Day 1: Test Taking Strategy

The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective? 1. "Elevating the affected leg is indicated." 2. "Keeping the affected leg flat encourages healing." 3."Engaging in activity as tolerated should be encouraged." 4."Maintaining bathroom privileges is the most important action."

1. "Elevating the affected leg is indicated." Rationale:The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart, decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bed rest. Test-Taking Strategy(ies):Note the strategic word, effective, and focus on the subject, thrombophlebitis, and think about the pathophysiology associated with this condition and how gravity affects venous blood flow and edema. This will direct you to the correct option.Review:the nursing care for a client with thrombophlebitis. Tip for the Nursing Student:Thrombophlebitis is an inflammation of a vein, often accompanied by clot formation that can present serious circulatory problems.

A client who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action should the nurse take? 1. Call the primary health care provider. 2. Administer an opioid analgesic. 3. Apply warm moist heat for comfort. 4. Apply ice to minimize any developing swelling.

1. Call the primary health care provider. Rationale:Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the primary health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion. Options 2, 3, and 4 are incorrect actions Test-Taking Strategy(ies):Focus on the subject, a postoperative client who had peripheral arterial bypass surgery. Note the words "increasing pain." Also note that the surgery was 16 hours ago. The signs and symptoms described indicate a new problem. These factors should indicate that the primary health care provider needs to be notified. Tip for the Nursing Student:After arterial bypass surgery, warmth, redness, and edema of the affected extremity are expected occurrences because of the increased blood flow to the area.

Which clients are most likely at risk for a deep vein thrombosis (DVT)? Select all that apply. 1. Client with cancer 2. Client with cirrhosis 3. Client with a previous DVT 4. Client with ulcerative colitis 5. Client with spinal cord injury 6. Client with chronic kidney disease

1. Client with cancer 3. Client with a previous DVT 4. Client with ulcerative colitis 5. Client with spinal cord injury Rationale:A deep vein thrombosis (DVT) is a disorder involving a thrombus in one of the deep veins of the body, most commonly the iliac or femoral veins. Certain conditions predispose the client to higher incidence of a DVT such as those with history of active cancer, previous DVT, ulcerative colitis, and spinal cord injury. Cirrhosis and chronic kidney disease are not associated with the formation of a DVT. Test-Taking Strategy(ies):Note the strategic words, "most likely." Think about the pathophysiology associated with DVT formation and how it relates to Virchow's triad: blood stasis, endothelial injury, and hypercoagulability. Next, recall that certain chronic conditions predispose the client to a DVT.Review:Deep vein thrombosis (DVT).

A client diagnosed with angina pectoris is extremely anxious after being hospitalized. Which should the nurse do to minimize the client's anxiety? 1. Provide care choices to the client. 2. Keep the door open and the hallway lights on at night. 3.Encourage the client to limit visitors to as few as possible. 4.Arrange for the client to share a room with a cognitively alert client.

1. Provide care choices to the client. Rationale:General interventions to minimize anxiety in the hospitalized client include providing information, social support, and control over choices related to care, as well as acknowledging the client's feelings. Leaving the door open with the hallway lights on may keep the client oriented, but these actions may interfere with sleep and increase anxiety. Limiting visitors reduces social support. The sharing of a room may not necessarily meet the client's needs. Tip for the Nursing Student: Angina pectoris is chest pain resulting from myocardial ischemia caused by inadequate myocardial blood and oxygen supply. In addition to anxiety, the client with angina may experience dyspnea, pallor, sweating, palpitations and tachycardia, dizziness and faintness, hypertension, or digestive disturbances.

The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement? 1. "I need to avoid doing anything where there would be rough contact with the ICD insertion site." 2. "I can perform activities such as swimming, driving, or operating heavy equipment as I need to do them." 3. "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cut-off on the ICD." 4. "I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors as well as running motors."

2. "I can perform activities such as swimming, driving, or operating heavy equipment as I need to do them." Rationale:Postdischarge instructions typically include avoiding the following: tight clothing or belts over the ICD insertion site; rough contact with the ICD insertion site; electromagnetic fields, such as those surrounding electrical transformers; radio, television, and radar transmitters; metal detectors; and the running motors of cars or boats. Clients must also alert health care providers or dentists to the presence of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a primary health care provider regarding activities that are potentially hazardous to the self or others, such as swimming, driving, or operating heavy equipment. Test-Taking Strategy(ies):Note the strategic words, further instruction is needed, and that this indicates a negative event query. Options 1 and 3 can be eliminated because they are comparable or alike to standard post-pacemaker insertion instructions. From the remaining choices, noting the words heavy equipment will direct you to the correct option.

On the cardiac monitor, the nurse notes that a client is demonstrating an irregular rhythm, with no P waves, normal QRS complex, and a rapid ventricular response at 120 beats per minute. Which cardiac rhythm is being displayed on the monitor? 1. Atrial fibrillation 2. Sinus bradycardia 3. Normal sinus rhythm 4.Ventricular fibrillation

1. Atrial fibrillation Rationale:Atrial fibrillation or commonly called "A fib" is characterized by erratic or no identifiable P waves. In clients with this type of atrial dysrhythmia, the rhythm is irregular, QRS complex measurements are normal, and there can be a rapid ventricular response due to the erratic atria activity. Sinus bradycardia is defined as a heart rate below 60 beats per minute. The PR and QRS measurements are normal, measuring 0.12 to 0.2 second and 0.04 to 0.1 second, respectively. Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats per minute. Ventricular fibrillation is a life-threatening cardiac rhythm where there is no blood circulation. There are no P waves and the rhythm is chaotic. Test-Taking Strategy(ies):Focus on the subject, electrocardiogram rhythm strip and the details provided. Recalling that the ECG measurements noted in the question associate with this irregular atrial dysrhythmia will direct you to the correct option.Review:Electrocardiogram (ECG) and normal sinus rhythm. Tip for the Nursing Student:Sinus tachycardia is defined as a heart rate greater than 100 beats per minute.

The nurse provides discharge instructions to the client with thromboangiitis obliterans (Buerger's disease). The nurse evaluates that the teaching provided was effective if the client makes which statements? Select all that apply. 1. "I will need to take nifedipine as directed." 2."I will cut down my smoking to 2 cigarettes per day." 3. "I need to keep my legs and arms cool from the heat." 4. "I need to watch for signs and symptoms of skin breakdown." 5. "I will keep my legs elevated above heart level to improve circulation."

1. "I will need to take nifedipine as directed." 4. "I need to watch for signs and symptoms of skin breakdown." Rationale:Thromboangiitis obliterans (Buerger's disease) is an occlusive disease of the median and small arteries and veins. Interventions are directed at preventing the progression of thromboangiitis obliterans and include conveying the need for immediate smoking cessation and providing medications prescribed for vasodilation, such as nifedipine, a calcium channel blocker, or prazosin, an alpha-adrenergic blocking agent. The client should maintain warmth to the extremities, especially by avoiding exposure to cold to prevent vasoconstriction. The client should inspect the extremities and report signs of infection or ulceration. Teach the client to avoid elevating the extremities above heart level, because this position will decrease blood flow to the affected areas. T est-Taking Strategy(ies):Note the strategic word, effective. Because the goals of care for thromboangiitis obliterans are the same as for peripheral arterial disease, the answers to this question are the ones that promote vasodilation.Review:Home care measures for the client with thromboangiitis obliterans (Buerger's disease).

The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data? 1. A normal finding 2. An abnormal finding 3. An impending reinfarction 4.First-degree atrioventricular (AV) block

1. A normal finding Rationale:The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses. Tip for the Nursing Student:When performing an ECG, the nurse should document on the ECG requisition form any cardiac medications the client is taking.

The nurse is planning care for a client with the diagnosis of deep vein thrombosis (DVT) of the left leg. The client is experiencing severe edema and pain in the affected extremity. Which interventions should the nurse plan to implement in the care of this client? Select all that apply. 1. Elevate the left leg. 2. Apply moist heat to the left leg. 3. Administer acetaminophen as prescribed. 4. Ambulate in the hall three times per shift. 5. Administer anticoagulation as prescribed.

1. Elevate the left leg. 2. Apply moist heat to the left leg. 3. Administer acetaminophen as prescribed. 5. Administer anticoagulation as prescribed. Rationale:Management of the client with DVT who is experiencing severe edema and pain includes bed rest; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. In current practice, activity restriction may not be prescribed if the client is receiving low-molecular-weight anticoagulation; however, some primary health care providers may still prefer bed rest for the client. Test-Taking Strategy(ies):Focus on the subject, deep vein thrombosis (DVT). Noting that the client is experiencing severe edema and pain and recalling the complications associated with DVT will direct you to the correct options.Review:care of the client with deep vein thrombosis (DVT). Tip for the Nursing Student:The client with deep vein thrombosis is at risk for pulmonary embolism.

A client diagnosed with coronary artery disease suddenly reports feeling palpitations and an irregular heartbeat. Which assessment finding will determine whether the client is experiencing an inadequate stroke volume? 1. Pulse deficit 2. Pulse pressure 3. Pulsus alternans 4. Water hammer pulse

1. Pulse deficit Rationale:Palpitations are often a subjective complaint that accompanies dysrhythmias. Irregular rhythms produce varying strengths of stroke volume because of irregular ventricular filling times, and, therefore, arterial pulsations may become weakened or intermittently absent. The nurse determines this by assessing an apical-radial pulse. An apical rate that is greater than the radial rate is called a pulse deficit. The pulse pressure is the difference between the systolic and diastolic blood pressures. Pulsus alternans has a regular rhythm accompanied by pulse volume that alternates strong with weak. A water hammer pulse (Corrigan's pulse) is a bounding pulse in which a great surge is felt, followed by a sudden and complete absence of force or fullness in the artery. This type of pulse is associated with aortic regurgitation. Test-Taking Strategy(ies):Focus on the subject, assessment for inadequate stroke volume. Remember that stroke volume × heart rate = cardiac output. Measures that give a general indication of cardiac output are not specific enough to answer this question; therefore, eliminate options 2 and 4. Pulsus alternans occurs with a regular rhythm, so it can also be eliminated. Tip for the Nursing Student:To assess for a pulse deficit by a one-examiner technique, the nurse should auscultate and count the apical heartbeat first and then immediately palpate and count the radial pulse and compare the difference. In a two-examiner technique, the apical and radial rates are counted at the same time.

The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy should the nurse plan to incorporate into the care of the client? 1. Reducing anxiety 2. Increasing fluid volume 3. Decreasing cardiac output 4.Promoting a positive body image

1. Reducing anxiety Rationale:Reducing anxiety will help the client during treatment to increase cardiac output and decrease fluid volume. When cardiac output falls as a result of acute pulmonary edema, the sympathetic nervous system is stimulated. Stimulation of the sympathetic nervous system results in the fight-or-flight reaction, which further impairs cardiac function. A disturbed body image is not a common problem among clients with acute pulmonary edema. Test-Taking Strategy(ies):Focus on the subject, a psychosocial strategy for the client with acute pulmonary edema. Thinking about the physiological occurrences of this condition will assist you with eliminating the remaining options. In addition, recalling that severe dyspnea occurs should assist with directing you to the correct option.Review:the care of the client with pulmonary edema. Tip for the Nursing Student:If pulmonary edema occurs, the initial nursing action is to place the client in a high-Fowler's position.

A client comes to the health care clinic with reports of leg pain and cramping after hiking a few miles in the woods. The nurse should ask the client whether the pain is relieved by which action? 1. Stopping activity and resting 2. Elevating the legs and stretching the calves 3. Taking analgesic medication, such as acetaminophen 4. Taking anti-inflammatory medication, such as ibuprofen

1. Stopping activity and resting Rationale:Intermittent claudication (pain in the muscles) is a classic symptom of peripheral vascular disease, also known by other names, including peripheral arterial disease and chronic arterial insufficiency. It is described as a cramplike pain that occurs with exercise and is relieved by rest. Option 2 is incorrect, because this action would aggravate the pain. Medications do not relieve the pain, because the pain is caused by tissue ischemia. Measures that increase the circulation are much more effective. Tip for the Nursing Student:Intermittent claudication results from an inadequate blood supply to the extremities.

The nurse obtains an electrocardiogram (ECG) rhythm strip for an adult client who is anxious about the results. The ECG shows that the heart rate is 90 beats per minute. Which statement should the nurse make to the client to relieve anxiety? 1. The rate is normal. 2. There is no need to worry. 3.A slower heart rate is preferred. 4.Medication specific to the problem will be prescribed.

1. The rate is normal. Rationale:A normal adult resting pulse rate ranges between 60 and 100 beats per minute; therefore, the rate is normal. The nurse would not tell a client not to worry. Options 3 and 4 indicate that the ECG is abnormal. Test-Taking Strategy(ies):Recall knowledge of the basic range of pulse rates for an adult. Option 2 is not therapeutic because telling the client not to worry is an inappropriate action. Eliminate options 3 and 4 because they are comparable or alike and indicate that a problem exists.Review:the normal adult vital signs. Tip for the Nursing Student:Obtaining a baseline measurement of the client's vital signs will allow the nurse to determine any changes. The nurse can also measure the client's pulse rate and blood pressure in sitting, standing, and lying positions and compare the readings.

A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply. 1. Use pneumatic compression boots. 2. Maintain bed rest for 24 to 48 hours. 3. Assist with range-of-motion leg exercises. 4. Elevate the knees with the knee gatch on the bed. 5.Remove antiembolism stockings twice daily for assessment.

1. Use pneumatic compression boots. 3. Assist with range-of-motion leg exercises. 5.Remove antiembolism stockings twice daily for assessment. Rationale:The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis Test-Taking Strategy(ies):Focus on the subject, the risk of deep vein thrombosis or thrombophlebitis. Thinking about the pathophysiology and the causes associated with this complication will direct you to the correct options.Review:care of the client after hysterectomy and deep vein thrombosis or thrombophlebitis.

A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further teaching if which statement was made by the client? 1. "I need to eat a balanced diet." 2. "A heating pad on my leg will help soothe the leg pain." 3. "I need to take special care of my feet to prevent injury." 4."I should walk daily to increase the circulation to my legs."

2. "A heating pad on my leg will help soothe the leg pain." Rationale:The application of heat directly to the extremity is contraindicated. The limb may have decreased sensitivity and be more at risk for burns. Additionally, the direct application of heat raises the oxygen and nutritional requirements of the tissue even further. The long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition) Test-Taking Strategy(ies):Focus on the client's diagnosis of peripheral arterial disease, and note the strategic words, needs further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Noting the word heating in option 2 will direct you to the correct option.Review:the teaching points related to peripheral arterial disease. Tip for the Nursing Student:In severe cases of peripheral arterial disease, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright (without leg elevation) in a chair for comfort.

The nurse teaches a client at risk for coronary artery disease about lifestyle changes needed to reduce his risks. The nurse determines that the client understands these necessary lifestyle changes if the client makes which statements? Select all that apply. 1. "I will attempt to stop smoking." 2. "I will be sure to include some exercise such as walking in my daily activities." 3. "I will work at losing some weight so that my weight is at normal range for my age." 4. "I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs." 5. "It is acceptable to eat red meat and cheese every day as I have been doing, as long as I cut down on the butter." 6. "I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure."

2. "I will be sure to include some exercise such as walking in my daily activities." 3. "I will work at losing some weight so that my weight is at normal range for my age." 4. "I will limit my sodium intake every day and avoid eating high-sodium foods such as hot dogs." 6. "I will schedule regular doctor appointments for physical examinations and monitoring my blood pressure." Rationale:Coronary artery disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. Modifiable risk factors include elevated serum cholesterol levels, cigarette smoking, hypertension, impaired glucose tolerance, obesity, physical inactivity, and stress. The client is instructed to stop smoking (not cut down), and the nurse should provide the client with resources to do so. The client is also instructed to maintain a normal weight and include physical activity in the daily schedule. The client needs to limit sodium intake and foods high in cholesterol, including red meat and cheese. The client must follow up with regular primary health care provider appointments for physical examinations and monitoring blood pressure. Test-Taking Strategy(ies):Focus on the subject, lifestyle changes to reduce the risk of coronary artery disease. Think about the pathophysiology associated with coronary artery disease. Read each option carefully and recall that coronary artery disease affects the arteries that provide blood, oxygen, and nutrients to the myocardium. This will assist in selecting the correct options.Review:the lifestyle changes to reduce the risk of coronary artery disease.

A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat? 1. A regular apical pulse 2. An irregular apical pulse 3. A very slow regular apical pulse 4. A very rapid regular apical pulse

2. An irregular apical pulse Rationale:The most accurate means of assessing pulse rhythm is by auscultation of the apical pulse. When a client has PVCs, the rate is irregular and if the radial pulse is taken, a true picture of what is occurring is not obtained. A very slow regular apical pulse indicates bradycardia. A very rapid regular apical pulse indicates tachycardia. Test-Taking Strategy(ies):Focus on the subject, PVCs. Eliminate options 1, 3, and 4 that are comparable or alike and indicate a regular pulse.Review:the manifestations associated with premature ventricular contractions (PVCs).

A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse should assess the client for what manifestation? 1. Weight loss 2. Bilateral crackles 3. Distended neck veins 4. Peripheral pitting edema

2. Bilateral crackles Rationale:The client with pulmonary edema presents primarily with symptoms that are respiratory in nature because the blood flow is stagnant in the lungs, which lie behind the left side of the heart from a circulatory standpoint. The client would experience weight gain from fluid retention, not weight loss. Distended neck veins and peripheral pitting edema are classic signs of right-sided heart failure. Test-Taking Strategy(ies):Focus on the subject, pulmonary edema, and note the words "left-sided" heart failure. Knowing that blood flow is stagnant behind the area of failure allows you to eliminate each of the incorrect options. To remember the signs and symptoms of heart failure, remember "left, lungs" and "right, systemic." Option 2 relates to the lungs. Review:the signs of left-sided heart failure and pulmonary edema. Tip for the Nursing Student:If the client develops pulmonary edema, immediately place the client in a high-Fowler's position and contact the primary health care provider. Do not leave the client.

A client diagnosed with valvular heart disease is at risk for developing heart failure. What should the nurse assess as the priority when monitoring for heart failure? 1. Heart rate 2. Breath sounds 3. Blood pressure 4. Activity tolerance

2. Breath sounds Rationale:Breath sounds are the best way to assess for the onset of heart failure. The presence of crackles or an increase in crackles is an indicator of fluid in the lungs caused by heart failure. The remaining options are components of the assessment but are less reliable indicators of heart failure. Test-Taking Strategy(ies):Note the strategic word, priority. Focus on the subject, heart failure resulting from valvular heart disease. Use of the ABCs—airway, breathing, and circulation—will direct you to the correct option.Review:assessment of heart failure.

A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions should the nurse implement in the postprocedure period? Select all that apply. 1. Restricting visitors 2. Checking the client's groin for bleeding 3. Encouraging the client to increase fluid intake 4. Placing the client's bed in the high-Fowler's position 5. Instructing the client to move the toes when checking circulation, motion, and sensation

2. Checking the client's groin for bleeding 3. Encouraging the client to increase fluid intake 5. Instructing the client to move the toes when checking circulation, motion, and sensation Rationale:Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the primary health care provider. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high-Fowler's position (flexion) increases the risk of occlusion or hemorrhage. Test-Taking Strategy(ies):Note the strategic word, priority. Focus on the subject, cardiac catheterization. Also note the words femoral artery approach. Recalling that flexion or hyperextension is avoided after this procedure will assist in determining that option 4 is incorrect. There is no useful or helpful reason for restricting visitors, so eliminate option 1.Review:post-cardiac catheterization care. Tip for the Nursing Student:Inform the client undergoing a cardiac catheterization that he or she may experience a fluttery feeling as the catheter is passed through the heart, a flushed warm feeling when the dye is injected, a desire to cough, and palpitations caused by heart irritability.

Which is a sign of depression that a client could exhibit when recovering from a myocardial infarction? 1. Reports insomnia at night 2. Consumes 25% of meals and shows little interest when doing client teaching 3. Ignores activity restrictions and does not report the experience of chest pain with activity 4. Expresses apprehension about leaving the hospital and requests that someone stay in the room at night

2. Consumes 25% of meals and shows little interest when doing client teaching Rationale:Signs of depression include withdrawal, lack of interest, crying, anorexia, and apathy. Insomnia may be a sign of anxiety or fear. Ignoring symptoms and activity restrictions are signs of denial. Apprehension is a sign of anxiety. Tip for the Nursing Student:The nurse should monitor a depressed client closely for signs of suicidal ideation. If the client presents with increased energy, monitor closely because it could mean the client now has the energy to perform the suicide act.

A client has a possible diagnosis of deep venous thrombosis (DVT). Which diagnostic studies does the nurse anticipate will be prescribed to assist in the diagnosis of this disorder? Select all that apply. 1. Platelet count 2. D-dimer blood test 3. Electrocardiography 4.Venous duplex ultrasonography 5. Magnetic resonance imaging (MRI) 6.International Normalized Ratio (INR)

2. D-dimer blood test 4.Venous duplex ultrasonography Rationale:A deep venous thrombosis (DVT) is a disorder involving a thrombus in one of the deep veins of the body, most commonly the iliac or femoral veins. The D-dimer blood test is used in evaluation of DVT because the D dimer is a product of fibrin degradation and is indicative of fibrinolysis, which occurs with thrombosis. Venous duplex ultrasonography is a diagnostic test for DVT because it allows visualization of the vein, which provides a reliable diagnosis of venous thrombus. A platelet count will not provide information related to the presence of DVT. Electrocardiography evaluates the electrical activity of the heart. An MRI may be used for a variety of reasons, such as to detect the presence of a tumor. It will not diagnose DVT. An INR is a blood test used to evaluate the effectiveness of warfarin (Coumadin) therapy. Test-Taking Strategy(ies):Focus on the subject, diagnostic studies for DVT. Think about the pathophysiology associated with DVT, and think about each test in the options and how it may or may not relate to this pathophysiology. This will direct you to the correct options.Review:Deep venous thrombosis (DVT).

The nurse is assessing a patient who is known to have right-sided HF. What assessment finding is most consistent with this patient's diagnosis? 1. Pulmonary edema 2. Distended neck veins 3. Dry cough 4. Orthopnea

2. Distended neck veins Rationale:Right-sided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites, anorexia, nausea, nocturia, and weakness. The other answers do not apply.

A client has just been diagnosed with right leg venous thromboembolism (VTE). Which interventions should the nurse implement? Select all that apply. 1. Ice packs to the right leg 2. Elevation of the right leg 3. Hourly calf measurements 4.Vigorous range of motion to the right leg 5. Reposition the client carefully at regular intervals

2. Elevation of the right leg 5. Reposition the client carefully at regular intervals Rationale:Treatment for deep vein embolism (DVE) may require bed rest with repositioning of the client carefully at regular intervals, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Option 1 is incorrect because heat, not cold, may be prescribed. Option 4 is dangerous to the client because vigorous activity after clot formation can cause pulmonary embolus. Test-Taking Strategy(ies):Focus on the subject, venous thromboembolism. Use knowledge of the treatment for VTE as well as concepts related to gravity and the applications of heat and cold to answer the question.Review:the interventions for venous thromboembolism (VTE).

A client develops ventricular fibrillation in a coronary care unit. Which action is priority? 1. Administer oxygen 2. Initiate defibrillation 3. Initiate cardioversion 4. Administer sodium bicarbonate intravenously

2. Initiate defibrillation Rationale: Ventricular fibrillation is a lethal dysrhythmia and, once identified, must be terminated immediately by defibrillation so the sinus node can act again as the heart's pacemaker. Oxygen is administered to correct hypoxia, but if the heart is not pumping, oxygen will not be delivered to the tissues; it does not take priority over defibrillation. Cardioversion is not effective in ventricular fibrillation. Bicarbonate is administered to correct acidosis; it does not take priority over defibrillation.

A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse should ask the client about which symptom? 1. Chest pain that is dull and feels like heartburn 2. Leg pain that is sharp and occurs with exercise 3. Chest pain that is sudden and occurs with exertion 4. Leg pain that is achy and gets worse as the day progresses

2. Leg pain that is sharp and occurs with exercise Rationale:Intermittent claudication is a symptom characterized by a sudden onset of leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Chest pain can occur for a variety of reasons, including indigestion or angina pectoris. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses. Test-Taking Strategy(ies):Focus on the subject, intermittent claudication. Recalling that claudication refers to leg pain will assist in eliminating options 1 and 3. The word intermittent in the question will direct you to the correct option.Review:intermittent claudication.

A client has undergone angioplasty of the iliac artery. Which technique should the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery? 1. Palpate the pedal pulses. 2. Measure the abdominal girth. 3. Assess the client about the level of pain in the area. 4. Auscultate over the iliac area with a Doppler device.

2. Measure the abdominal girth. Rationale:Bleeding after iliac artery angioplasty causes blood to accumulate in the retroperitoneal area. This can most directly be detected by measuring abdominal girth. Palpation and auscultation of pulses determine patency. Assessment of pain is routinely done, and mild regional discomfort is expected. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject of bleeding from the angioplasty in the region of the iliac artery. Select the option that addresses an abdominal assessment because the iliac arteries are located in the peritoneal cavity. This will direct you to the correct option. Tip for the Nursing Student:After angioplasty, assess the insertion site frequently for the presence of bloody drainage or hematoma formation.

A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is aware that positioning will promote circulation. How should the nurse best position the patient? 1. In a high Fowler's position 2. On the left side-lying position 3. In a flat, supine position 4. In the Trendelenburg position

2. On the left side-lying position Rationale: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease lung congestion. Similarly, side-lying does not promote circulation.

A client with pulmonary edema is preparing for discharge. Which action, when identified by the client as a measure to prevent a reoccurrence of pulmonary edema, should lead the nurse to determine that the client understands the important discharge instructions? 1. Weighing self at least once each week 2. Sleeping with the head of the bed elevated 3. Taking an extra dose of diuretic if the client decides to eat a salty meal 4.Completing a nebulizer treatment if the client becomes short of breath

2. Sleeping with the head of the bed elevated Rationale:A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed elevated helps prevent circulatory overload. The client should weigh self on a daily basis, not weekly. It is unsafe for clients to regulate their own medication dosages based on symptoms. Shortness of breath is a sign of pulmonary congestion and the client should be evaluated for pulmonary edema. Tip for the Nursing Student:The client with pulmonary edema is immediately placed in a high-Fowler's position, with the legs in a dependent position, to reduce pulmonary congestion and relieve edema.

The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness? 1. Clear breath sounds 2. Systolic heart murmur 3.Temperature of 98.8° F 4.Negative blood cultures

2. Systolic heart murmur Rationale:A systolic heart murmur, once present in the client, will not resolve spontaneously and is therefore the least reliable indicator. Clear breath sounds are a normal finding, and in this instance could mean resolution of heart failure, if that was accompanying the endocarditis. Negative blood cultures and normothermia indicate resolution of infection. Test-Taking Strategy(ies):Focus on the subject, effective indicator of antimicrobial therapy for a client with infective endocarditis. Note the strategic word, effectiveness, and the word least. This creates a negative event query and asks you to look for the finding that will not respond to antimicrobial therapy and is an abnormal finding. The only choice that meets these criteria is the systolic murmur that does not resolve once it has developed.Review:care of the client with infective endocarditis.

The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how should the nurse best respond? 1. "Do you want me to call your daughter?" 2."Can you tell me a little about what has you so upset?" 3."Try not to be so upset. Psychological stress is bad for your heart." 4."I understand how you feel. I'd cry, too, if I had a major heart attack."

2."Can you tell me a little about what has you so upset?" Rationale:Clients with MI often have anxiety or fear. The nurse allows the client to express concerns by showing genuine interest and concern and facilitating communication using therapeutic communication techniques. The correct option provides the client with an opportunity to express concerns. The remaining options do not address the client's feelings or promote client verbalization. Test-Taking Strategy(ies):Note the strategic word, best. Use therapeutic communication techniques that have an exploratory approach because the question does not identify why the client is upset. This technique helps you eliminate each of the incorrect options. Tip for the Nursing Student:Cardiac rehabilitation is the process of actively assisting the client with cardiac disease to achieve and maintain a vital and productive life within the limitations of the heart disease.

The nurse is performing an assessment on a client diagnosed with chronic venous insufficiency. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. 1. Intermittent claudication 2.Brown discoloration of the skin 3.Edema that worsens at the end of the day 4.Dry and flaky skin and complaints of itching 5.Complaints of aching and heaviness in the legs 6.Diminished or absent arterial pulses in the affected extremity

2.Brown discoloration of the skin 3.Edema that worsens at the end of the day 4.Dry and flaky skin and complaints of itching 5.Complaints of aching and heaviness in the legs Rationale:Venous insufficiency is an abnormal circulatory condition characterized by decreased return of venous blood from the legs to the trunk of the body. Clients who have venous disease may report chronic aching pain and heaviness in the legs when they are in a dependent position. Additional manifestations include brown discoloration of the skin, edema that worsens at the end of the day, dry and flaky skin and complaints of itching, and dependent cyanosis. Skin temperature remains normal or may be slightly warmer than the unaffected area, and pulses are present, although they may be difficult to palpate if edema is present. Intermittent claudication and decreased or absent pulses are characteristics of arterial insufficiency. Test-Taking Strategy(ies):Focus on the subject, the manifestations of chronic venous insufficiency. Note the word venous in the question. Think about the anatomy and physiology of the venous system to assist in answering the question. Remember that intermittent claudication and decreased or absent pulses are characteristics of arterial, not venous, insufficiency.

A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed? 1. The physical demands of the client's lifestyle 2.The ability to comply with anticoagulant therapy for life 3.The ability to participate in a cardiac rehabilitation program 4.The likelihood of the client experiencing body image problems

2.The ability to comply with anticoagulant therapy for life Rationale:Mechanical valves carry the associated risk of thromboemboli, which require long-term anticoagulation with warfarin sodium. No data in the question indicate that physical demands exist in the client's lifestyle. Not all clients who undergo cardiac surgery require cardiac rehabilitation. Body image problems are important but not critical. Test-Taking Strategy(ies):Focus on the strategic word, essential. Recalling that mechanical valves are thrombogenic will direct you to the correct option.Review:care of the client undergoing a mechanical valve replacement. Tip for the Nursing Student:A priority concern when the client is taking an anticoagulant is bleeding.

A client diagnosed with Raynaud's disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change should the nurse teach the client to consider to help alleviate his stress? 1. Change to a less stressful job. 2. Seek help from a psychologist. 3. Consider a stress management program. 4. Use earplugs to minimize environmental noise.

3. Consider a stress management program. Rationale:Stress can trigger the vasospasm that occurs with Raynaud's disease, so referral to a stress management program or the use of biofeedback training may be helpful. Option 1 is unrealistic. Option 2 is not necessarily required at this time. Option 4 does not specifically address the subject. Test-Taking Strategy(ies):Focus on the subject, an intervention to alleviate stress. Note the relationship between this subject and the correct option.Review:the measures that reduce stress and Raynaud's disease. Tip for the Nursing Student:Raynaud's disease is vasospasm of the arterioles of the upper and lower extremities, which cause constriction of the cutaneous vessels.

A client having premature ventricular contractions states to the nurse, "I'm so afraid that something bad will happen." Which action by the nurse provides the most immediate help to the client? 1. Telephoning the client's family 2. Using a television to distract the client 3. Having a staff member stay with the client 4.Giving reassurance that nothing will happen to the client

3. Having a staff member stay with the client Rationale:When a client experiences fear, the nurse can provide a calm, safe environment by offering appropriate reassurance, using therapeutic touch, and having someone remain with the client as much as possible. Options 1 and 2 do not address the client's fear, and option 4 provides false reassurance. Test-Taking Strategy(ies):Note the strategic words, most immediate, in selecting the correct option. Options 1 and 2 are comparable or alike options because they do not address the immediate concern of fear. Next, focusing on the strategic words will direct you to the correct option.Review:measures to reduce a client's fear.

A client diagnosed with heart failure and secondary hyperaldosteronism is started on spironolactone to manage this disorder. The nurse informs the client that the need for dosage adjustment may be necessary if which medication is also being taken? 1. Alprazolam 2. Warfarin sodium 3. Potassium chloride 4.Verapamil hydrochloride

3. Potassium chloride Rationale:Spironolactone is a potassium-retaining diuretic. If the client is also taking potassium chloride or another potassium supplement, the risk for hyperkalemia exists. Potassium doses need to be adjusted while the client is taking this medication. A dosage adjustment would not be necessary if the client was taking alprazolam, warfarin sodium, or verapamil hydrochloride. Test-Taking Strategy(ies):Focus on the subject, dosage adjustment in a client taking spironolactone. Recalling that spironolactone is a potassium-retaining diuretic will direct you to the correct option.Review:spironolactone. Tip for the Nursing Student:Potassium-retaining diuretics act on the distal tubule to promote sodium and water excretion and potassium retention.

The nurse monitors the client status after a myocardial infarction (MI) for signs/symptoms of cardiogenic shock. Which signs/symptoms are indicative of this complication? Select all that apply. 1. Bradypnea 2. Hypertension 3. Tachycardia 4. Altered mental status 5.Pulmonary congestion 6.Poor peripheral pulses

3. Tachycardia 4. Altered mental status 5.Pulmonary congestion 6.Poor peripheral pulses Rationale:Cardiogenic shock occurs when the heart is unable to pump blood effectively to the body. It usually occurs after a major insult to the cardiac tissue such as a myocardial infarction. Manifestations of cardiogenic shock include tachycardia; hypotension; systolic BP less than 90 mm Hg or 30 mm Hg less than the client's baseline; low urine output; cold, clammy skin with poor peripheral pulses; agitation, restlessness, or confusion; pulmonary congestion; tachypnea; and continuing chest discomfort. Test-Taking Strategy(ies):Focus on the subject, signs/symptoms of cardiogenic shock. Think about the pathophysiology of cardiogenic shock. This will assist you in eliminating options 1 and 2. Remember that tachycardia, altered mental status, pulmonary congestion, and poor peripheral pulses are associated with poor perfusion, which occur with cardiogenic shock.Review:Cardiogenic shock

A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, "I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing." Which most therapeutic response should the nurse make to the client? 1. "I can understand what you mean. I'd be nervous too if I were in your shoes." 2."This surgery is so successful that I wouldn't be concerned at all if I were you." 3."Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about." 4."Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens."

3."Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about." Rationale:Clients frequently fear that they will ultimately lose a limb or become debilitated in some other way. Option 3 acknowledges the client's concerns and empowers the client to improve his or her health, which will ultimately reduce concern about the risk of complications. Option 1 feeds into the client's anxiety and is not therapeutic. Option 2 gives false reassurance. Option 4 is meant to be reassuring, but it offers no suggestions to empower the client. Test-Taking Strategy(ies):Note the strategic word, most. Use therapeutic communication techniques. Option 3 is the only option that acknowledges the client's concerns and addresses his or her control over the situation.Review:therapeutic communication techniques. Tip for the Nursing Student:The client undergoing femoral-popliteal bypass grafting who is returning home should progressively return to his or her normal routine. Additionally, the client should limit pushing or pulling objects for 6 weeks; maintain incision care and report signs of redness, swelling, or discharge; avoid crossing the legs; use prescribed medications; and maintain the prescribed therapeutic diet.

A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question? 1. "Does being exposed to heat seem to cause the episodes?" 2. "Do the signs and symptoms occur while you are asleep?" 3."Does drinking coffee or ingesting chocolate seem related to the episodes?" 4."Have you experienced any injuries that have limited your activity levels lately?"

3."Does drinking coffee or ingesting chocolate seem related to the episodes?" Rationale:Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes. Test-Taking Strategy(ies):Focus on the subject, precipitating factors for Raynaud's disease. Recalling that symptoms occur with vasoconstriction will assist in eliminating options 1, 2, and 4 because these events are unlikely to cause vasoconstriction. Tip for the Nursing Student:Because stress can trigger vasospasm, the nurse should teach the client with Raynaud's disease stress management techniques.

A client with superficial varicose veins states to the nurse, "I hate these things. They're so ugly. I wish I could get them to go away." Which therapeutic response would be most appropriate for the nurse to make to the client? 1. "You should try sclerotherapy. It's great." 2."What makes you so upset about having ugly varicose veins?" 3."What have you been educated about varicose veins and their management?" 4."I understand how you feel, but you know, they really don't look all that bad."

3."What have you been educated about varicose veins and their management?" Rationale:The client expressing distress about physical appearance has a risk for an altered body image. The nurse assesses the client's knowledge and self-management of the condition as a means of empowering the client and helping him or her adapt to the body change. Options 1 and 4 are not therapeutic. Option 2 focuses only on the cosmetic aspect of varicose veins. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Use therapeutic communication techniques. With questions that deal with client's feelings, select the option that facilitates the sharing of information and concerns by the client. The remaining options cut off or limit further comments by the client. Additionally, the correct option addresses assessment, which is the first step of the nursing process.Review:therapeutic communication techniques. Tip for the Nursing Student:Varicose veins occur from the weakening and dilation of vein walls and incompetence of the valves inside the veins. The client may feel pain in the legs with dull aching after standing, a feeling of fullness in the legs, and ankle edema.

A client with arterial leg ulcers tells the nurse, "I'm so discouraged. I have had this pain for more than a year now. The pain never seems to go away. I can't do anything, and I feel as though I'll never get better." The nurse determines that which is the priority client concern? 1. Fatigue 2. Uneasiness 3.Chronic pain 4.An acute illness

3.Chronic pain Rationale:The major focus of the client's complaint is the experience of pain. Pain that has a duration of more than 3 months is defined as chronic pain and does not indicate an acute illness. There are no data in the question that indicate fatigue or uneasiness. Test-Taking Strategy(ies):Note the strategic word, priority. Focusing on the words pain for more than a year now will direct you to the correct option.Review:chronic pain and leg ulcers. Tip for the Nursing Student:The client with nonhealing arterial ulcerations should monitor the site and report signs of infection. These signs include redness, edema, and warmth at the affected area. In addition, an elevated temperature and change in vital signs may be signs of infection and should be reported.

When planning the care of the client diagnosed with thromboangiitis obliterans (Buerger's disease), the nurse incorporates information on which support service to best help the client cope with the lifestyle changes that are needed to control the disease process? 1. Consultation with a dietician 2.Pain management clinic 3.Smoking cessation program 4.Referral to a medical social worker

3.Smoking cessation program Rationale:Smoking is highly detrimental to the client with Buerger's disease, and clients are recommended to stop completely. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated when smoking stops. None of the remaining options are directly related to the physiology associated with this condition. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, Buerger's disease. Recalling that the treatment goals are the same as for peripheral vascular disease will direct you to the correct option.Review:the treatment goals for Buerger's disease.

A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension? 1. Suggesting the client watch television during the procedure as a distraction 2.Talking to the client from the foot of the bed and assisting with the procedure 3.Staying beside the client to give information and encouragement during the procedure 4.Assuring the client that even though there are other clients needing care, the client's needs are most important

3.Staying beside the client to give information and encouragement during the procedure Rationale:Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure. Test-Taking Strategy(ies):Note the strategic word, best. Use therapeutic communication techniques. Option 3 is the only option that provides direct contact with and assistance to the client.Review:therapeutic communication techniques. Tip for the Nursing Student:A pericardiocentesis involves aspiration of fluid from the pericardium. It is generally done with the guidance of ultrasound so as to minimize complications.

The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse? 1. Physical contact should be avoided whenever possible. 2.The spouse would not feel or be harmed by the countershock. 3.The shock would be felt, but it would not cause the spouse any harm. 4. A warning device sounds before countershock, so there is time to move away.

3.The shock would be felt, but it would not cause the spouse any harm. Rationale:Clients and families are often fearful about the activation of the ICD. Their fears are about the device itself and also about the occurrence of life-threatening dysrhythmias that trigger its function. Family members need reassurance that, even if the device activates while they are touching the client, the level of the charge is not high enough to harm the family member, although it will be felt. The ICD emits a warning beep when the client is near magnetic fields, which could possibly deactivate it, but it does not beep before countershock. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Focus on the subject, the spouse's anxiety about implantable cardioverter-defibrillator (ICD), and use your knowledge of the function of the ICD to answer this question. This will direct you to the correct option. Remember that the shock would be felt, but it would not cause the spouse any harm.Review:the client teaching points related to the implantable cardioverter-defibrillator (ICD).

A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading? 1. 164/90 mm Hg 2. 156/89 mm Hg 3. 140/94 mm Hg 4. 128/84 mm Hg

4. 128/84 mm Hg Rationale:Normal blood pressure readings are less than 120/80 mm Hg. A blood pressure reading between 120/80 mm Hg and 139/89 mm Hg is considered to be a prehypertensive state. From the readings provided in the options, the correct option identifies the most successful outcome, although the reading indicates a prehypertensive state. Test-Taking Strategy(ies):Note the strategic word, most. The correct option identifies a reading that is closest to normal even though it identifies a prehypertensive state.Review:hypertension.

The nurse provides discharge instructions to a client after implantation of a permanent pacemaker. The nurse should instruct the client to avoid exposure to which item? 1. Hair dryers 2. Electric blankets 3. Electric toothbrushes 4. Airport metal detectors

4. Airport metal detectors Rationale:A pacemaker is shielded from interference from most electrical devices. Devices to be forewarned about include those with a strong electric current or magnetic field, such as antitheft devices in stores, metal detectors used in airports, and radiation therapy (if applicable and which might require relocation of the pacemaker). Radios, televisions, electric blankets, toasters, microwave ovens, heating pads, and hair dryers are considered to be safe. Test-Taking Strategy(ies):Focus on the subject, the item to avoid after implantation of a permanent pacemaker. Note that the correct option uses the word metal.Review:home care measures for the client with a pacemaker.

The nurse notes that the client's continuous electrocardiogram (ECG) complexes are very small and hard to evaluate. Which setting on the ECG monitor console should the nurse check? 1. Power button 2. Low rate alarm 3. High rate alarm 4. Amplitude or "gain"

4. Amplitude or "gain" Rationale:The amplitude, commonly called "gain," regulates the size of the complex and can be adjusted up and down to some degree. The power button turns the machine on and off. The low and high alarm settings indicate the heart rate limits beyond which an alarm will sound. Test-Taking Strategy(ies):Focus on the subject, ECG complexes that are small and hard to evaluate. Eliminate options 2 and 3 that are comparable or alike such as those focusing on the alarms. From the remaining choices, noting the relation of the subject to the word amplitude (meaning size or strength) will direct you to the correct choice.Review:the procedure for the use of an electrocardiogram (ECG) monitor.

A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit? 1. Pears 2. Apples 3. Bananas 4.Cranberries

4. Cranberries Rationale:Triamterene is a potassium-retaining diuretic, and the client should avoid foods that are high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, oranges, mangoes, cantaloupe, strawberries, nectarines, papayas, and dried prunes. Test-Taking Strategy(ies):Focus on the subject, the fruit that the client needs to avoid. Note that this is a negative event query asking you to choose the fruit the client should not eat. Recall that triamterene is a potassium-retaining diuretic and the intake of potassium presents dietary concerns related to the medication.Review:triamterene and food items that are high in potassium. Tip for the Nursing Student:Normal potassium levels range from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium level outside of these parameters needs to be reported.

The nurse is teaching a client with hypertension about items that contain sodium and reviews a written list of items sent from the cardiac rehabilitation department. The nurse tells the client that which item is lowest in sodium content? 1. Antacids 2. Laxatives 3. Toothpaste 4. Demineralized water

4. Demineralized water Rationale:Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Clients are advised to read labels for sodium content. Sodium intake can be increased with the use of several types of products, including toothpaste and mouthwashes; over-the-counter medications such as analgesics, antacids, cough remedies, laxatives, and sedatives; and softened water, as well as some mineral waters. Test-Taking Strategy(ies):Focus on the subject, the item that is lowest in sodium. Noting the word demineralized, which means having the minerals taken out of, will direct you to option 4.Review:items that are low and high in sodium. Tip for the Nursing Student:The normal sodium level is 135 to 145 mEq (135 to 145 mmol/L). A sodium imbalance is usually associated with a fluid volume imbalance.

A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, "If my doctor tells me to do it, I will. Otherwise, I won't." Which behavior should the nurse determine that the client is displaying? 1. Anger 2. Denial 3. Depression 4. Dependency

4. Dependency Rationale:Clients may experience numerous emotional and behavioral responses after an MI. Dependency is one response that may be manifested by the client's refusal to perform any tasks or activities unless specifically approved by the primary health care provider. Although the client's statement may express anger to some degree, it most specifically addresses dependency. There are no data in the question to support denial or depression. Test-Taking Strategy(ies):Focus on the subject of a client who refuses to perform tasks after an MI. Begin by eliminating options 2 and 3 because the client is not exhibiting signs of denial or depression. From the remaining options, focus on the client's statement to direct you to option 4.Review:psychosocial reactions after myocardial infarction and dependency. Tip for the Nursing Student:Dependency is evident when the client who sustained an MI is totally reliant on staff or others, prefers to be monitored by electrocardiogram (ECG) at all times, and is hesitant to leave the cardiac nursing unit or the hospital.

A client being seen in an ambulatory care unit has an arterial blood gas drawn. The nurse determines that the client understands the signs of complications at the injection site when the client stated to report which sign/symptom? 1. Pink nail beds 2. Positive radial pulse 3. Warm hand temperature 4. Formation of a hematoma

4. Formation of a hematoma Rationale:After arterial blood gas sampling, the site should be assessed for bleeding and hematoma formation, as well as injury to the artery or surrounding structures. The remaining options are normal findings. Test-Taking Strategy(ies):Focus on the subject, complications of arterial blood gas sampling. Note the words signs of complications in the question. These words indicate the need to select an abnormal finding. Specific knowledge of basic normal circulatory assessments helps you answer this question. The only abnormal finding is the correct option.Review:Arterial blood gas sampling.

The nurse is creating a teaching plan for the client with Raynaud's disease. Which instruction should the nurse include? 1. Daily cool baths will provide an analgesic effect. 2. A high-protein diet will minimize tissue malnutrition. 3.Vitamin K administration will prevent tendencies toward bleeding. 4. Keeping the hands and feet warm and dry will prevent vasoconstriction.

4. Keeping the hands and feet warm and dry will prevent vasoconstriction. Rationale:Raynaud's disease is a vasospasm of the arterioles and arteries of the upper and lower extremities. The use of measures to prevent vasoconstriction is helpful for the management of Raynaud's disease. The hands and feet should be kept dry. Gloves and warm fabrics should be worn in cold weather, and the client should avoid exposure to nicotine and caffeine. The avoidance of situations that trigger stress is also helpful. Taking daily cool baths, maintaining a high-protein diet, and administering vitamin K are not components of the treatment for this disorder. Test-Taking Strategy(ies):Focus on the subject, a teaching plan for the client with Raynaud's disease. Recalling the pathophysiology of the disorder and the need to promote vasodilation will direct you to the correct option.Review: the teaching points related to Raynaud's disease.

The nurse is teaching a client with a diagnosis of cardiomyopathy about home care safety measures. Which instruction is most important for the nurse to include? 1. Reporting pain 2. Appropriate vasodilator administration 3. Avoiding over-the-counter medications 4. Moving slowly from a sitting to a standing position

4. Moving slowly from a sitting to a standing position Rationale:Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety. Test-Taking Strategy(ies):Focus on the subject, to ensure client safety at home, and note the strategic words, most important. Recalling that blood pressure changes occur in cardiomyopathy will direct you to option 4.Review:client teaching related to cardiomyopathy. Tip for the Nursing Student:Treatment for cardiomyopathy is palliative, not curative, and the client needs to deal with numerous lifestyle changes and a shortened life span.

The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions? 1. Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses

4. Palpating for diminished or absent peripheral pulses Rationale:Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. A rash on the digits is not a characteristic of this disorder. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted. Test-Taking Strategy(ies):Focus on the subject, assessment for Raynaud's disease. Recall the physiological occurrences in Raynaud's disease. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Tip for the Nursing Student:Teach the client with Raynaud's disease to avoid smoking; wear warm clothing, socks, and gloves in cold weather; and avoid injuries to the fingers and hands.

The nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. What instruction should the nurse provide to this client? 1. Avoid sexual intercourse for at least 4 months. 2. Replace sublingual nitroglycerin tablets yearly. 3. Participate in an exercise program that includes overhead lifting and reaching. 4. Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss.

4. Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss. Rationale:After an acute MI, many clients are instructed to take an aspirin daily. Adverse effects include tinnitus, hearing loss, epigastric distress, gastrointestinal bleeding, and nausea. Sexual intercourse usually can be resumed in 4 to 8 weeks after an acute MI if the primary health care provider agrees and if the client has been able to achieve traditional parameters such as climbing two flights of steps without chest pain or dyspnea. Clients should be advised to purchase a new supply of nitroglycerin tablets every 6 months. Expiration dates on the medication bottle should also be checked. Activities that include lifting and reaching over the head should be avoided because they reduce cardiac output. Test-Taking Strategy(ies): Focus on the subject, a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. Noting the time limits in options 1 and 2 ("4 months" and "yearly," respectively) will assist you in eliminating these options. From the remaining options, "overhead lifting and reaching" in option 3 should indicate that this is incorrect.Review:the client teaching points after a myocardial infarction (MI) Tip for the Nursing Student:Acetylsalicylic acid (aspirin) is an antiplatelet medication that inhibits the aggregation of platelets in the clotting process, thereby prolonging the bleeding time.

The nurse provides information to a client who is scheduled for the implantation of an implantable cardioverter defibrillator (ICD) regarding care after implantation. The nurse tells the client that there is a need to keep a diary. What information should the nurse provide concerning the primary purpose of the diary? 1. Analyze which activities to avoid. 2. Document events that precipitate a countershock. 3. Provide a count of the number of shocks delivered. 4. Record a variety of data that are useful for the primary health care provider during medical management.

4. Record a variety of data that are useful for the primary health care provider during medical management. Test-Taking Strategy(ies):Note the strategic word, primary. Each of the incorrect options lists one of the items that should be logged in the diary, but the correct option is the only one that could be considered a "primary" purpose. Recording a variety of data is also the umbrella option.Review:the home care instructions for the client with an implantable cardioverter defibrillator (ICD). Tip for the Nursing Student:The client with an ICD should be taught to wear loose-fitting clothing over the ICD generator site and avoid contact sports to prevent trauma to the ICD generator and lead wires.

A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner? 1. Ask a family member to stay with the client during the procedure. 2. Give the client the call bell, and encourage its use if the client feels worse. 3. Leave the client alone only to gather the required equipment and medications. 4. Stay with the client, and ask another nurse to gather needed equipment and supplies.

4. Stay with the client, and ask another nurse to gather needed equipment and supplies. Rationale:Pulmonary edema is accompanied by extreme fear and anxiety. Because the client typically experiences a sense of impending doom, the nurse should remain with the client as much as possible. Family members can emotionally support the client, but they are not able to respond to physiological needs and symptoms. In fact, they are typically in psychological distress themselves. Options 2 and 3 do not provide for the psychological needs of the client in distress. Test-Taking Strategy(ies):Focus on the subject, a client with pulmonary edema who exhibits severe anxiety. Identify the word holistic. This word guides you to consider both the physical and emotional well-being of the client. The correct option is the only choice that addresses both needs.Review:the psychosocial aspects of care for the client with pulmonary edema.

The nurse in the emergency department is assessing a client reporting chest pain. Which finding should help the nurse determine that the pain is caused by myocardial infarction (MI)? 1. The client experienced no nausea or vomiting. 2. The pain is described as burning and gnawing. 3. The client reports that the pain began while pushing a lawnmower. 4. The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate.

4. The pain, unrelieved by nitroglycerin, was relieved with morphine sulfate. Rationale:The pain of myocardial infarction (MI) may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, is frequently accompanied by associated symptoms (nausea, vomiting, dyspnea, diaphoresis, anxiety), and requires opioid analgesics for relief. The pain of angina may radiate to the left arm, is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. A burning and gnawing pain is more likely noted in an upper gastrointestinal disorder. The pain of pushing a lawnmower is more likely to be related to a musculoskeletal problem. Test-Taking Strategy(ies):Note the subject, pain caused by an MI. Recall that a classic characteristic of the pain from MI is that it is unrelieved by rest and nitroglycerin.Review:Differences between angina and myocardial infarction (MI).

The home care nurse has given instructions to a client who was recently discharged from the hospital regarding the care of an arterial ischemic leg ulcer. The nurse determines that there is a need for further teaching if the client makes which statement? 1. "I should inspect my feet daily." 2. "I should wear shoes and socks." 3."I should cut my toenails straight across." 4."I should raise my legs above the level of my heart periodically."

4."I should raise my legs above the level of my heart periodically." Rationale:Foot care instructions for the client with peripheral arterial ischemia are the same instructions given to the client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above heart level unless instructed to do so as part of an exercise program (such as Buerger's postural exercises) or if venous stasis is also present. Daily foot inspection, wearing shoes and socks, and cutting toe nails straight across are accurate client statements. Test-Taking Strategy(ies):Note the strategic words, need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Note that the client has an arterial disorder. Recalling the anatomy of the blood vessels and the pattern of blood flow in the arteries will direct you to option 4.Review:the home care instructions for the client with an arterial ischemic leg ulcer.

A client being discharged to home after angioplasty via the right femoral groin has received the catheter insertion site discharge instructions from the nurse. Which client statement indicates that the client understands the instructions? 1. "Coolness or discoloration of the right foot is expected." 2."I should expect a large area of bruising at the right groin." 3."Temperature as high as 101° F (38.3° C) is not unusual a few days after the procedure." 4."Mild discomfort in the right groin may occur, and Tylenol should relieve the pain."

4."Mild discomfort in the right groin may occur, and Tylenol should relieve the pain." Rationale:The client may feel some mild discomfort at the catheter insertion site after angioplasty. This is usually relieved by analgesics such as acetaminophen (Tylenol). The client is taught to report to the primary health care provider any neurovascular changes to the affected leg; bleeding or bruising at the insertion site; and signs/symptoms of local infection, such as drainage at the site or increased temperature. Test-Taking Strategy(ies):Focus on the subject, client instructions after angioplasty. Knowing that bleeding and infection are complications of the procedure guides you in eliminating options 2 and 3. From the remaining options, eliminate option 1 knowing that neurovascular status should not be impaired by the procedure or by knowing that the area may be mildly uncomfortable.Review:the complications associated with angioplasty.

The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning." Which is the most appropriate nursing response? 1. "Your family can stay tonight if they wish." 2."Would you like a mild sedative to help you relax?" 3."The hospital is well equipped to shield a lightning strike." 4."Yes, all the wires must be scary. Let's talk about the cardiac monitor."

4."Yes, all the wires must be scary. Let's talk about the cardiac monitor." Rationale:The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary. Test-Taking Strategy(ies):Note the strategic words, most appropriate. Use therapeutic communication techniques. Remember to address the client's feelings first. The correct option is the only option that addresses the client's feelings.Review:therapeutic communication techniques. Tip for the Nursing Student:The client should be oriented to the room upon admission to the hospital. Any medical equipment should be explained, and explanations should be repeated for the client if necessary. Decreasing sensory stimulation will allow the client to rest, which is important for the process of recovery.

A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, "I know I need it, but I'm not sure this surgery is a great idea." Which nursing response should best help the nurse assess the client's preoperative concerns? 1. How does your family feel about the surgery?" 2. "Has anyone taught you about the procedure yet?" 3."You sound extremely worried. Has anyone told you that the technology is really quite safe?" 4."You sound uncertain about the procedure. Can you tell me more about what has you concerned?"

4."You sound uncertain about the procedure. Can you tell me more about what has you concerned?" Rationale:Anxiety is common in the client with the need for pacemaker insertion. This can be related to a fear of life-threatening dysrhythmias or of the surgical procedure. Option 4 is the correct choice because it is open-ended and uses clarification as a communication technique to explore the client's concerns. Option 1 is not indicated because it asks about the family and deflects attention away from the client's concerns. Options 2 and 3 are closed-ended and are not exploratory. Test-Taking Strategy(ies):Note the strategic word, best. Use therapeutic communication techniques, focusing on the subject, addressing the client's preoperative concerns. Option 1 can be eliminated first because it addresses the family rather than the client. From the remaining options, the only option that addresses the client's concerns is option 4.Review:therapeutic communication techniques

The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, "What's the use? I'll never remember all of this, and I'll probably die anyway!" The nurse determines that the client's statement is most likely due to which psychosocial concern? 1. Anger about the new medical regimen 2.The teaching strategies used by the nurse 3.Insufficient financial resources to pay for the medications 4.Anxiety about the ability to manage the disease process at hoe

4.Anxiety about the ability to manage the disease process at home Rationale:Anxiety and fear often develop after heart failure, and they can further tax the failing heart. The client's statement is made in the middle of receiving self-care instructions. There is no evidence in the question to support option 1, 2, or 3. Test-Taking Strategy(ies):Note the strategic words, most likely. Focus on the subject of a client with heart failure being discharged. Because the client is being prepared for home care, the implication with the question is self-management.Review:the psychosocial concerns of a client with heart failure. Tip for the Nursing Student:Heart failure results in inadequate cardiac output. The diminished cardiac output results in inadequate peripheral tissue perfusion.

After cardiac surgery to treat coronary artery disease, both the client and the family express anxiety regarding how to cope with the recovering process after discharge. Which available resource should the nurse plan to tell the client and family about to best address their concerns? 1. The United Way 2. The client's local church 3.The American Cancer Society Reach for Recovery 4.The American Heart Association Mended Hearts Club

4.The American Heart Association Mended Hearts Club Rationale:Most clients and families benefit from knowing that there are available resources to help them cope with the stress of self-care management at home. These can include telephone contact with the surgeon, cardiologist, and nurse; cardiac rehabilitation programs; and community support groups such as the American Heart Association Mended Hearts Club, which is a nationwide program with local chapters. The United Way provides a wide variety of services to people who may not otherwise be able to afford them. The library normally does not provide resources for coping with the recuperative process. The American Cancer Society Reach for Recovery helps women recover after mastectomy. Test-Taking Strategy(ies):Note the strategic word, best. Focus on the subject, the available resource for the client who had cardiac surgery. Note that the options identify three organizations and a church. Noting that the client had cardiac surgery will direct you to option 4.Review:the support services for clients who have had cardiac surgery.

The nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The nurse determines that the client understands the instructions if the client states that which is an appropriate activity? 1. Mowing the lawn 2. Playing a game of 18-hole golf 3. Lifting objects up to 30 pounds 4.Walking as tolerated, including outdoors

4.Walking as tolerated, including outdoors Rationale:The client can walk as tolerated after the repair or resection of an AAA, including walking outdoors. The client should not engage in any activities that involve pushing, pulling, or straining, and the client should not lift objects that weigh more than 15 to 20 pounds for 6 to 12 weeks. Driving is also prohibited for several weeks. Test-Taking Strategy(ies):Note the subject of a client being discharged after AAA resection and the words understands the instructions. Evaluate each option in terms of the strain that it could put on the sutured graft. This will direct you to the option. Review: the discharge instructions after abdominal aortic aneurysm (AAA).

A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial about his medical condition? 1. Requests a sedative for sleep at 10:00 pm 2. Expresses a hesitancy to leave the hospital 3. Consumes 25% of foods and fluids given for supper 4.Walks up and down three flights of stairs unsupervised

4.Walks up and down three flights of stairs unsupervised Rationale:Ignoring activity limitations and avoiding lifestyle changes are signs of the denial stage. Walking three flights of stairs should be a supervised activity during this phase of the recovery process. Option 1 is an appropriate client action on the evening before discharge. Option 2 may be a manifestation of anxiety or fear rather than denial. Option 3 is a manifestation of depression rather than denial Test-Taking Strategy(ies):Focus on the subject, the client action that indicates denial. Option 4 is the only option that identifies denial. Option 1 is an appropriate client request. Option 2 identifies anxiety or fear. Option 3 identifies depression.Review:the manifestations associated with denial. Tip for the Nursing Student:Pain relief increases oxygen supply to the myocardium; the nurse should administer morphine sulfate as prescribed as a priority in managing pain in the client having a myocardial infarction.

A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply. a. Dyspnea b. Flat neck veins c. Nausea and vomiting d. Chest pain or discomfort e. Hypotension and dizziness f. Hypertension and headache

a. Dyspnea d. Chest pain or discomfort e. Hypotension and dizziness Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Neither headache nor nausea and vomiting are associated with the effects of uncontrolled atrial fibrillation. Test-Taking Strategy(ies):Focus on the subject, the effects of uncontrolled atrial fibrillation. Recalling that flat neck veins are normal or indicate hypovolemia will assist you in eliminating option 2. Remembering that nausea and vomiting are associated with vagus nerve activity, not a tachycardic state, will assist you in eliminating option 3. From the remaining options, thinking of the effects of a falling cardiac output will direct you to the correct option.Review:the symptoms related to atrial fibrillation.

A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply. a. Fever b. Leukopenia c. Bradycardia d. Pericardial friction rub e. Decreased erythrocyte sedimentation rate f. Precordial chest pain that is intensifies by the supine position

a. Fever d. Pericardial friction rub f. Precordial chest pain that is intensifies by the supine position Rationale:In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common. Test-Taking Strategy(ies):Focus on the subject, bacterial pericarditis. The diagnosis will assist in determining that the client has a fever (option 1); the compensatory response to fever is an increased metabolic rate and tachycardia. Also remember that when the client has an inflammatory disease, the erythrocyte sedimentation rate will increase, as will the white blood cell count (leukocytosis, not leukopenia). Lastly, focusing on the diagnosis will assist in determining that a pericardial friction rub and severe precordial chest pain are present (options 4 and 6).Review:acute bacterial pericarditis. Tip for the Nursing Student:Monitor the client with pericarditis for signs of heart failure or cardiac tamponade as complications.

A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats per minute; respirations, 26 breaths per minute. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs should the nurse expect? a. BP 85/50 mm Hg, pulse 60 beats per minute, respirations 26 breaths per minute b. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute c. BP 130/70 mm Hg, pulse 104 beats per minute, respirations 20 breaths per minute d. BP 110/40 mm Hg, pulse 110 beats per minute, respirations 20 breaths per minute

b. BP 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute Rationale:The main function of digoxin is inotropic. It produces increased myocardial contractility that is associated with an increased cardiac output. This causes a rise in the BP in a client with heart failure. Digoxin also has a negative chronotropic effect (decreases heart rate) and will therefore cause a slowing of the heart rate. As cardiac output improves, there should be an improvement in respirations as well. The remaining choices do not reflect the physiological changes attributed to this medication. Tip for the Nursing Student:The nurse should monitor the client taking digoxin for digoxin toxicity. A normal serum digoxin level is 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). Test-Taking Strategy(ies):Focus on the subject, the physiologic changes that occur with digoxin administration. Recalling that digoxin slows the heart rate will assist in eliminating options 3 and 4, which show an increase in the heart rate. Next recalling that digoxin improves cardiac output will assist in eliminating option 1, which does not show improvement in blood pressure.

A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder? a. Exposure to heat b. Cigarette smoking c. .Diet low in vitamin C d. Excessive water intake

b. Cigarette smoking Rationale:Buerger's disease is an occlusive disease of the median small arteries and veins. It occurs predominantly among men who are more than 40 years old who smoke cigarettes. A familial tendency is noted, but cigarette smoking is consistently a risk factor. Symptoms of the disease improve with smoking cessation. Exposure to heat, diet low in vitamin C, and excessive water intake are not risk factors. Test-Taking Strategy(ies):Note the strategic word, priority. Recalling the pathophysiology related to this disorder and that it is an occlusive disease of the median small arteries and veins will direct you to the correct option.Review:the risk factors for Buerger's disease.

The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take? a. Prepare for defibrillation. b. Continue to monitor the rhythm. c. Prepare to administer lidocaine hydrochloride. d. Notify the primary health care provider immediately.

b. Continue to monitor the rhythm. Rationale:As an isolated occurrence, the PVC is not life-threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the primary health care provider needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output. Test-Taking Strategy(ies):Focus on the subject, the action to take for an isolated PVC. Noting the word "isolated" should direct you to the option that addresses continued monitoring. Also, use of the ABCs—airway, breathing, and circulation—will direct you to the correct option.Review:the implications of premature ventricular contraction (PVC)

A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). What information about the balloon-tipped catheter should nurse plan to include when providing client education concerning the procedure? a. mesh-like device within the catheter will be inflated causing it to spring open. b. The catheter will be used to compress the plaque against the coronary blood vessel wall. c. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade. d. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.

b. The catheter will be used to compress the plaque against the coronary blood vessel wall. Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization. Test-Taking Strategy(ies):Focus on the subject, percutaneous transluminal coronary angioplasty (PTCA). Look at the name of the procedure. "Angioplasty" refers to repair of a blood vessel; this will assist in eliminating options 1 and 4. From the remaining options, recalling that a procedure that cuts something away would have the suffix -ectomy will assist in eliminating option 3.Review: percutaneous transluminal coronary angioplasty (PTCA). Tip for the Nursing Student:Complications of PTCA include arterial dissection or rupture, embolization of plaque fragments, spasm, and acute myocardial infarction.

The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker. Which client statement indicates that an understanding of self-care is evident? a. "I will never be able to operate a microwave oven again." b. "I should expect occasional feelings of dizziness and fatigue." c. "I will take my pulse in the wrist or neck daily and record it in a log." d. "Moving my arms and shoulders vigorously helps check pacemaker functioning.

c. "I will take my pulse in the wrist or neck daily and record it in a log." Rationale:Clients with permanent pacemakers must be able to take their pulse in the wrist and/or neck accurately so as to note any variation in the pulse rate or rhythm that may need to be reported to the primary health care provider. Clients can safely operate most appliances and tools, such as microwave ovens, video recorders, AM-FM radios, electric blankets, lawn mowers, and leaf blowers, as long as the devices are grounded and in good repair. If the client experiences any feelings of dizziness, fatigue, or an irregular heartbeat, the primary health care provider is notified. The arms and shoulders should not be moved vigorously for 6 weeks after insertion. Test-Taking Strategy(ies):Focus on the subject, client understanding about care to a pacemaker. Recalling that a pacemaker assists in controlling cardiac rate and rhythm will direct you to the correct option.Review:client teaching points related to a pacemaker. Tip for the Nursing Student:A responsibility of the nurse is to teach a client with a pacemaker how to measure the pulse rate.

The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client needs additional teaching if the client states that which sign/symptom is associated with this condition? a. Epistaxis b. Dizziness c. Blurred vision d. A feeling of fullness in the head

d. A feeling of fullness in the head Rationale:A feeling of fullness in the head is more likely associated with a sinus condition than hypertension. Cerebrovascular symptoms of hypertension include early morning headaches, occipital headaches, epistaxis, dizziness, blurred vision, lightheadedness, and vertigo. The client should be aware of these signs/symptoms and report them if they occur. The client should also be taught to self-monitor the blood pressure. Test-Taking Strategy(ies):Note the strategic words, needs additional teaching. These words indicate a negative event query and ask you to select an option that is an incorrect sign or symptom. Focus on the subject, signs/symptoms of an elevated blood pressure. A feeling of fullness in the head is the vague option, whereas epistaxis, dizziness, and blurred vision are specific and related to hypertension.Review:the signs and symptoms of hypertension. Tip for the Nursing Student:There is no known cause for primary (essential) hypertension. Secondary hypertension occurs as a result of other diseases or conditions.

The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes securely in place? a. Secure the electrodes with adhesive tape. b. Place clear, transparent dressings over the electrodes. c. Apply lanolin to the skin before applying the electrodes. d. Cleanse the skin with alcohol before applying the electrodes.

d. Cleanse the skin with alcohol before applying the electrodes. Rationale:Alcohol defats the skin and helps the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode make better contact with the diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence. Test-Taking Strategy(ies):Focus on the subject, electrocardiogram (ECG). Note that options 1 and 2 are comparable or alike in that they both provide an external form of providing security of the electrodes. From the remaining options, note that option 4 addresses cleansing the skin