythmia causes alteration in comfort; angina is caused by decreased oxygen to the myocardium. *2. Any abnormal electrical activity of the heart causes decreased cardiac output.* 3. Impaired gas exchange is the result of pulmonary complications, not cardiac dysrhythmias. 4. Not all clients with cardiac dysrhythmias have activity intolerance.

The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1. The client who had wisdom teeth removed a week ago. 2. The nursing student who received a measles immunization two (2) months ago. 3. The mother with a six (6)-week-old newborn. 4. The client who developed an allergy to aspirin in childhood.

1. Oral surgeries are associated with transient bacteremia, and the client cannot donate for 72 hours after an oral surgery. 2. The client cannot donate blood for one (1) month following rubella immunization. *3. The client cannot donate blood for six (6) months after a pregnancy because of the nutritional demands on the mother.* 4. Recent allergic reactions prevent donation because passive transference of hypersensitivity can occur. This client has an allergy developed during childhood.

65. The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement *first*? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer.

1. Oxygen may be needed, but it is not the first intervention. 2. This would be appropriate to determine if the urine output is at least 30 mL/hr, but it is not the first intervention. *3. The nurse must assess the client to determine if the pain is expected pain secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider.* 4. Using the incentive spirometer will increase the client's alveolar ventilation and help prevent atelectasis, but it is not the first intervention

44. The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the recovery room nurse implement? 1. Assess the client's chest tube output. 2. Monitor the client's chest dressing. 3. Evaluate the client's endotracheal (ET) lip line. 4. Keep the client's affected leg straight.

1. Percutaneous balloon valvuloplasty is not an open-heart surgery; therefore, the chest will not be open and the client will not have a chest tube. 2. This is not an open-heart surgery; therefore, the client will not have a chest dressing. 3. The endotracheal (ET) tube is inserted if the client is on a ventilator, and this surgery does not require Putting the client on a ventilator. *4. In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to prevent hemorrhaging at the insertion site.*

5. The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been *effective*? 1. The client's peripheral pitting edema has gone from 3 to 4. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform activities of daily living without dyspnea. 4. The client has minimal jugular vein distention.

1. Pitting edema from 3 to 4 indicates a worsening of the CHF. 2. The client's ability to take the radial pulse would evaluate teaching, not medical treatment. *3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client's condition is improving. The client's heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.* 4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment.

39. The client has just received a mechanical valve replacement. Which behavior by the client indicates the client *needs more* teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity.

1. Prophylactic antibiotics before invasive procedures prevent infectious endocarditis. 2. The client is undergoing anticoagulant therapy and should use a soft-bristle toothbrush to help prevent gum trauma and bleeding. *3. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) interfere with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore, the client should not take aspirin daily.* 4. The client should alternate rest with activity to prevent fatigue to help decrease the workload of the heart.

68. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus 2. Decreased urine output 3. Hemoptysis 4. Deep vein thrombosis

1. Pulmonary embolus would occur with an embolization of vegetative lesions from the tricuspid valve on the right side of the heart. *2. Bacteria enter the bloodstream from invasive procedures and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues.* 3. Coughing up blood (hemoptysis) occurs when the vegetation breaks off the tricuspid valve in the right side of the heart and enters the pulmonary artery. 4. Deep vein thrombosis is a complication of immobility, not of a vegetative embolus from the left side of the heart.

61. The client is diagnosed with pericarditis. Which are the *most common* signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus 2. Complaints of fatigue and arthralgias 3. Petechiae and splinter hemorrhages 4. Increased chest pain with inspiration

1. Pulsus paradoxus is the hallmark of cardiac tamponade; a paradoxical pulse is markedly decreased in amplitude during inspiration. 2. Fatigue and arthralgias are nonspecific signs/symptoms that usually occur with myocarditis. 3. Petechiae on the trunk, conjunctiva, and mucous membranes and hemorrhagic streaks under the fingernails or toenails occur with endocarditis. *4. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements (deep inspiration, coughing), changes in body position, and swallowing.*

13. Which interventions should the nurse discuss with the client diagnosed with coronary artery disease? *Select all that apply.* 1. Instruct the client to stop smoking. 2. Encourage the client to exercise three (3) days a week. 3. Teach about coronary vasodilators. 4. Prepare client for a carotid endarterectomy. 5. Eat foods high in monosaturated fats.

1. Smoking is the one risk factor that must be stopped totally; there is no compromise. *2. Exercising helps develop collateral circulation and decrease anxiety; it also helps clients to lose weight.* *3. Clients with coronary artery disease are usually prescribed nitroglycerin, which is the treatment of choice for angina.* 4. Carotid endarterectomy is a procedure to remove atherosclerotic plaque from the carotid arteries, not the coronary arteries. 5. The client should eat polyunsaturated fats, not monosaturated fats, to help decrease atherosclerosis.

4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement *first*? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position.

1. Sponging the client's forehead would be appropriate, but it is not the first intervention. 2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. 3. Taking the vital signs would be appropriate, but it is not the first intervention. *4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client's forehead.*

64. The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

1. Steroids, such as prednisone, not NSAIDs, must be tapered off to prevent adrenal insufficiency. 2. NSAIDs will not make clients drowsy. *3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain.* 4. NSAIDs should be taken regularly around the clock to help decrease inflammation, which, in turn, will decrease pain.

14. Which laboratory data *confirm* the diagnosis of congestive heart failure? 1. Chest x-ray (CXR) 2. Liver function tests 3. Blood urea nitrogen (BUN) 4. Beta-type natriuretic peptide (BNP)

1. The CXR will show an enlarged heart, but it is not used to confirm the diagnosis of congestive heart failure. 2. Liver function tests may be ordered to evaluate the effects of heart failure on the liver, but they do not confirm the diagnosis. 3. The BUN is elevated in heart failure, dehydration, and renal failure, but it is not used to confirm congestive heart failure. *4. BNP is a hormone released by the heart muscle in response to changes in blood volume and is used to diagnose and grade heart failure.*

The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse take? 1. Call the HCP to question the order because blood must infuse within four (4) hours. 2. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate. 3. Notify the lab to split each unit into half-units and infuse each half for four (4) hours. 4. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.

1. The HCP has written an appropriate order for this client, who has heart failure, and does not need to be called to verify the order before the nurse implements it. 2. Blood or blood components have a specified amount of infusion time, and this is not eight (8) hours. The time constraints are for the protection of the client. *3. The correct procedure for administering a unit of blood over eight (8) hours is to have the unit split into halves. Each half-unit is treated as a new unit and checked accordingly. This slower administration allows the compromised client, such as one with heart failure, to assimilate the extra fluid volume.* 4. This rate has all ready been determined by the HCP to be unsafe for this client.

73. The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. THe concept of perfusion is identified by the nurse. Which should the nurse implement *first*? 1. Notify the health care provider 2. Call a rapid response team (RRT) 3. Determine the telemetry monitor reading. 4. Push the code blue button.

1. The HCP will be notified but the first action is to call for the Code Blue team and initiate CPR. 2. A rapid response team (RRT) is called to prevent an arrest situation from occurring. This client is in an arrest situation. 3. The client has clinical signs of death; CPR must be initiated and the code team notified. *4. The first action is to immediately notify the code team and initiate CPR per protocol.*

21. The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to *question* administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62.

1. The apical pulse is within normal limits—60 to 100 beats per minute. 2. The serum calcium level is not monitored when calcium channel blockers are given. 3. Occasional PVCs would not warrant immediate intervention prior to administering this medication. *4. The client's blood pressure is low, and a calcium channel blocker would cause the blood pressure to bottom out.*

The client diagnosed with end-stage congestive heart failure is being cared for by the home health nurse. Which intervention should the nurse teach the caregiver? 1. Report any time the client starts having difficulty breathing. 2. Notify the HCP if the client gains more than 3 lb in a week. 3. Teach how to take the clients apical pulse for one full minute. 4. Encourage the client to participate in 30 minutes of exercise a day.

1. The client diagnosed with CHF will be short of breath on exertion and with activity. The significant other should report difficulty breathing not subsiding with rest of stopping activity. *2. Two to three pounds of weight gain reflects fluid retention as a result of heart failure, which warrants notifying the HCP.* 3. The caregiver must not administer the digoxin if the radial pulse is less that 60 bpm. The apical pulse is more difficult to assess in a client than the radial pulse. 4. The client in end-stage CHF is dying and should not exercise daily; activity intolerance as a result of decreased cardiac output is the number-one life-limiting problem.

9. The client with coronary artery disease is prescribed transdermal nitroglycerin, a coronary vasodilator. Which behavior indicates the client *understands* the discharge teaching concerning this medication? 1. The client places the medication under the tongue. 2. The client removes the old patch before placing the new. 3. The client applies the patch to a hairy area. 4. The client changes the patch every 36 hours.

1. The client does not understand how to apply this medication; it is placed on the skin, not under the tongue. *2. This behavior indicates the client understands the discharge teaching.* 3. The patch needs to be in a nonhairy place so that it makes good contact with the skin. 4. The patch should be changed every 12 or 24 hours but never every two (2) hours. It takes two (2) hours for the patch to warm up and begin delivering the optimum dose of medication.

78. The nurse is caring for a client who suddenly complains of crushing substernal pain while ambulating in the hall. Which nursing action should the nurse implement *first*? 1. Call a code blue. 2. Assess the telemetry reading. 3. Take the client's apical pulse. 4. Have the client sit down.

1. The client has not arrested. The nurse might call the rapid response team (RRT) but not a code blue. 2, 3. The client is in distress; the nurse should implement a procedure that will alleviate the distress. *4. The client began to have a problem during physical exertion. Stopping the exertion should be the first action taken by the nurse.*

The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolus. Which action should the nurse implement first? 1. Administer oxygen ten (10) L via nasal cannula. 2. Place the client in a high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.

1. The client needs oxygen, but the nurse can do something that will help the client before applying oxygen. *2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system.* 3. This is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not the first intervention in this situation.

53. Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillating the client.

1. The client should be defibrillated at 200, 300, and 360 joules. 2. The oxygen source should be removed to prevent any type of spark during defibrillation. 3. The nurse should use defibrillator pads or defibrillator gel to prevent any type of skin burns while defibrillating the client. *4. If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout "all clear."*

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? *Select all that apply.* 1. Place the client in a low-Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bed rest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

1. The client should be in a high-Fowler's position to facilitate lung expansion. *2. The system must be patent and intact to function properly.* 3. The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion. *4. Looping the tubing prevents direct pres- sure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue.* *5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.*

3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which intervention should be included in the plan? *Select all that apply.* 1. Notify health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct client to remove the saltshaker from the dinner table. 4. Encourage client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. *2. The client should not take digoxin if radial pulse is less than 60.* *3. The client should be on a low-sodium diet to prevent water retention.* 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct client to take the diuretic in the morning to prevent nocturia.

33. The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take *first* when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.

1. The client should take the coronary vasodilator nitroglycerin sublingually, but it is not the first intervention. *2. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina, chest pain.* 3. The client should keep a diary of when angina occurs, what activity causes it, and how many tablets are taken before chest pain is relieved. 4. If the chest pain (angina) is not relieved with three (3) nitroglycerin tablets, the client should call 911 or have someone take him to the emergency department. Notifying the HCP may take too long.

Which statement by the client indicates the discharge teaching for the client diagnosed with a pulmonary embolus is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a medic alert band at all times."

1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding. 2. This is appropriate for a client with a mechan- ical valve replacement, not a client receiving anticoagulant therapy. 3. Aspirin, enteric-coated or not, is an anti- platelet, which may increase bleeding tendencies and should be avoided. *4. The client should wear a medic alert band at all times so that if any accident or situa- tion occurs, the health-care providers will know the client is receiving anticoagulant therapy.*

2. Which *pre-procedure* information should be taught to the female client having an exercise stress test in the morning? 1. Wear open-toed shoes to the stress test. 2. Inform the client not to wear a bra. 3. Do not eat anything for four (4) hours. 4. Take the beta blocker one (1) hour before the test.

1. The client should wear firm-fitting, solid athletic shoes. 2. The client should wear a bra to provide adequate support during the exercise. *3. NPO decreases the chance of aspiration in case of emergency. In addition, if the client has just had a meal, the blood supply will be shunted to the stomach for digestion and away from the heart, perhaps leading to an inaccurate test result.* 4. A beta blocker is not taken prior to the stress test because it will decrease the pulse rate and blood pressure by direct parasympathetic stimulation to the heart.

12. The unlicensed nursing assistant comes and tells the primary nurse that the client diagnosed with coronary artery disease is having chest pain. Which action should the nurse take first? 1. Tell the assistant to go take the client's vital signs. 2. Ask the assistant to have the telemetry nurse read the strip. 3. Notify the client's health-care provider. 4. Go to the room and assess the client's chest pain.

1. The client with CAD who is having chest pain is unstable and requires further judgment to determine appropriate actions to take, and the assistant does not have that knowledge. 2. The assistant could go ask the telemetry nurse, but this is not the first action. 3. The client's HCP may need to be notified, but this is not the first intervention. *4. Assessment is the first step in the nursing process and should be implemented first; chest pain is priority.*

11. The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily.

1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. *2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.* 3. Weight gain is monitored in clients with CHF and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. 4. Ambulating frequently and performing leg stretching exercises will not be effective in alleviating the leg cramps.

The client is admitted to the emergency department with chest trauma. When assessing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy bloody sputum and consolidation. 4. Barrel chest and polycythemia.

1. The client with pneumothorax would have absent breath sounds and tachypnea. *2. Unequal lung expansion and dyspnea would indicate a pneumothorax.* 3. Consolidation occurs when there is no air moving through the alveoli as in pneumonia; frothy sputum occurs with congestive heart failure. 4. Barrel chest and polycythemia are signs of chronic obstructive pulmonary disease.

The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.

1. The client would not be experiencing abnor- mal bleeding with this INR. 2. This is the antidote for an overdose of antico- agulant and the INR does not indicate this. *3. A therapeutic INR is 2-3; therefore, the nurse should administer the medication.* 4. There is no need to increase the dose; this result is within the therapeutic range.

27. The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement *after* the procedure? 1. Perform passive range of motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high-Fowler's position. 4. Assess the gag reflex prior to feeding the client.

1. The client's right leg should be kept straight to prevent arterial bleeding from the femoral insertion site for the catheter used to perform the catheterization. *2. The nurse must make sure that blood is circulating to the right leg so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.* 3. The head of the bed should be elevated no more than 10 degrees. The client should be kept on bed rest, flat with the affected extremity straight, to help decrease the chance of femoral artery bleeding. 4. The gag reflex is assessed if a scope is inserted down the trachea (bronchoscopy) or esophagus (endoscopy) because the throat is numbed when inserting the scope. A catheter is inserted in the femoral or brachial artery when performing a cardiac catheterization.

67. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client *needs more* teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

1. The full course of antibiotics must be taken to help ensure complete destruction of streptococcal infection. 2. Antibiotics kill bacteria but also destroy normal body flora in the vagina, bowel, and mouth, leading to a superinfection. *3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.* 4. A throat culture is taken to diagnose group A beta hemolytic streptococcus and is positive in 25%-40% of clients with acute rheumatic fever.

The client has a right-sided chest tube. As the client is getting out of the bed it is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

1. The health-care provider will have to be noti- fied, but this is not the first intervention. Air must be prevented from entering the pleural space from the outside atmosphere. 2. The client should breathe regularly or take deep breaths until the tubes are reinserted. 3. The nurse must take action and prevent air from entering the pleural space. *4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.*

The client receiving a continuous heparin drip complains of sudden chest pain on inspiration and tells the nurse, "Something is really wrong with me." Which intervention should the nurse implement *first*? 1. Increase the heparin drip rate. 2. Notify the health-care provider. 3. Assess the client's lung sounds. 4. Apply oxygen via nasal cannula.

1. The heparin drip may be increased because the client has now thrown a pulmonary embolus (PE), but this needs an HCP's order. 2. The HCP will be notified because the client has a suspected embolus, but it is not the first intervention. 3. The client has probably thrown a pulmonary embolus, and assessing the lungs will not do anything for a client who may die. PEs are life threatening, and assessing the client is not priority in a life-threatening situation. *4. The client probably has a pulmonary embolus, and the priority is to provide additional oxygen so oxygenation of tissues can be maintained.*

76. The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data *support* this concept? 1. The client has a large abdomen and a positive tympanic wave. 2. The client has paroxysmal nocturnal dyspnea. 3. The client has 2+ glucose in the urine 4. The client has a comorbid condition of MI.

1. The indicates ascites, which can happen in heart failure but does not necessarily do so; it can also be liver failure or another issue. *2. Dyspnea occurring at night when the client is in recumbent position indicates that cardiac muscle is not able to compensate for extra fluid returning to the heart during sleep.* 3. The could indicate diabetes but not heart failure. 4. The client is at risk for heart failure as a result of the MI, but it does not happen with all MI clients and does not support the diagnosis.

The client has just been diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bed rest.

1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. 2. The client's respiratory system will be assessed, not the gastrointestinal system. 3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. *4. Bed rest reduces metabolic demands and tissue needs for oxygen.*

The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is two thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. 4. The client diagnosed with Crohn's disease who is complaining of perineal discomfort.

1. The likelihood of a client who has already received more than half of the blood product having a transfusion reaction is slim. The first 15 minutes have passed and to this point the client is tolerating the blood. 2. Clients diagnosed with leukemia have a cancer involving blood cell production. These are expected findings in a client diagnosed with leukemia. *3. This client has a potential for hemorrhage and is reporting blood in the vomitus. This client should be assessed first.* 4. Crohn's disease involves frequent diarrhea stools, leading to perineal irritation and skin excoriation. This is expected and not life threatening. Clients "1," "2," and "3" should be seen before this client.

15. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement *first*? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs.

1. The nurse must assume the chest pain is secondary to decreased oxygen to the myocardium and administer a sublingual nitroglycerin, which is a coronary vasodilator, but this is not the first action. 2. An ECG should be ordered, but it is not the first intervention. *3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.* 4. Assessment is often the first nursing intervention, but when the client has chest pain and a possible MI, the nurse must first take care of the client. Taking vital signs would not help relieve chest pain.

72. The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented *first*? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bed rest with bathroom privileges.

1. The nurse must obtain blood cultures prior to administering antibiotics. *2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify.* 3. An echocardiogram allows visualization of vegetations and evaluation of valve function. However, antibiotic therapy is priority before diagnostic tests, and blood cultures must be obtained before administering medication. 4. Bed rest should be implemented, but the first intervention should be obtaining blood cultures so that antibiotic therapy can be started as soon as possible.

29. Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

1. The nurse should always assess the apical pulse, but the pulse is not affected by a loop diuretic. *2. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication.* 3. The glucometer provides a glucose level, which is not affected by a loop diuretic. 4. The pulse oximeter reading evaluates peripheral oxygenation and is not affected by a loop diuretic.

19. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement *first*? 1. Call a code immediately. 2. Assess the client for a pulse. 3. Begin chest compressions. 4. Continue to monitor the client

1. The nurse should call a code if the client does not have vital signs. *2. The nurse must first determine if the client has a pulse. Pulseless ventricular tachycardia is treated as ventricular fibrillation. Stable ventricular tachycardia is treated with medications.* 3. Chest compression is only done if the client is not breathing and has no pulse. 4. Ventricular tachycardia is a potentially life-threatening dysrhythmia and needs to be treated immediately.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. *2. The insertion of a chest tube is an invasive procedure and so requires informed con- sent. Without a consent form, this procedure cannot be done on an alert and oriented client.* 3. This is a correct position to place the client for a chest tube insertion, but it is not the first intervention. 4. The physician will discuss the procedure with the client, then informed consent must be obtained, and then the nurse can do further teaching.

18. The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement *first*? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.

1. The nurse should medicate the client as needed, but it is not the first intervention. *2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.* 3. Turning will help decrease complications from immobility, such as pneumonia, but it will not help relieve the client's pain. 4. The nurse, not a machine, should always take care of the client.

82. The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse *question*? 1. Furosemide IVP to a client with a potassium level of 3.6 mEq/L. 2. Digoxin orally to a client diagnosed with rapid atrial fibrillation. 3. Enalapril orally to a client whose BP is 86/64 and apical pulse 65. 4. Morphine IVP to a client complaining of chest pain and who is diaphoretic.

1. The potassium level is within normal range; this medication would not be questioned. 2. Digoxin is given to clients with rapid atrial fibrillation to slow the heart rate; this medication would not be questioned. *3. Enalopril an ACE inhibitor, will lower the blood pressure even more. The nurse should hold the medication and notify the HCP that the medication is being held.* 4. This would be the first medication to be administered because it indicates a potential cardiac muscle perfusion issue.

17. The client is diagnosed with a myocardial infarction. Which referral would be *most appropriate* for the client? 1. Social worker 2. Physical therapy 3. Cardiac rehabilitation 4. Occupational therapist

1. The social worker addresses financial concerns or referrals after discharge, which is not indicated for this client. 2. Physical therapy addresses gait problems, lower-extremity strength building, and assisting with transfer, which is not required for this client. *3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation, which includes progressive exercise, diet teaching, and classes on modifying risk factors.* 4. Occupational therapy addresses the client in regaining activities of daily living and covers mainly fine motor activities.

49. The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement *first*? 1. Go to the client's room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client's room.

1. The telemetry nurse should not leave the monitors unattended at any time. 2. The telemetry nurse must have someone go assess the client, but this is not the first intervention. *3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor.* 4. The crash cart should be taken to a room when the client is experiencing a code.

58. The client that is one (1)-day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain.

1. The telemetry reading is accurate, and there is no need for the client to assess the client heart rate. 2. There is no reason to notify the surgeon for a client exhibiting sinus tachycardia. 3. Synchronized cardioversion is prescribed for clients in acute atrial fibrillation or ventricular fibrillation with a pulse. *4. Sinus tachycardia means the sino-atrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia.*

88. The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instructions should the nurse teach the client? 1. Call the health care provider if any chest pain happens. 2. Discuss when the client can resume sexual activity. 3. Explain the pharmacology of nitroglycerin tablets. 4. Encourage the client to sleep with the head of bed elevated.

1. The word "any" make this a wrong option. The nurse should teach the client what to do if chest pain occurs. Take one nitroglycerin tablet every 5 minutes times three (3), and if not relieved call 911. *2. The nurse should make sure the client is aware of when sexual activity can be safely resumed.* 3. The client needs to know how to take nitroglycerin but not the pharmacology of how the mediation works. 4. The client can sleep in any position of comfort.

50. The client shows ventricular fibrillation on the telemetry at the nurse's station. Which action should the telemetry nurse implement *first*? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation

1. There are many interventions that should be implemented prior to administering medication. 2. The treatment of choice for ventricular fibrillation is defibrillation, but it is not the first action. *3. The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.* 4. The first person at the bedside should start cardiopulmonary resuscitation (CPR), but the telemetry nurse should call a code so that all necessary equipment and personnel are at the bedside.

The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data would warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions. 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

1. These ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. *3. The normal pulse oximeter reading is 93%-100%. A reading of 90% indicates the client has an arterial oxygen level of around 60.* 4. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/ hour, and this would not warrant immediate intervention by the nurse.

21. The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement? 1. Notify the health-care provider. 2. Document that the pericarditis has resolved. 3. Ask the client to lean forward and listen again. 4. Prepare to insert a unilateral chest tube.

1. These assessment data are not life-threatening and do not warrant notifying the HCP. 2. The nurse should attempt to hear the friction rub in multiple ways before documenting that it is not heard. The nurse does not determine if pericarditis has resolved. *3. Having the client lean forward and to the left uses gravity to force the heart nearer to the chest wall, which allows the friction rub to be heard.* 4. Chest tubes are not the treatment of choice for not hearing a friction rub.

24. The client has just returned from a cardiac catheterization. Which assessment data would warrant *immediate* intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

1. These vital signs are within normal limits and would not require any immediate intervention. 2. The groin dressing should be dry and intact. *3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.* 4. The nurse must check the neurovascular assessment, and paresthesia would warrant immediate intervention, but no numbness and tingling is a good sign.

28. The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to *question* administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.

1. This blood pressure is normal and the nurse would administer the medication. *2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.* 3. A headache will not affect administering the medication to the client. 4. The potassium level is within normal limits, but it is usually not monitored prior to administering a beta blocker.

36. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a *new graduate* nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.

1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching, so this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. *3. A new graduate should be able to complete a pre-procedure checklist and get this client to the catheterization lab.* 4. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate.

10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the *most experienced* registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough.

1. This client is stable because discharge is scheduled for the following day. Therefore, this client does not need to be assigned to the most experienced registered nurse. 2. This client requires more custodial nursing care than care from the most experienced registered nurse. Therefore the charge nurse could assign a less experienced nurse to this client. *3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.* 4. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration. This client does not require the care of an experienced nurse as much as does the client with signs of shock.

48. The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a *new graduate* that just completed orientation to the medical floor? 1. The client admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) days post-myocardial infarction who is being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation who has an INR of five (5).

1. This client requires teaching and an understanding of the pre-procedure interventions for diagnostic tests; therefore a more experienced nurse should be assigned to this client. *2. Because this client is being discharged, it would be an appropriate assignment for the new graduate.* 3. Supraventricular tachycardia (SVT) is not life threatening, but the client requires intravenous medication and close monitoring and therefore should be assigned to a more experienced nurse. 4. A client with atrial fibrillation is usually taking the anticoagulant warfarin (Coumadin) and the therapeutic INR is 2-3. An INR of 5 is high and the client is at risk for bleeding.

Which assessment data would support that the client has experienced a pulmonary embolus? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

1. This is a sign of a deep vein thrombosis, which is a precursor to a PE, but it is not a sign of a pulmonary embolism. *2. The most common signs of a PE are sudden onset of chest pain when taking a deep breath and shortness of breath.* 3. These are signs of a myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications, but not specifically a PE.

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.

1. This is an expected finding in the suction compartment of the drainage system that indicates adequate suctioning is being applied. *2. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective. * 3. Blood in the drainage bottle is expected for a hemothorax but does not indicate the chest tubes have reexpanded the lung 4. Taking a deep breath without pain is good, but it does not mean the lungs have reexpanded.

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

1. This is incorrect information. It is the description of a spontaneous pneumothorax. 2. This is the description of an open pneumothorax. *3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.* 4. This is called an iatrogenic pneumothorax, which also may be caused by thoracentesis or lung biopsy. A tension pneumothorax could occur from this procedure, but it does not describe a tension pneumothorax.

6. To what area should the nurse place the stethoscope to best auscultate the apical pulse? 1. Above the right clavicle 2. Midsternal line at top 3. Erbs point 4. Mitral area

1. This is the best place to auscultate the aortic valve, the second intercostal right sternal notch. 2. This is the best place to auscultate the pulmonic valve, the second intercostal space left sternal notch. 3. This is the best place to auscultate the tricuspid valve, the third intercostal space left sternal border. *4. The best place to auscultate the apical pulse is over the mitral valve area, which is the fifth intercostal space midclavicular line.*

24. The client is three (3) hours post-myocardial infarction. Which data would *warrant immediate* intervention by the nurse? 1. Bilateral peripheral pulses two (2) 2. The pulse oximeter reading is 96% 3. The urine output is 240 mL in the last four (4) hours 4. Cool, clammy, diaphoretic skin

1. This pulse indicates the heart is pumping adequately. Normal pulses should be 2 to 3. 2. A pulse oximeter reading of greater than 93% indicates the heart is perfusing the periphery. 3. An output of 30 mL/hr indicates the heart is perfusing the kidneys adequately. *4. Cold, clammy skin is an indicator of cardiogenic shock, which is a complication of MI and warrants immediate intervention.*

The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.

1. This should be done but after preventing any more of the PRBCs from infusing. 2. Benadryl may be administered to reduce the severity of the transfusion reaction, but it is not first priority. 3. The nurse should assess the client, but in this case the nurse has all the assessment data needed to stop the transfusion. *4. The priority in this situation is to prevent a further reaction if possible. Stopping the transfusion and changing the fluid out at the hub will prevent any more of the transfusion from entering the client's bloodstream.*

The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and crossmatch for red blood cells immediately (STAT). 2. Initiate an IV with an 18-gauge needle and hang normal saline. 3. Have the client sign a consent for an exploratory laparotomy. 4. Notify the significant other of the client's admission.

1. This should be done, but the client requires the IV first. This client is at risk for shock. *2. The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible.* 3. The client will probably need to have surgery to correct the source of the bleeding, but stabilizing the client with fluid resuscitation is first priority. 4. This is the last thing on this list in order of priority.

38. Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency? 1. A loud S1, S2 split, and a mitral opening snap. 2. A holosystolic murmur heard best at cardiac apex. 3. A mid-systolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the 3rd left intercostal space.

1. This would be expected with mitral valve stenosis. *2. The murmur associated with mitral valve insufficiency is loud, high-pitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex.* 3. This would be expected with mitral valve prolapse. 4. This would be expected with aortic regurgitation.

17. The nurse is caring for clients on a cardiac floor. Which client should the nurse assess *first*? 1. The client with three (3) unifocal PVCs in a minute. 2. The client diagnosed with coronary artery disease that wants to ambulate. 3. The client diagnosed with mitral valve prolapse with an audible S3. 4. The client diagnosed with pericarditis that is in normal sinus rhythm.

1. Three (3) unifocal PVCs in a minute is not life threatening. 2. The client wanting to ambulate is not a priority over a client with a physiological problem. *3. An audible S3 indicates the client is developing left-sided heart failure and needs to be assessed immediately.* 4. A client in normal sinus rhythm will not be priority over someone with a potentially life-threatening situation.

The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? *Select all that apply.* 1. The client has spontaneous bleeding from around the IV site. 2. The client complains of chest pain on inspiration and has become restless. 3. The client's platelet count on admission was 420 and now is 200. 4. The client complains that the gums bleed when brushing the teeth. 5. The client has developed skin lesions at the IV site.

1. Type 2 HIT is an immune mediated disorder that typically occurs after exposure to heparin for 4 to 10 days and has life-threatening and limb-threatening thrombotic complications. The client clots rather than bleeds. Spontaneous bleeding is not associated with HIT. In general practice type 2 HIT is referred to as simple HIT. *2. HIT is not manifested by bleeding but by the development of clots, either deep venous or pulmonary, and sometimes arterially, which can cause a myocardial infarction. These are symptoms of a pulmonary embolus.* *3. HIT is a decrease in baseline platelet count by 50% of baseline.* 4. Bleeding is not associated with HIT

The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP? 1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received 10 units of platelets in brushing the teeth.

1. UAPs cannot assess. The nurse cannot delegate assessment. 2. The likelihood of a reaction is the greatest during the first 15 minutes of a transfusion. The nurse should never leave the client until after this time. The nurse should take and assess the vital signs during this time. 3. Auscultation of the lung sounds and administering blood based on this information are the nurse's responsibility. Any action requiring nursing judgment cannot be delegated. *4. The UAP can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding gums should be given prior to delegating the procedure.*

26. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. Which is the order of basic CPR? List in order of performance. 1. Perform head tilt chin lift. 2. Give two (2) rescue breaths. 3. Look, listen, and feel for breathing. 4. Begin cardiac compressions. 5. Shake and shout.

In the order of performance: 5, 1, 3, 2, 4 5. The first step in CPR is to determine if the client is unresponsive. 1. The rescuer performs the head tilt chin lift maneuver to open the client's airway. 3. The next action must be to determine if the client is breathing. 2. If the rescuer determines the client is not breathing, then two (2) rescue breaths should be given. 4. After determining that the client has no pulse, the rescuer begins compression.