Test 4 Saunder NCLEX Q

A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1.Anterior chest pain 2.Pericardial friction rub 3.Weakness and irritability 4. Chest pain that worsens on inspiration

2 Rationale: A pericardial friction rub is heard when inflammation of the pericardial sac is present during the inflammatory phase of pericarditis. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a wide variety of disorders. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy.

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1.The neurovascular status is normal because of increased blood flow through the leg. 2.The neurovascular status is moderately impaired, and the surgeon should be called. 3.The neurovascular status is slightly deteriorating and should be monitored for another hour. 4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1 Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1.Listening to lung sounds 2.Monitoring for organomegaly 3.Assessing for jugular vein distention 4.Assessing for peripheral and sacral edema

1 Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. 1.Presence of Aschoff's bodies 2.Absence of C-reactive protein 3.Elevated antistreptolysin O titer 4.Presence of Reed-Sternberg cell 5.Elevated erythrocyte sedimentation rate

1,3,5 Rationale: Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1.Emotional stress 2.Atrial fibrillation 3.Nutritional anemia 4.Peptic ulcer disease 5.Recent upper respiratory infection

1235 Rationale: Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1.Flat neck veins 2.A pulse rate of 60 beats/min 3.Muffled or distant heart sounds 4.Wheezing on auscultation of the lungs

3 Rationale: Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? 1.Rising blood pressure 2.Clearly audible heart sounds 3.Client expressions of relief 4.Rising central venous pressure

4 Rationale: Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. 1.Soak the feet in hot water daily. 2.Be careful not to injure the legs or feet. 3.Use a heating pad on the legs to aid vasodilation. 4.Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

2,4,5 Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Place in Fowler's position for eating. 2.Encourage coughing with deep breathing. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables.

234Rationale: The client with DVT may require bedrest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? 1. Ascites 2.Pedal edema 3. Bilateral lung crackles 4. Jugular vein distention

3 Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Adventitious breath sounds, such as crackles, are an indicator of decreased left-sided heart function. Peripheral edema, jugular vein distention, and ascites all can be present because of insufficiency of the pumping action of the right side of the heart.

The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? 1.Walk for as long as possible each day. 2.Cross the legs at the ankle only, not at the knee. 3.Lie down with the legs elevated and avoid sitting. 4.Sit in a chair 3 times a day for 3 hours at a time.

3Rationale: The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days after the procedure. Prolonged standing or sitting increases the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same reason.

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking? 1."None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2."Because most of the damage has already been done, it will be all right to cut down a little at a time." 3."If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."

4 Rationale: The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. Options 1, 2, and 3 are incorrect.

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1.Apnea monitor 2.Oxygen flowmeter 3.Telemetry cardiac monitor 4.Oxygen saturation monitor

4Rationale: Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's prescriptions? Select all that apply. 1.Elevation of the right leg 2.Ambulation in the hall every 4 hours 3.Application of moist heat to the right leg 4.Administration of acetaminophen (Tylenol) 5.Monitoring for signs of pulmonary embolism

1 345 Rationale: Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism.

A nurse is providing postoperative care for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse should be most concerned about monitoring for which potential complications? 1.Bleeding and infection 2.Thrombosis and infection 3.Bleeding and wound dehiscence 4.Wound dehiscence and evisceration

1 Rationale: After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Heparin therapy also predisposes the client to bleeding. Thrombosis is unlikely because the client is on heparin therapy. Wound dehiscence and evisceration are not concerns because no abdominal incision is made

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse's response incorporates the information that bearing down or straining would trigger which physical response? 1.Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility 2.Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility 3.Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility 4. Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility

1 Rationale: Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis.

A nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema

1 Rationale: Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, and leg is very swollen.

A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do next? 1.Review intake and output records for the last 2 days. 2.Prescribe daily weights starting on the following morning. 3.Request a sodium restriction of 1 g/day from the health care provider. 4.Change the time of diuretic administration from morning to evening.

1 Rationale: Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Therefore, the nurse should review intake and output records for the last 2 days. Strict sodium restrictions are reserved for clients with severe symptoms. Diuretics should be given in the morning whenever possible to avoid nocturia.

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1.Elevated antistreptolysin O (ASO) titer 2.Decreased erythrocyte sedimentation rate (ESR) 3.Negative result on antinuclear antibody (ANA) assay 4.Negative result on C-reactive protein (CRP) determination

1 Rationale: In the presence of rheumatic fever, the child will exhibit an elevated ASO titer, an elevated ESR, leukocytosis, and a positive result on CRP determination. A positive result on ANA testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and also will be positive with rheumatic fever.

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1."I will eat enough daily fiber to prevent straining at stool." 2. "I will try to exercise vigorously to strengthen my heart muscle." 3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

1 Rationale: Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1.Listening to lung sounds 2. Monitoring for organomegaly 3. Assessing for jugular vein distention 4. Assessing for peripheral and sacral edema

1 Rationale: The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value came back elevated? 1.Myoglobin 2.Cardiac troponin 3.C-reactive protein 4.Creatine kinase (CK)

2 Rationale: Cardiac troponin elevations indicate myocardial injury or infarction. Although the remaining options may also rise, they are not definitive enough to draw a conclusive diagnosis.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1.Use nail polish to protect the nail beds from injury. 2.Stop smoking because it causes cutaneous vasospasm. 3.Wear gloves for all activities involving use of both hands. 4. Always wear warm clothing even in warm climates to prevent vasoconstriction.

2 Rationale: Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. Options 1 and 4 are incorrect. It is not necessary to wear gloves for all activities.

A nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion? 1.The cardiac output is above the normal range. 2.The cardiac output is below the normal range. 3.The cardiac output is in the low-normal range. 4.The cardiac output is in the high-normal range.

2 Rationale: The normal cardiac output for the adult can range from 4 to 7 L/min. Therefore a cardiac output of 3.2 L/min is below normal range.

A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? 1."Apply warm packs to the leg." 2."Keep the leg elevated as much as possible." 3."Contact your health care provider right away to report this problem." 4."This normally occurs after surgery and will subside when the edema goes down."

3 Rationale: A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. Options 1, 2, and 4 are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration.

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? 1."I need to cut down on cigarette smoking." 2."I am so relieved that my heart is repaired." 3."I need to adhere to my dietary restrictions." 4."I am so relieved that I can eat anything I want to now."

3 Rationale: After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which condition? 1.Heart failure 2.Atrial fibrillation 3.Myocardial infarction 4.Ventricular tachycardia

3 Rationale: Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation.

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question should best help a nurse discriminate pain caused by a noncardiac problem? 1."Can you describe the pain to me?" 2."Have you ever had this pain before?" 3."Does the pain get worse when you breathe in?" 4."Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

3 Rationale: Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). The remaining options may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1.Anxiety related to the need to make lifestyle changes 2.Boredom resulting from having already learned the material 3.An attempt to ignore or deny the need to make lifestyle changes 4. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

3 Rationale: Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1.Pallor 2.Cough 3. Tachycardia 4. Slow and shallow breathing

3 Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1.Left atrium 2.Right atrium 3.Left ventricle 4.Right ventricle

3 Rationale: Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers that are primarily responsible for this disease process although these chambers may become affected as the disease becomes more chronic.

The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include to monitor the child for signs of which condition? 1.Bleeding 2.Failure to thrive 3.Heart failure (HF) 4. Decreased tolerance to stimulation

3 Rationale: Nursing care initially centers on observing for signs of HF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distention. Options 1, 2, and 4 are not conditions directly associated with this disorder.

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin (Lanoxin). The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/min. Which action should the nurse take? 1.Retake the apical pulse. 2.Withhold the medication. 3.Administer the medication. 4. Withhold the medication and notify the health care provider.

3 Rationale: The apical pulse rate for a 1-year-old infant is 90 to 130 beats/min. Because the apical rate is normal, options 1, 2, and 4 are incorrect.

A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? 1.Eat breakfast just before the procedure. 2.Wear firm, rigid shoes, such as workboots. 3.Wear loose clothing with a shirt that buttons in front. 4.Avoid cigarettes for 30 minutes before the procedure.

3 Rationale: The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client should receive nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client should wear rubber-soled, supportive shoes, such as athletic training shoes. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result.

A nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure (HF)? 1.Paleness of the skin 2.Strong sucking reflex 3.Diaphoresis during feeding 4. Slow and shallow breathing

3 Rationale: The early symptoms of HF include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF.

A nurse is preparing to ambulate a client on the third day after cardiac surgery. What should the nurse plan to do to enable the client to best tolerate the ambulation? 1.Remove telemetry equipment. 2.Provide the client with a walker. 3.Premedicate the client with an analgesic. 4.Encourage the client to cough and breathe deeply.

3 Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Providing the client with a walker and encouraging the client to cough and breathe deeply will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed.

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1.The client is not experiencing dyspnea. 2.The client is not experiencing nausea or vomiting. 3.The pain has not been relieved by rest and nitroglycerin tablets. 4. The client says the pain began while she was trying to open a stuck dresser drawer.

3 Rationale: The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety).

A hospitalized client is experiencing a decrease in blood pressure. The nurse plans care for the client, knowing that this change will have which primary effect on his or her heart? 1.Decreased heart rate 2.Increased contractility 3. Decreased myocardial blood flow 4. Increased resistance to electrical stimulation

3 Rationale: The primary effect of a decrease in blood pressure is reduced blood flow to the myocardium. This in turn decreases oxygenation of the cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase, not decrease, in response to this change. The effects of tissue ischemia lead to decreased contractility over time.

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? 1."I need to start exercising more to improve my health." 2."I will be sure to keep my appointment with the cardiologist." 3."I don't have anyone to help me with doing heavy housework at home." 4."I think I have a good understanding of what all my medications are for."

3 Rationale: To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct option indicate that the client will be successful in these areas.

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1.Cracked lips 2.Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3,Rationale: Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

he nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? 1.Tea 2.Cola 3.Coffee 4.Raspberry juice

4 Rationale: A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? 1.Monitor oxygen saturation with pulse oximetry. 2.Assess activity tolerance before and after exercise. 3.Observe the client's cardiac rhythm with telemetry. 4.Assess peripheral pulses with an ultrasonic Doppler device.

4 Rationale: Acute arterial insufficiency is associated with interruption of arterial blood flow to an organ, tissue, or extremity. It is associated with an acutely painful pasty-colored leg. The priority is for the nurse to perform a comprehensive assessment of peripheral circulation. When pulses are difficult to palpate, the Doppler device is useful to determine the presence of blood flow to the area. The Doppler directs sound waves toward the artery being examined, which emits an audible sound. The nurse must document that the pulse was present via Doppler and not palpation. Although options 1, 2, and 3 may be components of the assessment, they are not the priority.

The nurse is monitoring an infant with heart failure (HF). Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider (HCP)? 1.Bradypnea 2.Diaphoresis 3.Decreased blood pressure 4.A weight gain of 1 lb in 1 day

4 Rationale: HF is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. A weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the HCP. Tachypnea and increased blood pressure occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and usually occurs with exertional activities.

The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse should address with the client which most important measure to ensure client safety? 1.Assessing pain 2.Administering vasodilators 3.Avoiding over-the-counter medications 4. Moving slowly from a sitting to a standing position

4 Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy. Options 1 and 3, although important, are not directly related to the issue of safety.

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? 1.Checking for a rash on the digits 2.Observing for softening of the nails or nail beds 3.Palpating for a rapid or irregular peripheral pulse 4.Palpating for diminished or absent peripheral pulses

4 Rationale: Raynaud's disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin (Lanoxin). In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 2.4 ng/mL and an apical heart rate of 98 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1.Retake the apical pulse. 2. Administer the medication. 3. Withhold the medication for 1 hour. 4. Withhold the medication and notify the health care provider.

4 Rationale: The apical pulse rate for a newborn is 120 to 140 beats/min. The therapeutic digoxin level ranges from 0.5 to 2.0 ng/dL. Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider. Therefore options 1, 2, and 3 are incorrect.

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin (Lanoxin). In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 2.4 ng/mL and an apical heart rate of 98 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1.Retake the apical pulse. 2.Administer the medication. 3.Withhold the medication for 1 hour. 4.Withhold the medication and notify the health care provider.

4 Rationale: The apical pulse rate for a newborn is 120 to 140 beats/min. The therapeutic digoxin level ranges from 0.5 to 2.0 ng/dL. Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider. Therefore options 1, 2, and 3 are incorrect.

A nurse is caring for a client who has lost a significant amount of blood as a result of complications of a surgical procedure. The nurse understands that which client assessment will provide the earliest indication of new decreases in fluid volume? 1.Pulse rate 2.Blood pressure (BP) 3.Assessment for edema 4. Lung auscultation for crackles

1Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Options 3 and 4 indicate an increase in fluid volume. Although the BP will decrease, it is not the earliest indicator

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client? 1.Use the knee-gatch on the bed. 2.Cover the legs lightly when sitting in a chair. 3.Encourage the client to cross legs when sitting in a chair. 4. Provide pillows for the client to place under the knees as desired.

2 Rationale: Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, and discouraging leg-crossing. Clients should be encouraged to perform passive and active range of motion exercises. The knee gatch on the bed and pillows under the knees should be avoided because it places pressure on the blood vessels in the popliteal area, impeding venous return.

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? 1.Chest pain 2.Urge to cough 3.Warm, flushed feeling 4.Pressure at the insertion site

1 Rationale: The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site.

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding? 1.Hypotension 2.Flat neck veins 3.Complaints of nausea 4. Complaints of headache

1 Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output owing to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

A nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is most likely unrelated to the aneurysm? 1.Pulsatile abdominal mass 2.Hyperactive bowel sounds in the area 3.Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen

2 Rationale: Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass.

he nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action is most appropriate? 1.Administer the aspirin if the child's temperature is elevated. 2.Administer the aspirin if the child experiences any joint pain. 3.Consult with the health care provider to verify the prescription. 4.Administer acetaminophen (Tylenol) for temperature elevation.

3 Rationale: Anti-inflammatory agents, including aspirin, may be prescribed for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections. Therefore, the nurse should consult with the health care provider to verify the prescription. The nurse would not administer acetaminophen (Tylenol) without specific health care provider's prescriptions. Options 1 and 2 are not appropriate actions.

A nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit? 1.+4 Edema noted in lower extremities 2.Crackles auscultated from lung bases to apices 3.Blood pressure rises from 116/68 to118/74 mm Hg 4.Pulse rate increases from 100 beats/min to 136 beats/min

4 Rationale: The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.

home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? 1.A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer 4.A venous stasis ulcer

3 Rationale: Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which is in the client's hospital room as a priority item? 1.Over-bed trapeze 2.Dry sterile dressings 3.Surgical tourniquet 4. Incentive spirometer

3 Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items considering the surgical procedure that the client underwent.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? 1.Ad lib activities as tolerated 2.Strict bed rest for 24 hours after transfer 3.Bathroom privileges and self-care activities 4. Unsupervised hallway ambulation for distances up to 200 feet

3 Rationale: On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the need for further instructions? 1."I will not mix the medication with food." 2."I will take my child's pulse before administering the medication." 3."If more than one dose is missed, I will call the health care provider." 4."If my child vomits after medication administration, I will repeat the dose."

4 Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

A client with angina has a 12-lead electrocardiogram taken during an episode of chest pain. The nurse should examine the tracing for which electrocardiographic (ECG) change caused by myocardial ischemia? 1.Tall, peaked T waves 2.Prolonged PR interval 3.Widened QRS complex 4.ST segment elevation or depression

4 Rationale: An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block.

The home health nurse visits a client recovering from cardiogenic shock secondary to an anterior myocardial infarction and provides home care instructions to the client. Which statement by the client indicates an understanding of these home care measures? 1."I exercise every day after breakfast." 2."I've gained 8 pounds since discharge." 3."I take an antacid when I experience epigastric pain." 4. "I have planned periods of rest at 10:00 am and 3:00 pm daily."

4 Rationale: The client recovering from cardiogenic shock secondary to a myocardial infarction will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated myocardial infarction. The complication of cardiogenic shock increases the recovery period for healing. Paced activities with planned rest periods will decrease the chance of experiencing angina or delayed healing. It is best to allow the meal to settle prior to activity in order to improve circulation to the heart during exercise. Epigastric pain or a weight gain of 8 pounds is significant and should be reported to the health care provider, at which point follow-up should occur.

the nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse should provide which information to the client? 1.Oxygen has a calming effect. 2.Oxygen will prevent the development of any thrombus. 3.Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle. 4.The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.

4 Rationale: The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1."I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above my heart level for at least an hour every day."

4Rationale: Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in options 1, 2, and 3 are correct statements.

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1.Ambulates 10 feet farther each day 2.Verbalizes the benefits of increasing activity 3.Chooses a healthy diet that meets caloric needs 4.Sleeps without awakening throughout the night

1 Rationale: Each of the options indicates a positive outcome on the part of the client. Both options 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.

A nursing student who is researching a medication at the nursing station asks the registered nurse (RN) what an α1-adrenergic receptor is. The RN responds by telling the student that these receptors are found primarily in which peripheral vascular structures and produce which actions? 1.The peripheral arteries and veins, and when stimulated cause vasoconstriction 2.Arterial and bronchial walls, and when stimulated cause vasodilation and bronchodilation 3.The heart, and when stimulated cause an increase in heart rate, atrioventricular (AV) node conduction, and contractility 4. Several tissues, and when stimulated cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation

1 Rationale: Found in the peripheral arteries and veins, α1-adrenergic receptors cause a powerful vasoconstriction when stimulated. Options 2, 3, and 4 describe β1-, β2-, and α2-adrenergic receptors, respectively.

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1.Weighing the diapers 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

1 Rationale: Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.

A client is having a follow-up health care provider (HCP) office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which would be an appropriate action by the nurse based on evaluation of the client's comment? 1.Report the complaint to the HCP. 2.Instruct the client to apply warm packs. 3.Reassure the client that this is only temporary. 4.Advise the client to take acetaminophen (Tylenol) until it is gone.

1 Rationale: Hypersensitivity or a sensation of pins and needles in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported. Options 2, 3, and 4 are incorrect action and could be harmful; in addition, they delay the possible need for intervention about the client's complaint.

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? 1."Where is the pain located?" 2."Are you having any nausea?" 3."Are you allergic to any medications?" 4."Do you have your nitroglycerin with you?"

1 Rationale: If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. Although options 2, 3, and 4 all may be components of the assessment, none of these questions would be the initial assessment question with this client.

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? 1.Presence of Aschoff's bodies 2.Absence of C-reactive protein 3.Presence of Reed-Sternberg cells 4.Decreased antistreptolysin O titer

1 Rationale: Rheumatic fever develops after a group A β-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptolysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. What type of angina should the nurse determine that the client is experiencing? 1.Stable 2.Variant 3.Unstable 4.Intractable

1 Rationale: Stable angina is triggered by a predictable amount of effort or emotion. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy.

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option? 1.Maintain bed rest. 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

1 Rationale: Standard management for the client with DVT includes bed rest; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol).

A nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is non-reddened, with no apparent drainage. The client's temperature is 99° F orally. The white blood cell count is 7500 cells/mm3. How should the nurse interpret these findings? 1.Incision is slightly edematous but shows no active signs of infection. 2.Incision shows early signs of infection, although the temperature is nearly normal. 3.Incision shows no sign of infection, although the white blood cell count is elevated. 4.Incision shows early signs of infection, supported by an elevated white blood cell count.

1 Rationale: Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. An elevated temperature and white blood cell count 3 to 4 days postoperatively usually indicate infection. Therefore, option 1 is correct.

client has experienced a myocardial infarction. The nurse plans care for the client, knowing that the person's chest pain is caused by tissue hypoxia in which layer of the heart? 1.Myocardium 2.Endocardium 3.Parietal pericardium 4.Visceral pericardium

1 Rationale: The myocardial layer of the heart is damaged when a client experiences a myocardial infarction. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral pericardium are outer layers that protect the heart from injury and infection.

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as the most likely indicator that the client is experiencing complications of this therapy? 1.Tarry stools 2.Nausea and vomiting 3.Orange-colored urine 4. Decreased urine output

1 Rationale: Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1."I will avoid using table salt with meals." 2."It is best to exercise once a week for 1 hour." 3."I will take nitroglycerin whenever chest discomfort begins." 4. "I will use muscle relaxation to cope with stressful situations."

2 Rationale: Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously caused the pain and to take the medication at the first sign of chest discomfort.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1.Keep the legs aligned with the heart. 2.Elevate the legs higher than the heart. 3.Clean the skin with alcohol every hour. 4.Position the client onto the side every shift.

2 Rationale: In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.

a client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1.Sleep with the head of bed flat. 2.Weigh himself or herself on a daily basis. 3.Take a double dose of the diuretic if peripheral edema is noted. 4.Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.

2 Rationale: The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb in a short period are reported to the health care provider (HCP). The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the HCP.

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1."I'll need to become a strict vegetarian." 2."I should use polyunsaturated oils in my diet." 3."I need to substitute eggs and whole milk for meat." 4."I should eliminate all cholesterol and fat from my diet."

2 Rationale: The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? 1.Stable angina 2.Variant angina 3.Unstable angina 4.Nonanginal pain

2 Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.

fter instruction on the application of antiembolism stockings, the nurse determines that the client requires further teaching if which of these actions is performed? 1.The client puts on the stockings before getting out of bed. 2.The client bunches up the stockings for easier application. 3.The client ensures that stockings are pulled all the way up. 4.The client makes sure the rough seams of the stockings are on the outside.

2 Rationale: When applying antiembolism stockings the client should not bunch up the stockings. Instead the client should place the hand inside the stocking and pull the heel out. The foot of the stocking should then be placed over the client's foot and the rest of the stocking pulled up the leg. This will help to prevent wrinkling and twisting of the stocking. Options 1, 3, and 4 demonstrate correct application of the stockings.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse? 1.Call a code. 2.Call the health care provider. 3.Check the client's status and lead placement. 4.Press the recorder button on the electrocardiogram console.

3 Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.

The nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks after hospital discharge. The nurse should include which item in the instructions? 1.Driving is permitted so long as the lap and shoulder seat belts are worn. 2.Lifting should be restricted to objects that do not weigh more than 25 pounds. 3.Use the arms for balance, not weight support, when getting out of bed or a chair. 4. Activities that involve straining may be resumed so long as they do not cause pain.

3 Rationale: The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining on the sternum. Typical discharge activity instructions for the first 6 weeks include instructing the client to lift nothing heavier than 5 pounds, to not drive, and to avoid any activities that cause straining. These limitations are to allow for sternal healing, which takes approximately 6 week

A client who had coronary artery bypass surgery states to the home health nurse: "get so frustrated. I can't even do my gardening." The nurse then assesses the client for activity level since the surgery. Which client statement indicates a need for further teaching? 1."I pace my activities throughout the day." 2."I plan regular rest periods during the day." 3. "I avoid outdoor physical activity during the heat of the day." 4. "I try to walk immediately after lunch, after I've finished my morning housecleaning."

4 Rationale: Exercise is an integral part of the rehabilitation program. It is necessary for optimal physiological functioning and psychological well-being. Postoperative physical rehabilitation must be progressive with planned periods of rest. Exercise tolerance is judged by the client's response, such as heart rate and endurance. Planning regular rest periods, pacing activities, and avoiding outdoor activities during the heat of the day are appropriate client activities. The correct option lacks planned periods of rest, and the client has grouped too many activities in a brief period of time, which will decrease endurance. Also, exercise after meals can decrease the client's tolerance because of shunting of blood to the gastrointestinal tract for digestion.

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1.During sleep 2.When changing the infant's diapers 3.When the mother is holding the infant 4.When drawing blood for electrolyte level testing

4 Rationale: Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL, and fasting blood glucose level of 184 mg/dL. The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? 1.Age 2.Hypertension 3.Hyperlipidemia 4.Glucose intolerance

4 Rationale: Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors to CAD. Age greater than 40 years is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina? 1.It is most effectively managed by β-blocking agents. 2.It has the same risk factors as stable and unstable angina. 3.It can be controlled with a low-sodium, high-potassium diet. 4. Generally it is treated with calcium-channel-blocking agents

4 Rationale: Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium-channel blockers. β-Blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated.

the nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1.Immunoglobulin 2.Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer

4 Rationale: Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help to confirm the diagnosis of rheumatic fever.

A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse to describe the procedure. Which response should the nurse make? 1."It involves tying off the veins so that circulation is redirected in another area." 2."It involves surgically removing the varicosity, so anesthesia will be required." 3."It involves tying off the veins to prevent sluggishness of blood from occurring." 4."It involves injecting an agent into the vein to damage the vein wall and close it off."

4 Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with the use of a hook and wires applied through multiple small incisions in the leg. Other treatments include the application of radiofrequency (RF) energy, in which the vein is heated from the inside by the RF energy and shrinks; collateral veins nearby take over. Laser treatment is another alternative to surgery; in this treatment a laser fiber is used to heat and close the main vessel that is contributing to the varicosity.

A nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the HCP is referring to which arteries? 1.Circumflex coronary artery 2.Right coronary artery (RCA) 3.Posterior descending coronary artery (PDA) 4. Left anterior descending coronary artery (LAD)

4 Rationale: The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The circumflex coronary artery bifurcates from the left coronary artery and supplies the left atrium and the lateral wall of the left ventricle. The RCA supplies the right side of the heart, including the right atrium and right ventricle. The PDA supplies the posterior wall of the heart.

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction? 1.Take antibiotics until the chest pain is fully resolved. 2.Take acetaminophen (Tylenol) if the chest pain worsens. 3.Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4. Notify all health care providers (HCP) of the history of infective endocarditis before any invasive procedures.

4 Rationale: The client should alert any HCP about the history of infective endocarditis before any procedure that involves instrumentation. The HCP should place the client on prophylactic antibiotics if an invasive procedure is needed. Antibiotics should be taken for the full course of therapy. The client should notify the HCP if chest pain worsens or if dyspnea or other symptoms occur. The client should use a soft toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for bacterial infection.

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? 1.Oxygen saturation decreased from 96% to 91%. 2.Pulse rate increased from 80 to 104 beats per minute. 3. Blood pressure decreased from 140/86 to 112/72 mm Hg. 4. Respiratory rate increased from 16 to 19 breaths per minute.

4 Rationale: Vital signs that remain near baseline indicate good cardiac reserve with exercise. Only the respiratory rate remains within the normal range. Additionally, it reflects a minimal increase. A pulse rate increase to a rate over 100 beats per minute during mild exercise does not show tolerance, nor does a 5% decrease in oxygen saturation levels. In addition, blood pressure decreasing by more than 10 mm Hg is not a sign indicating tolerance of activity.

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? 1."I'm not supposed to eat cold cuts." 2."I can have most fresh fruits and vegetables." 3."I'm going to weigh myself daily to be sure I don't gain too much fluid." 4."I'm going to have a ham and cheese sandwich and potato chips for lunch."

4 Rationale: When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.

A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1.Dietitian 2. Medical social worker 3. Pain management clinic 4. Smoking-cessation program

4Rationale: Buerger's disease is a vascular occlusive disease that affects the medium and small arteries and veins. Smoking is highly detrimental to the client with Buerger's disease, so stopping smoking completely is recommended. Because smoking is a form of chemical dependency, referral to a smoking-cessation program may be helpful for many clients. For many clients with Buerger's disease, symptoms are relieved or alleviated once smoking stops. A dietitian, a medical social worker, and a pain management clinic are not specifically associated with the lifestyle changes required in this disorder although they may be needed if secondary problems arise.

A child with rheumatic fever will be arriving in the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1."Has the child complained of back pain?" 2."Has the child complained of headaches?" 3."Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?

4Rationale: Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A b-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever.