Exam 2

The nurse performs discharge teaching for a patient with an implantable cardioverter-defibrillator. Which statement by the patient indicates to the nurse that further teaching is needed? "I can expect redness and swelling of the incision site for a few days." "I should not keep my cell phone in my shirt pocket on that side." "My family needs to keep up to date on how to perform CPR." "The device may set off the metal detectors in an airport."

"I can expect redness and swelling of the incision site for a few days."

A client with endocarditis is being discharged home. What statement indicates effectiveness of client teaching about preventing recurrence of the infection? "I will ask for antibiotics before I have dental work done." "I am going to take an aspirin a day to prevent lesions around my valve." "I will always be on antibiotic therapy." "I will start an antibiotic when I am exposed to anyone with infections."

"I will ask for antibiotics before I have dental work done."

A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse, "It will be 6 weeks before I can take a bath or return to my usual activities." "I will notify the airlines when I make a reservation that I have a pacemaker." "I won't lift the arm on the pacemaker side up very high until I see the doctor." "I must avoid cooking with a microwave oven or being near a microwave in use."

"I won't lift the arm on the pacemaker side up very high until I see the doctor."

When computing a heart rate from the ECG tracing, the nurse counts 15 of the small blocks between the R waves of a patient whose rhythm is regular. From these data, the nurse calculates the patient's heart rate to be which of the following? 60 Beats/min 75 Beats/min 100 Beats/min 150 Beats/min

100 Beats/min

The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? 1115 1500 1530 1600

1500

When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular cardiac rhythm, the nurse finds there are 25 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as

60 bpm

Results of a patient's most recent blood work indicate an elevated neutrophil level. You recognize that this diagnostic finding most likely suggests Hypoxemia. An infection. A risk of hypocoagulation. An acute thrombotic event.

An infection.

The nurse understands that which of the following medications will be administered indefinitely following mechanical valve surgery ? Antihypertensive Antiplatelet Antidiuretic Anticoagulant

Anticoagulant

The nurse is caring for a patient who is 24 hours postpacemaker insertion. Which of the following nursing interventions is most appropriate at this time? Reinforcing the pressure dressing as needed Encouraging range-of-motion exercises of the involved arm Assessing the incision for any redness, swelling, or discharge Applying wet-to-dry dressings every 4 hours to the insertion site

Assessing the incision for any redness, swelling, or discharge

The nurse is caring for a client who has had a dysrhythmic event. The nurse is aware of the need to assess for signs of diminished cardiac output. What change in status may signal to the nurse a decrease in cardiac output? Increased blood pressure Bounding peripheral pulses Changes in level of consciousness Pallor skin

Changes in level of consciousness

The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The appropriate nursing action is to: Prepare for defibrillation Continue to monitor the rhythm Notify the provider immediately Prepare to administer lidocaine

Continue to monitor the rhythm

Which of the following conditions is most commonly responsible for myocardial infarction? Aneurysm Coronary artery thrombosis Renal failure Heart failure

Coronary artery thrombosis

The nurse should advise a client with iron deficiency anema to take which action in order to prevent staining of the teeth? Take iron with or immediately after meals Avoid taking iron simultaneously with an antacid Do not combine iron with other prescribed or over-the-counter medications Dilute liquid preparations of iron with juice and drink with a straw

Dilute liquid preparations of iron with juice and drink with a straw

The nurse is reviewing the laboratory results for newly admitted clients on the cardiovascular unit. Which client laboratory result is most important to communicate as soon as possible to the health care provider? Elevated Potassium Elevated Troponin Elevated WBC count Elevated Calcium

Elevated Troponin

What is the most important method to identify the presence of infection in a neutropenic patient? Frequent temperature monitoring Routine blood and sputum cultures Assessing for redness and swelling Monitoring WBC count

Frequent temperature monitoring

When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing intervention should the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? Titrate the heparin infusion according to the agency protocol Perform the initial assessment of the catheter insertion site Teach the patient about the usual postoperative plan of care Give the scheduled aspirin and lipid-lowering medication

Give the scheduled aspirin and lipid-lowering medication

Which of the following recurring conditions most commonly occurs in patients with cardiomyopathy? Pericardial effusion Myocardial infarction Heart failure Diabetes

Heart failure

If medical treatments fail, which of the following invasive procedures is necessary for treating cardiomyopathy? Cardiac catheterization Intra-aortic balloon pump Heart transplantation Coronary artery bypass graft (CABG)

Heart transplantation

A patient has developed atrial fibrillation and has a ventricular rate of 150 beats/minute. The nurse will assess the patient for: Flat neck veins Nausea and vomiting Hypotension and dizziness Hypertension and headache

Hypotension and dizziness

Following a splenectomy for the treatment of ITP, what laboratory test result would the nurse expect to find? Decreased RBCs Increased platelets Decreased WBCs Increased immunoglobulins

Increased platelets

When assessing a patient related to hematologic health, the nurse would: Inspect the skin for petechiae. Ask the patient about joint pain. Assess for vitamin C deficiency. Determine if the patient can perform ADLs.

Inspect the skin for petechiae.

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? Take the iron with dairy products to enhance absorption Increase the intake of vitamin E to enhance absorption Iron will cause the stools to darken in color Limit foods high in fiber due to the risk for diarrhea

Iron will cause the stools to darken in color

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the client's: P-R interval T wave QRS complex P wave

P wave

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure of 82/60 mmHg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? Administer digoxin Defibrillate the client Continue to monitor the client Prepare for transcutaneous pacing

Prepare for transcutaneous pacing

In providing care for a patient hospitalized with an acute exacerbation of polycythemia vera, the nurse gives priority to which activity? Maintaining protective isolation Promoting leg exercises and ambulation Protecting the patient from injury or falls Promoting hydration with a large oral fluid intake

Promoting leg exercises and ambulation

The nurse is caring for a client who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse BEST respond? Recognize that the view of the electrical current changes in relation to the lead placement. Recognize that the electrophysiological conduction of the heart differs with lead placement. Inform the technician that the ECG equipment has malfunctioned. Inform the provider that the client is experiencing a new onset of dysrhythmia.

Recognize that the view of the electrical current changes in relation to the lead placement.

A client with a myocardial infarction develops acute mitral valve regurgitation. The nurse knows to assess for which manifestation that would indicate that the client is developing pulmonary congestion? Tachycardia Hypertension (HTN) Shortness of breath Murmur

Shortness of breath

A patient whose cardiac monitor shows sinus tachycardia, rate 102, is apneic and no pulses are palpable by the nurse. What is the first action that the nurse should take? Start CPR. Defibrillate. Administer atropine per hospital protocol. Give 100% oxygen per non-rebreather mask.

Start CPR.

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? Notify the client's health care provider Stop the transfusion immediately Remove the client's IV access Assess the client's chest sounds and vital signs

Stop the transfusion immediately

The nurse knows that ventricle repolarization (resting) can be found in the: PR interval QRS complex P wave T wave

T wave

Which patient teaching points should the nurse include when providing discharge instructions to a patient with a new permanent pacemaker and the caregiver? Select all that apply. Take and record a daily pulse Avoid or limit air travel Obtain and wear a Medic Alert ID device at all times Avoid lifting arm on the side of the pacemaker above the shoulder. Do not use a microwave oven because it interferes with pacemaker function

Take and record a daily pulse, Obtain and wear a Medic Alert ID device at all times, Avoid lifting arm on the side of the pacemaker above the shoulder.

Which of the following statements best describes the electrical activity of the heart represented by measuring the PR interval on the ECG? The length of time it takes to depolarize the atrium The length of time it takes for the atria to depolarize and repolarize The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers The length of time it takes for the electrical impulse to travel from the SA node to the AV node

The length of time for the electrical impulse to travel from the SA node to the Purkinje fibers

A nurse is caring for a patient with pericarditis and auscultates a pericardial friction rub. What action does the nurse ask the patient to do to distinguish a pericardial friction rub from a pleural friction rub? There is really no question to ask the patient to tell the difference. The nurse places the patient flat for at least 4 minutes. The nurse has the patient stand during auscultation. The nurse asks the patient to hold the breath during auscultation.

The nurse asks the patient to hold the breath during auscultation.

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis? The patient rates the pain at a level 3 to 5 (0 to 10 scale). The patient states that the pain has increased in frequency over the last week. The patient states that the pain "goes away" with one sublingual nitroglycerin tablet. The patient states that the pain "wakes me up at night."

The patient states that the pain "goes away" with one sublingual nitroglycerin tablet.

After the nurse delivers 50 joules by synchronized cardioversion, the patient develops ventricular fibrillation. Which action should the nurse take immediately? Ask the patient to report any chest pain or discomfort. Turn the synchronizer switch to the "off" position. Administer 250 mL of 0.9% saline solution intravenously. Assess the apical pulse and blood pressure.

Turn the synchronizer switch to the "off" position.

Which of the following types of angina is most closely related to an impending myocardial infarction (MI)? Angina decubitus Chronic stable angina Nocturnal angina Unstable angina

Unstable angina

The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm. Which method will be best to use? Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes. Count the number of large squares in the R-R interval and divide by 300. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10. Calculate the number of small squares between one QRS complex and the next and

Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

A patient in asystole is likely to receive which of the following drug treatments? Vasopressin and epinephrine Lidocaine and amiodarone Digoxin and procainamide β-Adrenergic blockers and dopamine

Vasopressin and epinephrine

The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How will the nurse document the rhythm? Ventricular couplets Ventricular bigeminy Ventricular R-on-T phenomenon Ventricular multifocal contractions

Ventricular bigeminy

For which of the following dysrhythmias is defibrillation primarily indicated? Ventricular fibrillation Third-degree AV block Uncontrolled atrial fibrillation Ventricular tachycardia with a pulse

Ventricular fibrillation

When a patient requires defibrillation, in which order will the nurse accomplish the following steps? Put a comma and space between each answer choice (a, b, c, d, etc.) a. Turn the defibrillator on. b. Deliver the electrical charge. c. Select the appropriate energy level. d. Place the paddles on the patient's chest. e. Check the location of other personnel and call out "all clear."

a, d, c, e, b

A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to pharmacologic therapy for several days. The nurse anticipates that the patient may need teaching about: electrical cardioversion. IV adenosine (Adenocard). anticoagulant therapy with warfarin (Coumadin). insertion of an implantable cardioverter-defibrillator (ICD).

anticoagulant therapy with warfarin (Coumadin).

The nurse prepares a client for synchronized cardioversion knowing that cardioversion differs from defibrillation in that defibrillation delivers a lower dose of electrical energy cardioversion is a treatment for atrial bradydysrhythmias defibrillation is synchronized to deliver a shock during the QRS complex clients should be sedated if cardioversion is done on a nonemergency basis

clients should be sedated if cardioversion is done on a nonemergency basis

A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of: vitamin B12 vitamin A vitamin C folic acid

vitamin B12