NUR 313 Test 2 Cardiology

66. When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching? Select all that apply. ■ 1. Becoming increasingly short of breath at rest. ■ 2. Weight gain of 2 lb or more in 1 day. ■ 3. High intake of sodium for breakfast. ■ 4. Having to sleep sitting up in a reclining chair. ■ 5. Weight loss of 2 lb in 1 day

1, 2, 4. The client stating that he would call the physician with increasing shortness of breath, weight gain over 2 lb in 1 day, and having to sleep sitting up, indicates that he has understood the teaching because these signs and symptoms suggest worsening of the client's heart failure. Although the client will most likely be placed on a sodium-restricted diet, the client would not need to notify the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake for the rest of that day and in the future. CN: Reduction of risk potential; CL: Evaluate

1. A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time? ■ 1. Monitor daily weights and urine output. ■ 2. Permit unrestricted visitation by family and friends. ■ 3. Provide client education on medications and diet. ■ 4. Reduce pain and myocardial oxygen demand.

1. 4. Nursing management for a client with a myocardial infarction should focus on pain management and decreasing myocardial oxygen demand. Fluid status should be closely monitored. Client education should begin once the client is stable and amenable to teaching. Visitation should be based on client comfort and maintaining a calm environment. CN: Physiological adaptation; CL: Synthesize

74. A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time? ■ 1. Medication therapy. ■ 2. Diet modification. ■ 3. Activity restrictions. ■ 4. Dental care

1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does. CN: Reduction of risk potential; CL: Evaluate

64. The nurse is admitting a 68-year-old male to the medical floor. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? ■ 1. Assess respiratory status. ■ 2. Draw blood for laboratory studies. ■ 3. Insert a Foley catheter. ■ 4. Weigh the client.

1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate, lung sounds, and SpO2 to identify any signs of respiratory symptoms of heart failure requiring immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter, and weigh the client. CN: Physiological adaptation; CL: Synthesize

10. A 60-year-old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first: ■ 1. Administer the morphine. ■ 2. Obtain a 12-lead ECG. ■ 3. Obtain the blood work. ■ 4. Order the chest radiograph.

10. 1. Although obtaining the ECG, chest radiograph, and blood work are all important, the nurse's priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority action. CN: Physiological adaptation; CL: Synthesize

100. A 74-year-old female is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to: ■ 1. Maintain skin integrity. ■ 2. Maintain cardiac conduction stability. ■ 3. Decrease cardiac output. ■ 4. Increase activity level.

100. 2. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours. CN: Reduction of risk potential; CL: Synthesize

101. The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client: ■ 1. Selects a low-cholesterol diet to control coronary artery disease. ■ 2. States a need for bed rest for 1 week after discharge. ■ 3. Verbalizes safety precautions needed to prevent pacemaker malfunction. ■ 4. Explains signs and symptoms of myocardial infarction (MI)

101. 3. Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb or stretching and bending and to count the pulse once per week, that are necessary to maintain proper pacemaker function. The client will not necessarily be placed on a low cholesterol diet. The client should resume activities as he is able, and does not need to remain on bed rest. The client should know signs and symptoms of MI, but is not at risk because of the pacemaker. CN: Basic care and comfort; CL: Evaluate

102. Upon assessment of third degree heart block on the monitor, the nurse should first: ■ 1. Call a code. ■ 2. Begin cardiopulmonary resuscitation. ■ 3. Have transcutaneous pacing ready at the bedside. ■ 4. Prepare for defibrillation.

102. 3. Transcutaneous pads should be placed on the client with third degree heart block. For a client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is performed for ventricular fibrillation or ventricular tachycardia with no pulse. CN: Management of care; CL: Synthesize

103. Ventricular tachycardia is displayed on the cardiac monitor of a client admitted to the telemetry unit. Which should the nurse do first? ■ 1. Prepare for immediate cardioversion. ■ 2. Begin cardiopulmonary resuscitation (CPR). ■ 3. Check for a pulse. ■ 4. Prepare for immediate defibrillation.

103. 3. The presence of a pulse determines the treatment for ventricular tachycardia. It is also important to assess the client's heart rate and level of consciousness. Cardioversion may be used to treat hemodynamically unstable tachycardias. Assessment of instability is required before cardioversion. It is not appropriate to begin CPR unless the pulse is absent. Defibrillation is used to treat ventricular fibrillation or pulseless ventricular tachycardia. CN: Physiological adaptation; CL: Synthesize

104. The nurse is preparing the client for cardioversion. The nurse should do which of the following? Select all that apply. ■ 1. Use a conducting agent between the skin and the paddles. ■ 2. Place the paddles over the client's clothing. ■ 3. Call "clear" before discharging the electrical current. ■ 4. Record the delivered energy and the resulting rhythm. ■ 5. Exert 5 to 10 lb of pressure on each paddle to ensure good skin contact.

104. 1, 3, 4. A conducting agent is placed between the skin and the paddles to conduct the electrical current when discharged. The nurse must make sure to call "clear" before discharging the electrical current to prevent injury to others who may be helping with the client. Each paddle is placed directly on the conductive pads that are on the client's skin. Applying approximately 20 to 25 lb of pressure on each paddle is recommended to ensure good skin contact. The nurse must record the amount of electrical current delivered and the resulting rhythm. CN: Reduction of risk potential; CL: Synthesize

105. A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital's emergency department, where the admitting nurse quickly assesses the client's condition. The most effective way to determine the effectiveness of CPR is noting whether the: ■ 1. Pulse rate is normal. ■ 2. Pupils are reacting to light. ■ 3. Mucous membranes are pink. ■ 4. Systolic blood pressure is at least 80 mm Hg

105. 2. Pupillary reaction is the best indication of whether oxygenated blood has been reaching the client's brain. Pupils that remain widely dilated and do not react to light probably indicate that serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be pink, and systolic blood pressure may be 80 mm Hg or higher, and serious brain damage may still have occurred. CN: Reduction of risk potential; CL: Evaluate

106. A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect? ■ 1. The ventricular rate is increasing. ■ 2. The absent pulse is now palpable. ■ 3. The number of premature ventricular contractions is decreasing. ■ 4. The fine ventricular fibrillation changes to coarse ventricular fibrillation.

106. 3. Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia. CN: Pharmacological and parenteral therapies; CL: Evaluate

107. During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for laceration by forceful compressions over the xiphoid process? ■ 1. Lung. ■ 2. Liver. ■ 3. Stomach. ■ 4. Diaphragm

107. 2. Because of its location near the xiphoid process, the liver is the organ most easily damaged from pressure exerted over the xiphoid process during CPR. The pressure on the victim's chest wall should be sufficient to compress the heart but not so great as to damage internal organs. Injury may result, however, even when CPR is performed properly. CN: Reduction of risk potential; CL: Apply

108. When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum: ■ 1. 0.5 to 1 inch. ■ 2. 1 to 1.5 inches. ■ 3. 1.5 to 2 inches. ■ 4. 2 to 2.5 inches

108. 3. An adult's sternum must be depressed 1.5 to 2 inches with each compression to ensure adequate heart compression. CN: Reduction of risk potential; CL: Apply

109. If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first: ■ 1. Try using an ambu bag. ■ 2. Decrease the rate of compressions. ■ 3. Intubate the client. ■ 4. Reposition the airway

109. 4. If the chest wall is not rising with rescue breaths, the head should be repositioned first to ensure that the airway is adequately opened. An ambu bag allows for delivery of 100% oxygen. Compressions should be maintained at 100 per minute. CN: Physiological adaptation; CL: Synthesize

11. When administering a thrombolytic drug to the client experiencing a myocardial infarction (MI), the nurse explains that the purpose of the drug is to: ■ 1. Help keep him well hydrated. ■ 2. Dissolve clots that he may have. ■ 3. Prevent kidney failure. ■ 4. Treat potential cardiac arrhythmias.

11. 2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage. CN: Pharmacological and parenteral therapies; CL: Apply

110. During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by: ■ 1. Normal relaxation of the chest. ■ 2. Gentle pressure of the rescuer's hand on the upper chest. ■ 3. The pressure of cardiac compressions. ■ 4. Turning the head to the side

110. 1. The exhalation phase of ventilation is a passive activity that occurs during CPR as part of the normal relaxation of the victim's chest. No action by the rescuer is necessary. CN: Reduction of risk potential; CL: Apply

111. The rapid response team has been called to manage an unwitnessed cardiac arrest. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is: ■ 1. 1 to 2 minutes. ■ 2. 4 to 6 minutes. ■ 3. 8 to 10 minutes. ■ 4. 12 to 15 minutes

111. 2. After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain damage is almost certain. To prevent permanent brain damage, it is important to begin CPR promptly after a cardiopulmonary arrest. CN: Reduction of risk potential; CL: Apply

112. A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: ■ 1. Starts to become cyanotic. ■ 2. Cannot speak due to airway obstruction. ■ 3. Can make only minimal vocal noises. ■ 4. Is coughing vigorously.

112. 2. The Heimlich maneuver should be administered only to a victim who cannot make any sounds due to airway obstruction. If the victim can whisper words or cough, some air exchange is occurring and the emergency medical system should be called instead of attempting the Heimlich maneuver. Cyanosis may accompany or follow choking; however, the Heimlich maneuver should only be initiated when the victim cannot speak. CN: Reduction of risk potential; CL: Apply

113. When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically: ■ 1. Above the umbilicus. ■ 2. At the level of the xiphoid process. ■ 3. Over the victim's midabdominal area. ■ 4. Below the xiphoid process and above the umbilicus.

113. 4. The thrusts should be delivered below the xiphoid process, but above the umbilicus, to minimize the risk of internal injuries. CN: Reduction of risk potential; CL: Apply

114. The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. Which is the priority nursing action? ■ 1. Activate the rapid response team. ■ 2. Assess the client's orientation and vital signs. ■ 3. Call the physician. ■ 4. Administer a bolus of lidocaine.

114. 2. The priority action is to assess the client and determine whether the rhythm is life-threatening. More information, including vital signs, should be obtained and the physician should be quickly notified. A bolus of lidocaine may be ordered to treat this arrhythmia. This is not a code-type situation unless the client has been determined to be in a life-threatening situation. CN: Physiological adaptation; CL: Synthesize

115. The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should: ■ 1. Begin chest compressions. ■ 2. Call the rapid response team. ■ 3. Remove the family from the room. ■ 4. Ventilate the client with an ambu bag

115. 2. The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided. CN: Management of care; CL: Synthesize

116. Which activity would be appropriate to delegate to unlicensed personnel for a client diagnosed with a myocardial infarction who is stable? ■ 1. Evaluate the lung sounds. ■ 2. Help the client identify risk factors for CAD. ■ 3. Provide teaching on a 2 g sodium diet. ■ 4. Record the intake and output.

116. 4. Unlicensed personnel are able to measure and record intake and output. The nurse is responsible for client teaching, physical assessments, and evaluating the information collected on the client. CN: Management of care; CL: Synthesize

117. The nurse is assessing a client with heart failure who is receiving home health care monitoring using electronic devices including scales, blood pressure monitoring, and structured questions to which the client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3 days. April 3 2010 April 4 2010 April 5 2010 Weight 160 162 165 Blood Pressure 120/80 130/88 140/90 The nurse calls the client to follow up. The nurse should ask the client which of the following first: ■ 1. "How are you feeling today?" ■ 2. "Are you having shortness of breath?" ■ 3. "Did you calibrate the scales before using them?" ■ 4. "How much fluid did you drink during the last 24 hours?"

117. 2. The client has gained 5 lb in 3 days with a steady increase in blood pressure. The client is exhibiting signs of heart failure and if the client is short of breath, this will be another sign. Asking how the client is feeling is too general and a more focused question will quickly determine the client's current health status. The scales should be calibrated periodically, but a 5 lb weight gain, along with increased blood pressure, is not likely due to problems with the scale. The weight gain is likely due to fluid retention, not drinking too much fluid. CN: Management of care; CL: Analyze

118. The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective? ■ 1. 90 percent of clients have not gained weight. ■ 2. 75 percent of the clients viewed the educational DVD. ■ 3. 80 percent of the clients reported that they are taking their medications. ■ 4. 5 percent of the clients required hospitalization in the last 90 days.

118. 4. The goals of managing clients outside of the hospital are for the clients to maintain health and prevent readmission, thus interventions, such as monitoring and teaching appear to have contributed to the low readmission rate in this group of clients. Although it is important that clients do not gain weight, view educational material and continue to take their medication, the primary indicator of effectiveness of the program is the lack of re-hospitalization. CN: Management of care; CL: Evaluate

119. The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported? ■ 1. Give the report face-to-face with both nurses in a quiet room. ■ 2. Audiotape the report for future reference and documentation. ■ 3. Use a printed checklist with information individualized for the client. ■ 4. Document essential transfer information in the client's electronic health record

119. 3. Using an individualized, printed checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information. CN: Safety and infection control; CL: Evaluate

12. The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following? ■ 1. Atrial fibrillation. ■ 2. Ventricular tachycardia. ■ 3. Premature ventricular contractions (PVCs). ■ 4. Third-degree heart block.

12. 3. PVCs are characterized by a QRS of longer than 0.10 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS complex, and the T wave is usually inverted. CN: Reduction of risk potential; CL: Analyze

13. A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial line is inserted. Which of the following orders should the nurse question? ■ 1. Call for urine output < 30 mL/hour for 2 consecutive hours. ■ 2. Metoprolol (Lopressor) 5 mg I.V. push. ■ 3. Prepare for a pulmonary artery catheter insertion. ■ 4. Titrate Dobutamine (Dobutrex) to keep systolic BP > 100.

13. 2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a beta blocker will further depress myocardial contractility. The metoprolol should be discontinued. The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will improve contractility and increase the cardiac output that is depressed in cardiogenic shock. CN: Physiological adaptation; CL: Synthesize 14

14. If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock, which characteristic sign should the nurse expect to observe? ■ 1. Oliguria. ■ 2. Bradycardia. ■ 3. Elevated blood pressure. ■ 4. Fever.

14. 1. Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. CN: Reduction of risk potential; CL: Analyze

15. The physician orders continuous I.V. nitroglycerin infusion for the client with myocardial infarction. Essential nursing actions include which of the following? ■ 1. Obtaining an infusion pump for the medication. ■ 2. Monitoring blood pressure every 4 hours. ■ 3. Monitoring urine output hourly. ■ 4. Obtaining serum potassium levels daily.

15. 1. I.V. nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion. CN: Pharmacological and parenteral therapies; CL: Synthesize

16. When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by: ■ 1. Left ventricular overload. ■ 2. Impending circulatory collapse. ■ 3. Extracellular electrolyte imbalances. ■ 4. Insufficient oxygen reaching the heart muscle.

16. 4. An MI interferes with or blocks blood circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina. The pain is not due to ventricular overload, circulatory collapse, or electrolyte imbalances. CN: Physiological adaptation; CL: Apply

17. The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following? ■ 1. Atrial fibrillation. ■ 2. Ventricular tachycardia. ■ 3. Premature ventricular contractions. ■ 4. Sinus tachycardia.

17. 4. Sinus tachycardia is characterized by normal conduction and a regular rhythm, but with a rate exceeding 100 bpm. A P wave precedes each QRS, and the QRS is usually normal. CN: Reduction of risk potential; CL: Analyze

18. While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an I.V. infusion of 5% dextrose in water (D5W) and oxygen at 2 L/minute. The nurse's first course of action should be to: ■ 1. Increase the I.V. infusion rate. ■ 2. Notify the physician promptly. ■ 3. Increase the oxygen concentration. ■ 4. Administer a prescribed analgesic

18. 2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the I.V. infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability. CN: Physiological adaptation; CL: Synthesize

19. Which of the following is an expected outcome for a client on the second day of hospitalization after a myocardial infarction (MI)? The client: ■ 1. Has severe chest pain. ■ 2. Can identify risk factors for MI. ■ 3. Agrees to participate in a cardiac rehabilitation walking program. ■ 4. Can perform personal self-care activities without pain.

19. 4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after and MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program. CN: Physiological adaptation; CL: Evaluate

69. A client is scheduled for a cardiac catheterization. The nurse should do which of the following preprocedure tasks? Select all that apply. ■ 1. Administer all ordered oral medications. ■ 2. Check for iodine sensitivity. ■ 3. Verify that written consent has been obtained. ■ 4. Withhold food and oral fluids before the procedure. ■ 5. Insert a urinary drainage catheter

2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodine sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours before the procedure. Oral medications are withheld unless specifically ordered. A urinary drainage catheter is rarely required for this procedure. CN: Reduction of risk potential; CL: Apply

62. A client receiving a loop diuretic should be encouraged to eat which of the following foods? Select all that apply. ■ 1. Angel food cake. ■ 2. Banana. ■ 3. Dried fruit. ■ 4. Orange juice. ■ 5. Peppers.

2, 3, 4. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are examples of food high in potassium. Angel food cake, yellow cake, and peppers are listed by the National Kidney Foundation as low in potassium. CN: Pharmacological and parenteral therapies; CL: Apply

76. A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. ■ 1. Begin Warfarin (Coumadin). ■ 2. Check the postoperative CBC, INR, PTT, & platelet levels. ■ 3. Confirm availability of blood products. ■ 4. Monitor the mediastinal chest tube drainage. ■ 5. Start a Dopamine (Intropin) drip for a systolic BP < 100

2, 3, 4. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR & PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding, therefore availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Coumadin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine. CN: Physiological adaptation; CL: Synthesize

2. A client with chest pain is prescribed intravenous nitroglycerin (Tridil). Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip? ■ 1. Serum potassium is 3.5 mEq/L. ■ 2. Blood pressure is 88/46. ■ 3. ST elevation is present on the electrocardiogram. ■ 4. Heart rate is 61.

2. 2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The potassium and heart rate are within normal range. CN: Pharmacological and parenteral therapies; CL: Analyze

63. The nurse finds the apical impulse below the fifth intercostal space. The nurse suspects:■ 1. Left atrial enlargement. ■ 2. Left ventricular enlargement. ■ 3. Right atrial enlargement. ■ 4. Right ventricular enlargement.

2. A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement. CN: Physiological adaptation; CL: Analyze

61. Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet? ■ 1. Apples. ■ 2. Tomato juice. ■ 3. Whole wheat bread. ■ 4. Beef tenderloin.

2. Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice. CN: Reduction of risk potential; CL: Apply

72. A client experiences initial indications of excitation after having an I.V. infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having: ■ 1. Palpitations. ■ 2. Tinnitus. ■ 3. Urinary frequency. ■ 4. Lethargy.

2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine. CN: Pharmacological and parenteral therapies; CL: Analyze

73. A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority? ■ 1. Assess the 12-lead EKG. ■ 2. Assess the blood pressure. ■ 3. Assess the lung sounds. ■ 4. Assess the urine output.

2. The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds. CN: Physiological adaptation; CL: Synthesize

20. Which of the following is an expected outcome when a client is recieving an I.V. administration of furosemide? ■ 1. Increased blood pressure. ■ 2. Increased urine output. ■ 3. Decreased pain. ■ 4. Decreased premature ventricular contractions.

20. 2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias. CN: Pharmacological and parenteral therapies; CL: Evaluate

21. After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help: ■ 1. Prepare the client for ambulation. ■ 2. Promote urinary and intestinal elimination. ■ 3. Prevent thrombophlebitis and blood clot formation. ■ 4. Decrease the likelihood of pressure ulcer formation.

21. 3. This type of exercise is a preventive strategy taught to all clients who are hospitalized and on bed rest. This activity is taught to the client to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. It is venous stasis that increases one's risk for thrombophlebitis and blood clot formation. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation. CN: Physiological adaptation; CL: Apply

22. Which of the following reflects the principle on which a client's diet will most likely be based during the acute phase of myocardial infarction? ■ 1. Liquids as desired. ■ 2. Small, easily digested meals. ■ 3. Three regular meals per day. ■ 4. Nothing by mouth.

22. 2. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable. CN: Physiological adaptation; CL: Apply

23. The nurse is assessing clients at a health fair. Which client is at greatest risk for coronary artery disease? ■ 1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. ■ 2. A 43-year-old male with a family history of CAD and cholesterol level of 158. ■ 3. A 56-year-old male with an HDL of 60 who takes atorvastatin (Lipitor). ■ 4. A 65-year-old female who is obese with an LDL of 188.

23. 4. The woman who is 65 years old, overweight and has an elevated LDL is at greatest risk. Total cholesterol > 200, LDL > 100, HDL < 40 in men, HDL < 50 in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin is a medication to reduce LDL and decrease risk of CAD. The combination of postmenopausal, obesity, and high LDL cholesterol places this client at greatest risk. CN: Health promotion and maintenance; CL: Analyze

24. A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? ■ 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a lowfat diet." ■ 2. "The triglycerides are elevated and will not return to normal without these medications." ■ 3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." ■ 4. "The medications are not indicated since your lab values are all normal."

24. 3. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. CN: Physiological adaptation; CL: Apply

25. If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: ■ 1. Explaining how the old behavior leads to poor health. ■ 2. Withholding praise until the new behavior is well established. ■ 3. Rewarding the client whenever the acceptable behavior is performed. ■ 4. Instilling mild fear into the client to extinguish the behavior.

25. 3. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward. CN: Psychosocial adaptation; CL: Synthesize

26. Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: ■ 1. Control chest pain. ■ 2. Reduce coronary artery vasospasm. ■ 3. Control the arrhythmias associated with MI. ■ 4. Revascularize the blocked coronary artery.

26. 4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area. CN: Pharmacological and parenteral therapies; CL: Apply

27. After the administration of t-PA, the assessment priority is to: ■ 1. Observe the client for chest pain. ■ 2. Monitor for fever. ■ 3. Monitor the 12-lead electrocardiogram (ECG) every 4 hours. ■ 4. Monitor breath sounds.

27. 1. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever. CN: Reduction of risk potential; CL: Analyze

28. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? ■ 1. Cardiac arrhythmias. ■ 2. Hypertension. ■ 3. Seizure. ■ 4. Hypothermia.

28. 1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue. CN: Reduction of risk potential; CL: Synthesize

29. Contraindications to the administration of tissue plasminogen activator (t-PA) include which of the following? ■ 1. Age greater than 60 years. ■ 2. History of cerebral hemorrhage. ■ 3. History of heart failure. ■ 4. Cigarette smoking.

29. 2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications. CN: Pharmacological and parenteral therapies; CL: Apply

3. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago. Upon assessment, the nurse identifies a new systolic murmur at the apex. The nurse should first: ■ 1. Assess for changes in vital signs. ■ 2. Draw an arterial blood gas. ■ 3. Evaluate heart sounds with the client leaning forward. ■ 4. Obtain a 12 Lead electrocardiogram.

3. 1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left midclavicular line. The murmur worsens during expiration and in the supine or left-side position. Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical activity of the heart; an echocardiogram views valve function. CN: Physiological adaptation; CL: Synthesize

67. A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action? ■ 1. A low, grade 1 intensity mitral regurgitation murmur. ■ 2. SpO2 is 94% on 2 liters of oxygen via nasal cannula. ■ 3. The client has become more somnolent. ■ 4. Urine output has decreased from 60 mL/hour to 40 mL over the last hour

3. A complication of balloon valvuloplasty is emboli resulting in a stroke. The client's increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the procedure. The oxygen status and urine output should be monitored closely, but do not warrant concern. CN: Reduction of risk potential; CL: Synthesize

70. A client has returned to the medical-surgical unit after a cardiac catheterization. Which is the most important initial postprocedure nursing assessment for this client? ■ 1. Monitor the laboratory values. ■ 2. Observe neurologic function every 15 minutes. ■ 3. Observe the puncture site for swelling and bleeding. ■ 4. Monitor skin warmth and turgor.

3. Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required. CN: Reduction of risk potential; CL: Analyze

65. The nurse's discharge teaching plan for the client with heart failure should stress the importance of which of the following? ■ 1. Maintaining a high-fiber diet. ■ 2. Walking 2 miles every day. ■ 3. Obtaining daily weights at the same time each day. ■ 4. Remaining sedentary for most of the day.

3. Heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 lb or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life-threatening. Following a high-fiber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles every day, would not be appropriate at discharge. The client's exercise program would need to be planned in consultation with the physician and based on the history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended. CN: Reduction of risk potential; CL: Create

71. A 70-year-old female is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client's childhood health history included: ■ 1. Chickenpox. ■ 2. Poliomyelitis. ■ 3. Rheumatic fever. ■ 4. Meningitis

3. Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chickenpox, poliomyelitis, and meningitis are not associated with mitral stenosis. CN: Physiological adaptation; CL: Analyze

30. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client is presently complaining of indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse's next action would be to: ■ 1. Call for the physician. ■ 2. Start an I.V. line. ■ 3. Obtain a portable chest radiograph. ■ 4. Draw blood for laboratory studies.

30. 2. Advanced cardiac life support recommends that at least one or two I.V. lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the I.V. line. CN: Physiological adaptation; CL: Synthesize

31. Crackles heard on lung auscultation indicate which of the following? ■ 1. Cyanosis. ■ 2. Bronchospasm. ■ 3. Airway narrowing. ■ 4. Fluid-filled alveoli

31. 4. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds. CN: Physiological adaptation; CL: Analyze

32. A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: ■ 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. ■ 2. Administer oxygen via nasal cannula. ■ 3. Offer pain medication for the chest heaviness. ■ 4. Inform the physician of the chest heaviness.

32. 1. Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician. CN: Reduction of risk potential; CL: Synthesize

33. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? ■ 1. Cancer. ■ 2. Hypertension. ■ 3. Liver disease. ■ 4. Myocardial damage.

33. 4. Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction. Myoglobin does not help diagnose cancer, hypertension, or liver disease. CN: Reduction of risk potential; CL: Analyze

34. An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of: ■ 1. Left ventricular atrophy. ■ 2. Irregular heartbeats. ■ 3. Peripheral vascular occlusion. ■ 4. Pacemaker placement.

34. 1. In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress. CN: Physiological adaptation; CL: Apply

35. During the previous few months, a 56-yearold woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she visits an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client prevent this problem? ■ 1. Visit her friend early in the day. ■ 2. Rest for at least an hour before climbing the stairs. ■ 3. Take a nitroglycerin tablet before climbing the stairs. ■ 4. Lie down once she reaches the friend's apartment.

35. 3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair-climbing to help the client remain pain free. Visiting her friend early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode. CN: Reduction of risk potential; CL: Synthesize

36. The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals should the nurse tell the client would be best on her low-cholesterol diet? ■ 1. Hamburger, salad, and milkshake. ■ 2. Baked liver, green beans, and coffee. ■ 3. Spaghetti with tomato sauce, salad, and coffee. ■ 4. Fried chicken, green beans, and skim milk.

36. 3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol. CN: Basic care and comfort; CL: Apply

37. Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician? ■ 1. A change in the pattern of her pain. ■ 2. Pain during sexual activity. ■ 3. Pain during an argument with her husband. ■ 4. Pain during or after an activity such as lawn-mowing

37. 1. The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn-mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities. CN: Reduction of risk potential; CL: Apply

38. The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: ■ 1. Open and dilate blocked coronary arteries. ■ 2. Assess the extent of arterial blockage. ■ 3. Bypass obstructed vessels. ■ 4. Assess the functional adequacy of the valves and heart muscle

38. 2. Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage. A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and therefore would need the procedure to assess the extent of arterial blockage. CN: Reduction of risk potential; CL: Apply

39. The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat angina. Priority goals for the client immediately after PTCA should include: ■ 1. Minimizing dyspnea. ■ 2. Maintaining adequate blood pressure control. ■ 3. Decreasing myocardial contractility. ■ 4. Preventing fluid volume deficit.

39. 4. Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis. Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control should not be a problem after the procedure. Increased myocardial contractility would be a goal, not decreased contractility. CN: Reduction of risk potential; CL: Synthesize

4. A client with acute chest pain is receiving I.V. morphine sulfate. Which of the following results are intended effects of morphine in this client? Select all that apply. ■ 1. Reduces myocardial oxygen consumption. ■ 2. Promotes reduction in respiratory rate. ■ 3. Prevents ventricular remodeling. ■ 4. Reduces blood pressure and heart rate. ■ 5. Reduces anxiety and fear.

4. 1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting enzyme- inhibitor drugs, not morphine, may help to prevent ventricular remodeling.

75. In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that: ■ 1. The client will remain in the ICU for 5 days. ■ 2. The client will sleep most of the time while in the ICU. ■ 3. Noise and activity within the ICU are minimal. ■ 4. The client will receive medication to relieve pain.

4. Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replaceent surgery. CN: Reduction of risk potential; CL: Synthesize

40. Which of the following is not a risk factor for the development of atherosclerosis? ■ 1. Family history of early heart attack. ■ 2. Late onset of puberty. ■ 3. Total blood cholesterol level greater than 220 mg/dL. ■ 4. Elevated fasting blood glucose concentration

40. 2. Late onset of puberty is not generally considered to be a risk factor for the development of atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and physical inactivity. CN: Physiological adaptation; CL: Apply

41. As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: ■ 1. Antispasmodic effects on the pericardium. ■ 2. Causing an increased myocardial oxygen demand. ■ 3. Vasodilation of peripheral vasculature. ■ 4. Improved conductivity in the myocardium.

41. 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium. CN: Pharmacological and parenteral therapies; CL: Apply

42. A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should instruct the client that: ■ 1. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect. ■ 2. Nitroglycerin should be avoided if the client is experiencing this serious side effect. ■ 3. Taking the nitroglycerin with a few glasses of water will reduce the problem. ■ 4. The client should lie in a supine position to alleviate the headache

42. 1. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin, acetaminophen or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain and exacerbate other symptoms, such as shortness of breath. CN: Physiological adaptation; CL: Synthesize

43. Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? ■ 1. Take one tablet every 2 to 5 minutes until the pain stops. ■ 2. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. ■ 3. Take one tablet, then an additional tablet every 5 minutes for a total of three tablets. Call the physician if pain persists after three tablets. ■ 4. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician

43. 3. The correct protocol for nitroglycerin use involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three tablets. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. CN: Pharmacological and parenteral therapies; CL: Synthesize

44. A client with angina has been taking nifedipine. The nurse should teach the client to: ■ 1. Monitor blood pressure monthly. ■ 2. Perform daily weights. ■ 3. Inspect gums daily. ■ 4. Limit intake of green leafy vegetables

44. 3. The client taking nifedipine should inspect the gums daily to monitor for gingival hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than monthly. These clients would not generally need to perform daily weights or limit intake of green leafy vegetables. CN: Pharmacological and parenteral therapies; CL: Synthesize

45. Captopril (Capoten), furosemide (Lasix), and metoprolol (Toprol XL) are ordered for a client with systolic heart failure. The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9 a.m., the nurse reviews the following lab tests (see chart). Which of the following should the nurse do first? ■ 1. Administer the medications. ■ 2. Call the physician. ■ 3. Withhold the captopril. ■ 4. Question the metoprolol dose. Laboratory Results Sodium 140 mEq/L Potassium 6.8 mEq/L Chloride 101 meq/L CO 2 Content 26 mEq/L BUN 18 mg/dL Creatinine 1.0 mg/dL Hemoglobin 12 g/dL Hematocrit 37%

45. 3. The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I. The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client's heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should report the high potassium level and that the captopril was withheld. CN: Pharmacological and parenteral therapies; CL: Syntehsize

46. A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: ■ 1. Decrease circulatory overload. ■ 2. Improve the myocardial workload. ■ 3. Prevent thrombus formation. ■ 4. Regulate cardiac rhythm.

46. 3. Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm. CN: Reduction of risk potential; CL: Evaluate

47. A client has a history of heart failure and has been taking several medications, including furosemide (Lasix), digoxin (Lanoxin) and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows firstdegree atrioventricular block. The nurse should assess the client for signs of which condition? ■ 1. Hyperkalemia. ■ 2. Digoxin toxicity. ■ 3. Fluid deficit. ■ 4. Pulmonary edema.

47. 2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing. CN: Pharmacological and parenteral therapies; CL: Analyze

48. A nurse is assessing a client with heart failure. The nurse should assess the client based on which compensatory mechanisms that are activated in the presence of heart failure? Select all that apply. ■ 1. Ventricular hypertrophy. ■ 2. Parasympathetic nervous stimulation. ■ 3. Renin-angiotensin-aldosterone system. ■ 4. Jugular venous distention. ■ 5. Sympathetic nervous stimulation.

48. 1, 3, 5. When the heart begins to fail, the body activates three major compensatory systems: ventricular hypertrophy, the renin-angiotensinaldosterone system, and sympathetic nervous stimulation. Parasympathetic stimulation and jugular venous distention are not compensatory mechanisms associated with heart failure. CN: Physiological adaptation; CL: Apply

49. Which of the following sets of conditions is an indication that a client with a history of leftsided heart failure is developing pulmonary edema? ■ 1. Distended jugular veins and wheezing. ■ 2. Dependent edema and anorexia. ■ 3. Coarse crackles and tachycardia. ■ 4. Hypotension and tachycardia.

49. 3. Signs of pulmonary edema are identical to those of acute heart failure. Signs and symptoms are generally apparent in the respiratory system and include coarse crackles, severe dyspnea, and tachypnea. Severe tachycardia may occur due to sympathetic stimulation in the presence of hypoxemia. Blood pressure may be decreased or elevated depending on the severity of the edema. Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure. CN: Physiological adaptation; CL: Analyze

5. A client receives fibrinolytic therapy upon admission following a myocardial infarction. He is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? ________________________ mL/hour

5. 24 mL/hour First, calculate how many units are in each milliliter of the medication: 25,000 units 50 units = 500 mL 1 mL Next, calculate how many milliliters the client receives per hour: 1,200 units 1 hour 50 units 1 mL = 1,200 24 units 1 hour 1 mL 1 50 units = 24 mL/hour. ÷ × CN: Pharmacological and parenteral therapies; CL: Apply

50. A 69-year-old female has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should the nurse assess first? ■ 1. Blood pressure. ■ 2. Skin breakdown. ■ 3. Serum potassium level. ■ 4. Urine output.

50. 1. It is a priority to assess blood pressure first because people with pulmonary edema typically experience severe hypertension that requires early intervention. The client probably does not have skin breakdown on admission; however, when the client is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse should monitor urine output after the client is stable. CN: Reduction of risk potential; CL: Analyze

51. Which of the following nursing diagnoses would be appropriate for a client with systolic heart failure? Select all that apply. ■ 1. Ineffective peripheral tissue perfusion related to a decreased stroke volume. ■ 2. Activity intolerance related to impaired gas exchange and perfusion. ■ 3. Dyspnea related to pulmonary congestion and impaired gas exchange. ■ 4. Decreased cardiac output related to impaired cardiac filling. ■ 5. Impaired renal perfusion related to a decreased cardiac output.

51. 1, 2, 3, 5. A decrease in cardiac output occurs from a decreased stroke volume with impaired contractility in systolic heart failure. This impairs peripheral and renal perfusion. The impaired perfusion and impaired oxygenation cause the symptoms of activity intolerance. The decreased systolic function causes an increase in residual volume and pressure in the left ventricle. A retrograde buildup of pressure from the left ventricle to left atria increases hydrostatic pressure in the pulmonary vasculature. This causes a leakage of fluid into the interstitial tissue of the lungs resulting in pulmonary symptoms. With diastolic heart failure, there is impaired ventricular filling due to a rigid ventricle and reduced ventricular relaxation. CN: Physiological adaptation; CL: Analyze

52. In which of the following positions should the nurse place a client with suspected heart failure? ■ 1. Semi-sitting (low Fowler's position). ■ 2. Lying on the right side (Sims' position). ■ 3. Sitting almost upright (high Fowler's position). ■ 4. Lying on the back with the head lowered (Trendelenburg's position)

52. 3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg's position. CN: Reduction of risk potential; CL: Synthesize

53. The major goal of therapy for a client with heart failure and pulmonary edema should be to: ■ 1. Increase cardiac output. ■ 2. Improve respiratory status. ■ 3. Decrease peripheral edema. ■ 4. Enhance comfort.

53. 1. Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema. CN: Reduction of risk potential; CL: Apply

54. A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? ■ 1. Dilated coronary arteries. ■ 2. Increased myocardial contractility. ■ 3. Decreased cardiac arrhythmias. ■ 4. Decreased electrical conductivity in the heart

54. 2. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary reasons for its use in clients with heart failure and pulmonary edema. CN: Pharmacological and parenteral therapies; CL: Evaluate

55. Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug's desired effect? ■ 1. 5 to 10 minutes. ■ 2. 30 to 60 minutes. ■ 3. 2 to 4 hours. ■ 4. 6 to 8 hours

55. 1. After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously. CN: Pharmacological and parenteral therapies; CL: Evaluate

56. The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help: ■ 1. Prevent electrolyte imbalances. ■ 2. Retard rapid drug absorption. ■ 3. Excrete excessive fluids accumulated during the night. ■ 4. Prevent sleep disturbances during the night

56. 4. When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night. CN: Pharmacological and parenteral therapies; CL: Apply

57. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse should suspect atrial fibrillation when palpation of the radial pulse reveals: ■ 1. Two regular beats followed by one irregular beat. ■ 2. An irregular pulse rhythm. ■ 3. Pulse rate below 60 bpm. ■ 4. A weak, thready pulse

57. 2. Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction. CN: Reduction of risk potential; CL: Analyze

58. When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following? ■ 1. Stasis of blood in the atria. ■ 2. Increased cardiac output. ■ 3. Decreased pulse rate. ■ 4. Elevated blood pressure.

58. 1. Atrial fibrillation occurs when the sinoatrial node no longer functions as the heart's pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate. CN: Reduction of risk potential; CL: Synthesize

59. The nurse should teach the client that signs of digoxin toxicity include which of the following? ■ 1. Rash over the chest and back. ■ 2. Increased appetite. ■ 3. Visual disturbances such as seeing yellow spots. ■ 4. Elevated blood pressure.

59. 3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with digoxin toxicity. CN: P

6. A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do? ■ 1. Put the tablet under the tongue until it is absorbed. ■ 2. Swallow the tablet with 120 mL of water. ■ 3. Chew the tablet until it is dissolved. ■ 4. Place the tablet between his cheek and gums

6. 3. The client is having symptoms of a myocardial infarction. The first action is to prevent platelet formation and block prostaglandin synthesis. The nitroglycerin tablet will be absorbed fastest if the client chews the tablet. CN: Physiological adaptation; CL: Apply

60. The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a: ■ 1. Low sodium level. ■ 2. High glucose level. ■ 3. High calcium level. ■ 4. Low potassium level.

60. 4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity. CN: Pharmacological and parenteral therapies; CL: Analyze

7. The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority? ■ 1. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. ■ 2. Confusion, urine output 15 mL over the last 2 hours, orthopnea. ■ 3. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities. ■ 4. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

7. 2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fibrillation there is a loss of atrial kick, but the blood pressure and heart rate are stable. CN: Physiological adaptation; CL: Analyze

77. The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: ■ 1. Observe careful hand-washing procedures. ■ 2. Clean the incisional area with an antiseptic. ■ 3. Use prepackaged sterile dressings to cover the incision. ■ 4. Place soiled dressings in a waterproof bag before disposing of them.

77. 1. Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections. CN: Reduction of risk potential; CL: Synthesize

78. For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? ■ 1. Ensure a liberal fluid intake. ■ 2. Provide an alkaline-ash diet. ■ 3. Prevent constipation. ■ 4. Enrich the client's diet with dairy products.

78. 1. In an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi. CN: Physiological adaptation; CL: Synthesize

79. The nurse should teach the client who is receiving warfarin sodium that: ■ 1. Partial thromboplastin time values determine the dosage of warfarin sodium. ■ 2. Protamine sulfate is used to reverse the effects of warfarin sodium. ■ 3. International Normalized Ratio (INR) is used to assess effectiveness. ■ 4. Warfarin sodium will facilitate clotting of the blood

79. 3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots. CN: Pharmacological and parenteral therapies; CL: Apply

8. The nurse notices that a client's heart rate decreases from 63 to 50 beats per minute on the monitor. The nurse should first: ■ 1. Administer Atropine 0.5 mg I.V. push. ■ 2. Auscultate for abnormal heart sounds. ■ 3. Prepare for transcutaneous pacing. ■ 4. Take the client's blood pressure.

8. 4. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done. CN: Physiological adaptation; CL: Synthesize

80. Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of: ■ 1. A manual toothbrush. ■ 2. An electric toothbrush. ■ 3. An irrigation device. ■ 4. Dental floss

80. 1. Daily dental care and frequent checkups by a dentist who is informed about the client's condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis. CN: Reduction of risk potential; CL: Create

81. Before a client's discharge after mitral valve replacement surgery, the nurse should evaluate the client's understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon? ■ 1. Showering. ■ 2. Lifting anything heavier than 10 lb. ■ 3. A program of gradually progressive walking. ■ 4. Light housework.

81. 2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge. CN: Safety and infection control; CL: Evaluate

82. Three days after mitral valve surgery, a 45-year-old female comments that she hears a "clicking" noise coming from her chest and her "rather large" chest incision. The nurse's response should reflect the understanding that the client may be experiencing which of the following? ■ 1. Anxiety related to altered body image. ■ 2. Anxiety related to altered health status. ■ 3. Altered tissue perfusion. ■ 4. Lack of knowledge regarding the postoperative course.

82. 1. Verbalized concerns from this client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion. CN: Psychosocial adaptation; CL: Analyze

83. Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female diagnosed with stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace). An expected therapeutic effect is: ■ 1. Decrease in heart rate. ■ 2. Lessening of fatigue. ■ 3. Improvement in blood sugar levels. ■ 4. Increase in urine output

83. 1. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting the beta blocker. The mechanism of action does not improve blood sugar or urine output. CN: Pharmacologicl and parenteral therapies; CL: Evaluate

84. A client is taking clonidine (Catapres) for treatment of hypertension. The nurse should teach the client about which of the following common adverse effects of this drug? Select all that apply. ■ 1. Dry mouth. ■ 2. Hyperkalemia. ■ 3. Impotence. ■ 4. Pancreatitis. ■ 5. Sleep disturbance.

84. 1, 3, 5. Clonidine (Catapres) is a centralacting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug. CN: Pharmacological and parenteral therapies; CL: Apply

85. A client with hypertensive emergency is being treated with sodium nitroprusside (Nipride). In a dilution of 50 mg/250 mL, how many micrograms of Nipride are in each milliliter? ________________________ mcg.

85. 200 mcg First, calculate the number of milligrams per milliliter: 50 mg 1 mg 0.2 mg = = 250 mL 5 mL 1 mL Next, calculate the number of micrograms in each milligram: 0.2 mg × 1,000 mcg = 200 mcg

86. In teaching the hypertensive client to avoid orthostatic hypotension, the nurse should emphasize which of the following instructions? Select all that apply. ■ 1. Plan regular times for taking medications. ■ 2. Arise slowly from bed. ■ 3. Avoid standing still for long periods. ■ 4. Avoid excessive alcohol intake. ■ 5. Avoid hot baths.

86. 2, 3. Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation. CN: Reduction of risk potential; CL: Create

87. An industrial health nurse at a large printing plant finds a male employee's blood pressure to be elevated on two occasions 1 month apart and refers him to his private physician. The employee is about 25 lb overweight and has smoked a pack of cigarettes daily for more than 20 years. The client's physician prescribes atenolol (Tenormin) for the hypertension. The nurse should instruct the client to: ■ 1. Avoid sudden discontinuation of the drug. ■ 2. Monitor the blood pressure annually. ■ 3. Follow a 2-g sodium diet. ■ 4. Discontinue the medication if severe headaches develop

87. 1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a physician's order. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension. CN: Pharmacological and parenteral therapies; CL: Synthesize

88. The nurse teaches a client, who has recently been diagnosed with hypertension, about dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs? ■ 1. Mixed green salad with blue cheese dressing, crackers, and cold cuts. ■ 2. Ham sandwich on rye bread and an orange. ■ 3. Baked chicken, an apple, and a slice of white bread. ■ 4. Hot dogs, baked beans, and celery and carrot sticks.

88. 3. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic. CN: Basic care and comfort; CL: Apply

89. A client's job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following? ■ 1. Muscle aches. ■ 2. Thirst. ■ 3. Lethargy. ■ 4. Orthostatic hypotension.

89. 4. Possible dizziness from orthostatic hypotension when rising from a crouched or bent position increases the client's risk of being injured by the equipment. The nurse should assess the client's blood pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle aches, or thirst from working in a warm, dry room, but these are not as potentially dangerous as orthostatic hypotension. The client should not be experiencing lethargy. CN: Reduction of risk potential; CL: Analyze

9. A client is admitted with a myocardial infarction and new onset atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as: ■ 1. Heart rate irregular with S3. ■ 2. Heart rate irregular with S4. ■ 3. Heart rate irregular with aortic regurgitation. ■ 4. Heart rate irregular with mitral stenosis.

9. 1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood flow through an incompetent or stenotic valve. CN: Physiological adaptation; CL: Analyze

90. An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program? ■ 1. Giving the client a written exercise program. ■ 2. Explaining the exercise program to the client's spouse. ■ 3. Reassuring the client that he or she can do the exercise program. ■ 4. Tailoring a program to the client's needs and abilities.

90. 4. Tailoring or individualizing a program to the client's lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client's spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program. CN: Psychosocial adaptation; CL: Synthesize

91. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? ■ 1. Review the negative effects of smoking on the body. ■ 2. Discuss the effects of passive smoking on environmental pollution. ■ 3. Establish the client's daily smoking pattern. ■ 4. Explain how smoking worsens high blood pressure.

91. 3. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior. CN: Psychosocial adaptation; CL: Synthesize

92. Essential hypertension would be diagnosed in a 40-year-old male whose blood pressure readings were consistently at or above which of the following? ■ 1. 120/90 mm Hg. ■ 2. 130/85 mm Hg. ■ 3. 140/90 mm Hg. ■ 4. 160/80 mm Hg.

92. 3. American Heart Association standards define hypertension as a consistent systolic blood pressure level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg. CN: Reduction of risk potential; CL: Analyze

93. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol: ■ 1. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. ■ 2. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. ■ 3. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure. ■ 4. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

93. 1. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II. CN: Pharmacological and parenteral therapies; CL: Apply

94. The most important long-term goal for a client with hypertension would be to: ■ 1. Learn how to avoid stress. ■ 2. Explore a job change or early retirement. ■ 3. Make a commitment to long-term therapy. ■ 4. Lose weight

94. 3. Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension. CN: Psychosocial adaptation; CL: Synthesize

95. The client has had hypertension for 20 years. The nurse should assess the client for? ■ 1. Renal insufficiency and failure. ■ 2. Valvular heart disease. ■ 3. Endocarditis. ■ 4. Peptic ulcer disease

95. 1. Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension. CN: Reduction of risk potential; CL: Synthesize

96. The nurse is developing a care plan with an older adult and is instructing the client that hypertension can be a silent killer. The nurse should instruct the client to be aware of signs and symptoms of other system failures and encourage the client to report signs of which of the following diseases that are often a result of undeteced high blood pressure? ■ 1. Cerebrovascular accidents (CVAs). ■ 2. Liver disease. ■ 3. Myocardial infarction. ■ 4. Pulmonary disease.

96. 1. Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease. CN: Reduction of risk potential; CL: Create

97. A client treated for hypertension with furosemide (Lasix), atenolol (Tenormin), and ramipril (Altace) develops a second degree heart block Mobitz type 1. Which of the following actions should the nurse take? ■ 1. Administer a 250 mL fluid bolus. ■ 2. Withhold the atenolol. ■ 3. Prepare for cardioversion. ■ 4. Set up for an arterial line.

97. 2. The client may be asymptomatic and the underlying cause should be assessed. Drugs that block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers, digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing. There is no indication for a fluid bolus, cardioversion, or arterial line. CN: Pharmacological and parenteral therapies; CL: Synthesize

98. When teaching a client about self-care following placement of a new permanent pacemaker to his left upper chest, the nurse should include which information? Select all that apply. ■ 1. Take and record daily pulse rate. ■ 2. Avoid air travel because of airport security alarms. ■ 3. Immobilize the affected arm for 4 to 6 weeks. ■ 4. Avoid using a microwave oven. ■ 5. Avoid lifting anything heavier than 3 lb

98. 1, 5. The nurse must teach the client how to take and record his pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the physician. The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function. CN: Reduction of risk potential; CL: Create

99. A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first? ■ 1. Prepare for transcutaneous pacing. ■ 2. Prepare to defibrillate the client at 200 joules. ■ 3. Administer an I.V. lidocaine infusion. ■ 4. Schedule the operating room for insertion of a permanent pacemaker.

99. 1. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of thirddegree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted. CN: Physiological adaptation; CL: Synthesize

68. A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis

The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb's point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area. CN: Physiological adaptation; CL: Apply