Medical-Surgical Nursing Midterm Exam

Client with hypertension

Based on the etiology and main cause of heart failure, the nurse knows that which client has the greatest need for health promotion measures to prevent heart failure?

An irregular heart rhythm and ECG strip that indicate atrial fibrillation

For which finding in a client with mitral valve stenosis would the nurse immediately notify the primary health care provider because of the potential for decompensation?

Within the range prescribed by the HCP to keep saturation at 90% or more

To improve gas exchange, how much supplemental oxygen would the nurse provide a client with HF?

Monitor the ECG strip for early signs of toxicity such as bradycardia. Auscultate the apical pulse heart relate and rhythm for a full minute before administering the drug. Observe for signs of toxicity, which are often nonspecific such as anorexia. Report any changes in heart rate or rhythm to the health care provider. Monitor serum digoxin and potassium. Check the health care provider's prescription for parameters to hold the drug.

What are the priority nursing actions related to caring for an older adult client with HF who is prescribed digoxin? Select all that apply.

Dependent edema Neck vein distention Hepatomegaly

What assessment findings would the nurse expect to find in a client with right heart failure? Select all that apply.

Sit up and lean forward

What does the nurse instruct a client with pericarditis to do so make him or her will feel more comfortable?

Acute pericarditis

What does the nurse suspect when a client describes substernal pain that radiates to the left shoulder, is gratings, and worsens with inspiration and coughing?

Pulse alternans

What does the nurse suspect when assessment of a client with HF reveals pulses that alternate in strength?

Nocturnal coughing

What early sign of left ventricular failure is a client most likely to report to the nurse?

Crackles in the lung bases Dyspnea at rest Disorientation

What early symptoms indicate to the nurse that a client's HF is getting worse and pulmonary edema is developing? Select all that apply

Place the diaphragm at the left lower sternal border

What is the best method for the nurse to use when auscultations a client's pericardial friction rub with a stethoscope?

Surgical removal of the pericardium

What is the definitive treatment for chronic constrictive pericarditis?

Weigh the client daily at the same time and using the same scale

What is the most reliable method of monitoring for fluid gain or less in a client with heart failure?

Perfusion

What is the priority concept for a client who has heart failure?

Administer high-flow oxygen therapy by face mask.

What is the priority intervention when a client comes to the emergency department (ED) with extreme anxiety, tachycardia, struggling for air, and a moist cough productive of frothy and blood-tinged sputum?

"What was your most strenuous activity during the past week?"

When a client admits that he or she sometimes has trouble catching his or her breath, which question would the nurse ask to obtain more information about the client's symptoms?

Sympathetic stimulation

When a client develops heart failure, what initial compensatory mechanism of the heart does the nurse expect to occur that will maintain cardiac output?

Implantable cardio enter/defibrillator

When a client has an ejection fraction of less than 30%, about which potential treatment does the nurse prepare to educate the client?

The activity is too stressful

When a client with heart failure walks 200 feet down the hall and develops a feeling of heaviness in the legs, how does the nurse interpret this finding?

Echocardiography

When the client asks the nurse about the best method of diagnosing heart failure, what teaching would the nurse provide?

When a client has fluid overload

When would the nurse expect the release of B-type natriuretic peptide (BNP) for a client with heart failure?

Reduced heart rate Increased contractility Slowed conduction through the AV node Inhibition of sympathetic activity with enhanced parasympathetic activity

Which are potential benefits of a client receiving the drug digoxin?

Alcohol abuse Infection Chemotherapy Poor nutrition

Which are potential causes of dilated cardiomyopathy? Select all that apply

Pericardial chest pain Presence of a pericardial friction rub New ST elevation in all ECG leads or PR-segment depression New or worsening pericardial effusion

Which are proposed criteria for diagnosis of a client with acute pericarditis? Select all that apply.

Valve leaflets enlarge and bulge up into the left atrium during systole. Most clients are asymptomatic and this abnormality is benign Many clients have normal heart rates and blood pressures. A mid-systolic click and late systolic murmur is best heard at the apex of the heart

Which are the characteristics that the nurse would expect when a client is diagnosed with mitral valve prolapse (MVP)? select all that apply.

Neck vein distention Paradoxical pulse Muffled heart sounds Tachycardia

Which assessment findings would cause the nurse to suspect cardiac tamponade in a client? Select all that apply.

Shortness of breath Hypotension Decreased activity tolerance Fluid gain (edema, increased weight) Atrial fibrillation or flutter

Which assessment findings would suggest to the nurse that a client who received a heart transplant was experiencing organ rejection? Select all that apply.

Wheezes or crackles S3 heart sound Paroxysmal nocturnal dyspnea Oliguria during the day

Which assessment findings would the nurse expect to find in a client with left heart failure? Select all that apply

Older adult who is not a surgical candidate

Which client with valvular heart disease would benefit from the non surgical invasive procedure balloon valvuloplasty?

Clients who are IV drug users Clients with poor dental health Clients with opioid addictions Clients with systemic alterations in immunity Clients postoperative after valve replacement

Which clients are at greatest risk for development of infective endocarditis? Select all that apply.

cardiac tamponade

Which complication is a client at most risk for when the nurse notes that excessive fluid was seen in the pericardial cavity on echocardiogram?

Age generally less than 65 years New York Heart Association Class III of IV Normal or only slightly increased pulmonary vascular resistance Absence of active infection

Which criteria are appropriate for a client with dilated cardiomyopathy to become a candidate for heart transplant surgery? Select all that apply

Nitroglycerin sublingual Furosemide IV Nitroglycerin IV

Which drugs would the nurse prepare to administer to a client with HF who has developed pulmonary edema? Select all that apply.

Anticoagulants

Which essential medications would the nurse provide teaching about postoperatively for a client who received a prosthetic valve replacement?

Osler nodes on palms of hands and soles of feet Splinter hemorrhages Janeway lesions on the hands and feet Anorexia and weight loss

Which findings does the nurse expect when assessing a client with infective endocarditis? Select all that apply.

A client with mild mitral valve stenosis will likely to be asymptomatic Classic signs include dyspnea, angina, and syncope Rumbling apical diastolic murmur Right-sided heart failure with jugular (neck) vein distention

Which findings would the nurse expect in a client with mitral valve stenosis? Select all that apply.

Restrict the client's fluids to 2 L/day and keep accurate intake and output

Which instruction would the nurse give the assistive personnel (AP) who is helping a client with HF and excessive aldosterone secretion?

Sodium restriction Position client in semi-Fowler or high-Fowler Administration of loop diuretics

Which interventions would the nurse expect to include in the care of a client with pulmonary edema caused by HF? Select all that apply.

Cold symptoms (e.g., cough) lasting more than 3 to 5 days Excessive awakening at night to urinate Development of dyspnea or aging at rest or worsening angina Increased swelling in feet, ankles, or hands

Which key points would the nurse include when teaching a client about signs and symptoms of return or worsening of heart failure, that must be reported to the primary health care provider? Select all that apply.

Symptoms, what to do when they get worse Medications Activity Weight Diet

Which major self-management categories will the nurse include when teaching a client, newly diagnosed with heart failure, who is about to be discharged? Select all that apply

"Your xenograft valve will need to be replaced in about 7 to 10 years."

Which priority information would the nurse be sure to provide for a client who is scheduled for mitral valve replacement with a xenograft valve?

"Remind your health care provider to provide you with a prescription for prophylactic antibiotics."

Which priority teaching would the nurse provide to a client with infective endocarditis who is scheduled for an invasive dental procedure?

Dyspnea on exertion Angina Harsh, systolic crescendo-decrescendo murmur Orthopnea

Which signs and symptoms would the nurse expect to assess when a client is diagnosed with aortic stenosis? Select all that apply.

Exertional fatigue and dyspnea Dependent edema Hepatic engorgement

Which signs or symptoms would the nurse expect when assessing a client with chronic constrictive pericarditis? Select all that apply.

"I've had to remove all of my rings for the past month."

Which statement by a client with a history of hypertension and heart problems would cause the nurse to suspect development of heart failure?

"I must weigh myself once a week and watch for signs of fluid retention."

Which statement by a client with heart failure indicates to the nurse the need for additional teaching?

Report dyspnea, syncope, dizziness, edema, and palpitations to your health care provider. Use an electric razor to avoid skin cuts. Notify your health provider for any bleeding or excessive bruising. Watch for and report any fever or drainage and redness at the surgical site.

Which topics would the nurse be sure to cover when providing discharge instructions for a client with prosthetic valve surgery? Select all that apply.

Hospitalization for initial IV antibiotics, followed by continued IV antibiotics at home

Which treatment best applies to the care of a client newly diagnosed with infective endocarditis?

Hypertrophic

Which type of cardiomyopathy may present with sudden death as the first symptom?

Mitral valve stenosis and regurgitation

Which type of heart valvular disease does the nurse suspect when a client's assessment reveals pitting edema?

Surgical aortic heart valve replacement

Which urgent intervention is required when the nurse reviews the results of diagnostic testing for a client with aortic stenosis and discovers that the surface area of the valve is less than 1 cm?