med-surg cardio exam

Nurse Perry is evaluating the renal function of a male client. After documenting urine volume and characteristics, nurse Perry assesses which signs as the best indicator of renal function. a. BP b. consciousness c. distention of the bladder d. pulse rate

a. BP Perfusion can be best estimated by BP, which is an indirect reflection of the adequacy of cardiac output.

Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza's highest priority would be... a. hourly urine output b. temperature c. able to turn side to side d. able to sip clear liquid

a. hourly urine output after nephrectomy, it is necessary to measure urine output hourly. This is done to assess the effectiveness of the remaining kidney also to detect renal failure early.

During the second day of hospitalization of the client after a myocardial infarction. Which of the following is an expected outcome? a. able to perform self-care activities w/o pain b. severe chest pain c. can recognize the risk factors of myocardial infarction d. can participate in cardiac rehabilitation walking program

a. able to perform self-care activities w/o pain By the 2nd day of hospitalization after suffering a MI, clients are able to perform care w/o chest pain.

Kate who has undergone mitral valve replacement suddenly experiences continuous bleeding from the surgical incision during post-op period. Which of the following pharmaceutical agents should nurse Aiza prepare to administer to Kate? a. protamine sulfate b. quinidine sulfate c. vitamin C d. coumadin

a. protamine sulfate Protamine sulfate is used to prevent continuous bleeding in clients who have undergone open heart surgery.

Mrs. Chua a 78 yo client is admitted with the diagnosis of mild chronic heart failure. the nurse expects to hear when listening to clients lungs indicative of chronic heart failure would be: a. stridor b. crackles c. wheezes d. friction rubs

b. crackles left sided heart failure causes fluid accumulation in the capillary network of the lung. fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration

Among the following s/sx, which would most likely be present in a client with mitral regurgitation? a. altered LOC b. exertional dyspnea c. increased creatinine phosphokinase concentration d. chest pain

b. exertional dyspnea Weight gain due to retention of fluids and worsening heart failure causes exertional dyspnea in clients with mitral regurgitation.

Patrick who is hospitalized following a myocardial infarction asks the nurse why he is taking morphine. The nurse explains that morphine: a. decrease anxiety and restlessness b. prevents shock and relieves pain c. dilates coronary blood vessels d. helps prevent fibrillation of the heart

b. prevents shock and relieves pain morphine is a central nervous system depressant used to relieve the pain associated with myocardial infarction, it also decreases apprehension and prevents cardiogenic shock.

A 64 yo male client with a long hx of CV problem including htn and angina is to be scheduled for cardiac catheterization. During pre-cardiac catheterization teaching Nurse Cherry should inform the client that the primary purpose of the procedure is... a. to determine the existence of CHD b. to visualize the disease process in the coronary arteries c. to obtain the heart chambers pressure d. to measure oxygen content of different heart chambers

b. to visualize the disease process in the coronary arteries The lumen of the arteries can be assessed by cardiac catheterization. Angina is usually caused by narrowing of the coronary arteries

A 68 yo client is diagnosed with a right-sided brain attack and is admitted to the hospital. In caring for this client, the nurse should plan to: a. application of elastic stockings to prevent flaccid by muscle b. use hand roll and extend the left upper extremity on a pillow to prevent contractions c. use a bed cradle to prevent dorsiflexion of feet d. do passive range of motion exercise

b. use hand roll and extend the left upper extremity on a pillow to prevent contractions the left side of the body will be affected in a right-sided brain attack

What would be the primary goal of therapy for a client with pulmonary edema and heart failure? a. enhance comfort b. increase cardiac output c. improve respiratory status d. peripheral edema decreased

b.increase cardiac output the primary goal of therapy for the client with pulmonary edema or heart failure is increasing cardiac output. Pulmonary edema is an acute medical emergency requiring immediate intervention.

A female client is taking Cascara Sagrada. Nurse Betty informs the client that the following may be experienced as side effects of this medication: a. GI bleeding b. peptic ulcer disease c. abdominal cramps d. partial bowel obstruction

c. abdominal cramps the most frequent side effects of Cascara Sagrada (laxative) is abdominal cramps and nausea.

Nurse Linda is caring for a client with head injury and monitoring client with decerebrate posturing. Which of the following is a characteristic of this type of posturing? a. upper extremity flexion with lower extremity flexion b. upper extremity flexion with lower extremity extension c. extension of the extremities after a stimulus d. flexion of the extremities after stimulus

c. extension of the extremities after a stimulus decerebrate posturing is the extension of the extremities after a stimulus which may occur with upper brain stem injury.

During the first several hours after cardiac catheterization, it would be most essential for nurse Cherry to... a. elevate clients bed to 45 degrees b. instruct the client to c/db every 2 hours c. frequently monitor clients apical pulse and BP d. monitor clients temp every hour

c. frequently monitor clients apical pulse and BP BP is monitored to detect hypotension which may indicate shock or hemorrhage. apical pulse is taken to detect arrhythmia's related to cardiac irritability.

In reducing the risk for endocarditis, good dental care is a important measure. To promote good dental care in client with mitral stenosis in teaching plan should in proper use of... a. dental floss b. electric toothbrush c. manual toothbrush d. irrigation device

c. manual toothbrush The use of electronic toothbrush, irrigation device or dental floss may cause bleeding of gums, allowing bacteria to enter and increasing the risk of endocarditis.

John suddenly experiences a seizure, and nurse Gina notices that John exhibits uncontrollable jerking movements. Nurse Gina documents John experienced which type of seizure a. tonic seizure b. absence seizure c. myoclonic seizure d clonic seizure

c. myoclonic seizure Myoclonic seizure is characterized by sudden uncontrollable jerking movement of a single or multiple muscle groups.

Nurse Trisha teaches a client with heart failure to take oral Furosemide in the morning. the reason for this is to help... a. retard rapid drug absorption b. excrete excessive fluids accumulated at night c. prevent sleep disturbances during night d. prevention of electrolyte imbalance

c. prevent sleep disturbances at night. when diuretics are taken in the morning, client will void frequently during daytime and will not need to void frequently at night.

Nurse Lilly has been assigned to a client with Raynaud's disease. Nurse Lilly realizes that the etiology of the disease in unknown but it is characterized by: a. episodic vasospastic disorder of capillaries b. episodic vasospastic disorder of small veins c. episodic vasospastic disorder of the aorta d. episodic vasospastic disorder of the small arteries

d. episodic vasospastic disorder of the small arteries Raynaud's disease is characterized by vasospasms of the small cutaneous arteries that involves fingers and toes.

Smoking cessation is a critical strategy for the client with Burghers disease, nurse Jasmine anticipates that the male client will go home with a prescription for which medication? a. paracetamol b. ibuprofen c. nitroglycerin d. nicotine (nicotrol)

d. nicotine (nicotrol) Nicotine (nicotrol)is given in controlled and decreasing doses for the management of nicotine withdrawal syndrome.

Dr. Marquez orders a continuous intravenous nitroglycerin infusion for a client suffering from myocardial infarction. Which of the following is the most essential nursing action? a. monitoring urine output frequently b. monitoring BP every 4 hours c. obtaining serum potassium levels daily d. obtaining infusion pump for the medication

d. obtaining infusion pump for the medication administration of intravenous nitroglycerin infusion requires pump for accurate control of medication.

Kris with a hx of chronic infection of the urinary system complains of urinary frequency and burning sensation. To figure out whether the current problem is in renal origin, the nurse should assess whether the client has discomfort or pain in the... a. urinary meatus b. pain in the labium c. suprapubic area d. right or left costovertebral angle

d. right or left costovertebral angle Discomfort or pain is a problem that originates in the kidney. It is felt at the costovertebral angle on the affected side.

Which of the following should the nurse teach the client about the signs of digitalis toxicity? a. increased appetite b. elevated BP c. skin rash over the chest and back d. visual disturbances such as seeing yellow spots

d. visual disturbances such as seeing yellow spots. seeing yellow spots and colored vision are common symptoms of digitalis toxicity.