Nclex questions 4100 exam 3

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? 1.Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg 2.Nonarousable, sinus rhythm, BP 88/60 mm Hg 3.Arousable, marked bradycardia, BP 86/54 mm Hg 4.Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

1 Rationale:After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate BP, and a sinus rhythm indicate successful response to defibrillation.

The 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.

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.

Atenolol has been prescribed for a client, and the client asks the nurse about the action of the medication. How should the nurse respond regarding the action of this medication? 1.Slows the heart rate 2.Increases cardiac output 3.Increases myocardial oxygen demand 4.Maintains the blood pressure at a level within the 140/90 mm Hg range

1 Rationale:Atenolol is a beta-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks beta-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing myocardial oxygen demand, and decreasing blood pressure.

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client's heart rhythm? 1.Atrial fibrillation 2.Sinus tachycardia 3.Ventricular fibrillation 4.Ventricular tachycardia

1 Rationale:Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombus formation.

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 provides education to the client based on which physiological concept? 1.Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. 2.Vagus nerve stimulation causes an increase in heart rate and cardiac contractility. 3.Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. 4.Sympathetic nerve stimulation causes an increase 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 client with rapid-rate atrial fibrillation asks the nurse why the health care provider (HCP) is going to perform carotid sinus massage. The nurse educates the client about the treatment. Which statement by the client indicates that the teaching has been effective? 1."The vagus nerve slows the heart rate." 2."The diaphragmatic nerve slows the heart rate." 3."The diaphragmatic nerve overdrives the rhythm." 4."The vagus nerve increases the heart rate, overdriving the rhythm."

1 Rationale:Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. Others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm. The remaining options are incorrect descriptions of this procedure.

The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which starting energy range level, depending on the specific health care provider (HCP) prescription? 1.120 joules 2.200 joules 3.250 joules 4.350 joules

1 Rationale:For cardioversion procedures, the defibrillator is charged to the energy level prescribed by the HCP. Countershock usually is started at 120 to 200 joules. The number of joules in the remaining options are incorrect.

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm

1 Rationale:Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1."This is a normal finding." 2."This is indicative of atrial flutter." 3."This is indicative of atrial fibrillation." 4."This is indicative of impending reinfarction."

1 Rationale:The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. The remaining options are incorrect and indicate that further education is needed.

The nurse is teaching a client who has had a laryngectomy for laryngeal cancer how to use an artificial larynx. Which statement should the nurse include in the teaching? 1."Hold the device alongside the neck." 2."Insert the device into the tracheostomy." 3."Swallow air into the esophagus to make speech." 4."Hold the device over the upper portion of the sternum."

1 Rationale:The artificial larynx is an electronic device that assists the client to produce speech after laryngectomy. There are 2 types: one is held at the side of the neck and the other is inserted into the mouth. The vibration produces a mechanical-sounding speech that is monotone in quality but intelligible. There is no need to insert the device into the tracheostomy or to hold the device over the sternum. Esophageal speech involves swallowing air, trapping it in the esophagus, and releasing it to create sound.

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1."Pulse rate will increase." 2."Blood pressure will decrease." 3."Edema will be present in the legs." 4."Crackles in the lungs will be present."

1 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. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid overload.

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 determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? 1."My pulse rate should be less than what my pacemaker is set at." 2."I'll need to call my health care provider if I feel tired or dizzy." 3."I'll have to avoid carrying the grocery bags into the house for the next 6 weeks." 4."It's safe to use my microwave as long it is properly grounded and well shielded."

1 Rationale:The client should call the health care provider (HCP) if the pulse rate is less than what the pacemaker is set at because this could be a sign of pacemaker or battery failure. Option 1 indicates the client needs further teaching, whereas the remaining options are correct statements.

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 rapid ventricular rate of 150 beats/minute. 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/minute is at risk for low cardiac output because of 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.

The nurse has just completed education on myocardial infarction (MI) to a group of new nurses. Which statement made by one of the nurses indicates that the teaching has been effective? 1."Chest pain is caused by tissue hypoxia in the myocardium." 2."Chest pain is caused by tissue hypoxia in the vessels of the heart." 3."Chest pain is caused by tissue hypoxia in the parietal pericardium." 4."Chest pain is caused by tissue hypoxia in the visceral pericardium."

1 Rationale:The myocardial layer of the heart is damaged when a client experiences an MI. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. The obstruction, which causes the interruption in blood flow and ensuing hypoxia, affects the myocardial layer. The endocardiumis 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 an 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 community health nurse has conducted a teaching session for community members about the risk factors for laryngeal cancer. Which statement by a person attending the session indicates that teaching was effective? 1."Exposure to airborne carcinogens can cause this type of cancer." 2."Alcohol consumption is not associated with this type of cancer." 3."Cigarette smoking does not contribute to the development of this type of cancer." 4."Overuse of the voice is not associated with this type of cancer unless it causes spitting up of blood."

1 Rationale:To decrease the risk of laryngeal cancer, the client should be instructed to avoid cigarette smoking, alcohol consumption, exposure to airborne carcinogens, and vocal abuse. The client is instructed to schedule routine physical examinations. The client also should be instructed to seek medical care if difficulty in swallowing, persistent hoarseness, enlarged lymph nodes in the neck, or unexplained weight loss occurs.

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? 1.It can develop into ventricular fibrillation at any time. 2.It is almost impossible to convert to a normal rhythm. 3.It is uncomfortable for the client, giving a sense of impending doom. 4.It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

1 Rationale:Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (if the client is awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? 1.Tidaling is present. 2.There is a leak in the system. 3.The client has residual pneumothorax. 4.Suction should be added to the system.

1 Rationale:When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system. Options 2, 3, and 4 are inaccurate interpretations.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the health care provider and prepares to implement which priority interventions? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low Fowler's side-lying position

1, 2, 3, 4 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. Test-Taking Strategy: Note the strategic words priority interventions and focus on the client's diagnosis. Recall the pathophysiology associated with pulmonary edema and use the ABCs—airway, breathing, and circulation—to help determine priority interventions. Review priority interventions for the client with pulmonary edema if you had difficulty with this question.

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply. 1. Facial edema in the morning 2.Weight loss of 20 lb (9 kg) in 1 month 3. Serum calcium level of 12 mg/dL (3.0 mmol/L) 4. Serum sodium level of 136 mg/dL (136 mmol/L) 5. Serum potassium level of 3.4 mg/dL (3.4 mmol/L) 6. Numbness and tingling of the lower extremities

1, 3, 6 Rationale: Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL (3.0 mmol/L) indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL (136 mmol/L) is a normal level.

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? 1.Prothrombin time of 12.5 seconds 2.Activated partial thromboplastin time of 60 seconds 3.Activated partial thromboplastin time of 28 seconds 4.Activated partial thromboplastin time longer than 120 seconds

2 Rationale:Common laboratory ranges for activated partial thromboplastin time (aPTT) are 30 to 40 seconds. Because the aPTT should be 1.5 to 2.5 times the normal value, the client's aPTT would be considered therapeutic if it was 60 seconds. Prothrombin time assesses response to warfarin therapy.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak, because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Clamp the chest tube and notify the health care provider immediately.

2 Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider's prescription.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1.Check for an air leak. 2.Document the findings. 3.Notify the health care provider. 4.Change the chest tube drainage system.

2 Rationale:Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

A client with myocardial infarction is developing cardiogenic shock. Because of the risk of myocardial ischemia, what condition should the nurse carefully assess the client for? 1.Bradycardia 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure

2 Rationale:Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. Which finding indicates that further preparation is needed for the procedure? 1.The client's digoxin has been withheld for the last 48 hours. 2.The client is wearing a nasal cannula delivering oxygen at 2 L/min. 3.The defibrillator has the synchronizer turned on and is set at 120 joules (J). 4.The client has received an intravenous dose of a conscious sedation medication.

2 Rationale:During the procedure, any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after the countershock. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 120 to 200 J for a biphasic machine. The client typically receives a dose of an intravenous sedative or antianxiety agent.

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hour, unchanged for the last 10 hours. The client's urine output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL (12.6 mmol/L) and the serum creatinine level is 1.8 mg/dL (159 mcmol/L), measured this morning. Which nursing action is the priority? 1.Check the urine specific gravity. 2.Call the health care provider (HCP). 3.Put the IV line on a pump so that the infusion rate is sure to stay stable. 4.Check to see if the client had a blood sample for a serum albumin level drawn.

2 Rationale:Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of acute kidney injury. Acute kidney injury can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female, 0.5-1.1 mg/dL (44-97 mcmol/L). Options 1 and 4 are not associated with the data in the question. The IV should have already been on a pump. Urine output lower than 30 mL/hour is reported to the HCP.

The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is 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.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? 1.Edema 2.Dyspnea 3.Frothy sputum 4.Diminished breath sounds

2 Rationale:In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign, after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1.Serous 2.Bloody 3.Serosanguineous 4.Bloody, with frequent small clots

2 Rationale:In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The post-myocardial infarction client is scheduled for a technetium-99m ventriculography (multigated acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure? 1.A urinary catheter 2.Signed informed consent 3.A central venous pressure (CVP) line 4.Notation of allergies to iodine or shellfish

2 Rationale:MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow and to determine left ventricular function. A radioisotope is injected intravenously; therefore, a signed informed consent is necessary. A urinary catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore, allergies to iodine and shellfish are not a concern.

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2 Rationale:Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1.Telfa dressing and Neosporin ointment 2.Petrolatum gauze and sterile 4 × 4 gauze 3.Benzoin spray and a hydrocolloid dressing 4.Sterile 4 × 4 gauze, Neosporin ointment, and tape

2 Rationale:On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the HCP as the tape of choice to make the dressing occlusive.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? 1.Stridor 2.Crackles 3.Scattered rhonchi 4.Diminished breath sounds

2 Rationale:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1.Hypovolemia 2.Acute kidney injury 3.Glomerulonephritis 4.Urinary tract infection

2 Rationale:The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.

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.

The nurse is admitting a client with laryngeal cancer to the nursing unit. What should the nurse assess for as the most common risk factor for this type of cancer? 1.Alcohol abuse 2.Cigarette smoking 3.Use of chewing tobacco 4.Exposure to air pollutants

2 Rationale:The most common risk factor associated with laryngeal cancer is cigarette smoking. Heavy alcohol use and the combined use of alcohol and tobacco increase the risk. Another risk factor is exposure to environmental pollutants.

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? 1."Ventricular fibrillation appears as irregular beats within a rhythm." 2."Ventricular fibrillation does not have P waves or QRS complexes." 3."Ventricular fibrillation is a regular pattern of wide QRS complexes." 4."Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves."

2 Rationale:Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Premature ventricular contractions (PVCs) appear as irregular beats within a rhythm. Ventricular tachycardia is a regular pattern of wide QRS complexes. Sinus tachycardia has a recognizable P wave, QRS complex, and T wave. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

A client's electrocardiogram shows that the ventricular rhythm is irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition? 1.Atrial flutter 2.Atrial fibrillation 3.Third-degree atrioventricular (AV) block 4.First-degree AV block

2 Rationale:With atrial fibrillation, the ventricular rhythm is irregular and there are usually no discernible P waves. Therefore, an atrial rhythm cannot be determined. In atrial flutter, the QRS complexes may be either regular or irregular, and the P waves occur as flutter waves. A client in third-degree AV block (also known as complete heart block) has regular atrial and ventricular rhythms, but there is no connection between the P waves and the QRS complexes. In other words, the PR interval is variable and the QRS complexes are normal or widened, with no relationship with the P waves. With first-degree AV block, the PR interval is longer than normal, and there is a connection between the occurrence of P waves and that of QRS complexes.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list? Select all that apply. 1.Restrict fluid intake. 2.Obtain a MedicAlert bracelet. 3.Keep the humidity in the home low. 4.Prevent debris from entering the stoma. 5.Avoid exposure to people with infections. 6.Avoid swimming and use care when showering.

2, 4, 5, 6 Rationale:The nurse should teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include obtaining a MedicAlert bracelet, preventing debris from entering the stoma, avoiding exposure to people with infections, and avoiding swimming and using care when showering. Additional interventions include wearing a stoma guard or high-collared clothing to protect the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2.Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation

3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3 The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

A client is admitted to the hospital with a diagnosis of myocardial infarction (MI). The client is started on alteplase therapy. The nurse determines that teaching has been effective when the client's significant other states that the purpose of the medication is to perform which action? 1.Thin the blood. 2.Slow the clotting of the blood. 3.Dissolve any clots in the coronary arteries. 4.Prevent further clots from forming in the coronary arteries.

3 Rationale:Alteplase converts plasminogen in the blood to plasmin. Plasmin is an enzyme that digests or dissolves fibrin clots wherever they exist. Heparin sodium and warfarin sodium thin the blood, slow clotting, and prevent further clots from forming.

The nurse employed in a cardiac unit determines that which client is the least likely to have an implanted cardioverter-defibrillator (ICD) inserted? 1.A client with syncopal episodes related to ventricular tachycardia 2.A client with ventricular dysrhythmias despite medication therapy 3.A client with an episode of cardiac arrest related to myocardial infarction 4.A client with 3 episodes of cardiac arrest unrelated to myocardial infarction

3 Rationale:An ICD detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. This device is implanted in clients who are considered high risk, including those who have syncopal episodes related to ventricular tachycardia, those who are refractive to medication therapy, and those who have survived sudden cardiac death unrelated to myocardial infarction.

A man has developed atrial fibrillation and has been placed on warfarin. The nurse is doing discharge dietary teaching with the client and determines that the client needs additional education if he states that he would choose which food while taking this medication? 1.Cherries 2.Potatoes 3.Broccoli 4.Spaghetti

3 Rationale:Anticoagulant medications work by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K are often omitted from the diet. Vitamin K is found in large amounts in green leafy vegetables, such as broccoli, cabbage, turnip greens, and lettuce. The other options listed are foods that are lower in vitamin K.

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/minute 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). The other options are not signs of cardiac tamponade.

The clinic nurse is providing instructions to a client with hypertension who will be taking captopril. Which statement by the client indicates a need for further instruction? 1."I need to change positions slowly." 2."I need to avoid taking hot baths or showers." 3."I need to drink at least 4 quarts (4 liters) of water daily." 4."I need to sit down and rest if dizziness or lightheadedness occurs."

3 Rationale:Captopril is an antihypertensive medication (angiotensin-converting enzyme [ACE] inhibitor). Orthostatic hypotension can occur in clients taking this medication. Adequate fluid is important, but 4 quarts (4 liters) of water daily could actually aggravate the hypertension. Clients are advised to avoid standing in one position for long periods, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension, such as dizziness, lightheadedness, weakness, and syncope.

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. 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 have 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.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises 4.Applying a heating pad to the lower extremities

3 Rationale:Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

A client seeks treatment in an ambulatory clinic for a complaint of hoarseness that has lasted for 6 weeks. On the basis of this symptom, the nurse should consider developing a plan of care for which possible medical diagnosis? 1.Thyroid cancer 2.Acute laryngitis 3.Laryngeal cancer 4.Bronchogenic cancer

3 Rationale:Hoarseness is a common early sign of laryngeal cancer but not of bronchogenic or thyroid cancer. Hoarseness that lasts for 6 weeks is not associated with an acute problem, such as laryngitis.

The nurse notes that a client's cardiac rhythm shows absent P waves, no PR interval, and an irregular rhythm. How should the nurse interpret this rhythm? 1.Bradycardia 2.Tachycardia 3.Atrial fibrillation 4.Normal sinus rhythm (NSR)

3 Rationale:In atrial fibrillation, the P waves are absent and replaced by fibrillatory waves. There is no PR interval, and the QRS duration usually is normal and constant and the rhythm is irregular. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second, and the QRS interval is 0.06 to 0.10 second.

A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1.Position the client in semi Fowler's position. 2.Add water to the suction chamber as it evaporates. 3.Instruct the client to avoid coughing and deep breathing. 4.Tape the connection sites between the chest tube and the drainage system.

3 Rationale:It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse should report the cardiac rhythm to be which rhythm? 1.Sinus bradycardia 2.Sick sinus syndrome 3.Normal sinus rhythm 4.First-degree heart block

3 Rationale:Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? 1.Heart rate 2.Skin color 3.Status of airway 4.Peripheral pulse strength

3 Rationale:Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority,

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? 1.Sensation of palpitations 2.Causative factors, such as caffeine 3.Blood pressure and oxygen saturation 4.Precipitating factors, such as infection

3 Rationale:Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders; states of hypoxemia; any number of physiological stressors, such as infection, illness, surgery, or trauma; and intake of caffeine, nicotine, or alcohol.

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/minute. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse report this rhythm? 1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm

3 Rationale:Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? 1."Strapping is useful only if the ribs are fractured in several places at once." 2."That's a good idea. I'll ask the health care provider for a prescription for the needed supplies." 3."That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4."That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."

3 Rationale:Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 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 reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? 1.Bundle of His 2.Purkinje fibers 3.Sinoatrial (SA) node 4.Atrioventricular (AV) node

3 Rationale:The SA node is responsible for initiating electrical impulses that are conducted through the heart. The impulse leaves the SA node and travels down through internodal and interatrial pathways to the AV node. From there, impulses travel through the bundle of His to the right and left bundle branches and then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction system. The ability of this specialized tissue to generate its own impulses is called automaticity.

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 work boots. 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.

The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction? 1."I need to protect the stoma from water." 2."Soaps should be avoided near the stoma." 3."I should use diluted alcohol on the stoma to clean it." 4."I should apply a non-oil-based ointment to the skin surrounding the stoma."

3 Rationale:The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway. A non-oil-based ointment applied to the skin around the stoma helps to prevent cracking.

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? 1.Pain with deep breathing 2.Increased chest tube drainage 3.Lung crackles in the remaining lung 4.Respiratory rate of 20 breaths/minute

3 Rationale:The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube because the lung has been removed. A respiratory rate of 20 breaths/minute is within normal limits.

A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? 1.Flat neck veins 2.Nausea and vomiting 3.Hypotension and dizziness 4.Clubbed fingertips and headache

3 Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output due 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.

The client has developed atrial fibrillation, with a ventricular rate of 150 beats/minute. The nurse should assess the client for which associated signs and/or symptoms? 1.Flat neck veins 2.Nausea and vomiting 3.Hypotension and dizziness 4.Hypertension and headache

3 Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/minute is at risk for low cardiac output because of 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 chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor. Which is the nurse's first action? 1.Check the blood pressure. 2.Call the health care provider (HCP). 3.Check the client and the chest leads. 4.Initiate cardiopulmonary resuscitation (CPR).

3 Rationale:This type of pattern on the cardiac monitor indicates either ventricular fibrillation or lead displacement. The first action of the nurse is always to check the client and the chest leads. If the client is nonresponsive and the leads are not the problem, CPR would be the next choice, along with designating another person to contact the HCP.

A thrombolytic is administered in the hospital emergency department to a client who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which fact regarding this medication? 1.Thrombolytics suppress the production of fibrin. 2.Thrombolytics act to prevent thrombus formation. 3.Thrombolytics act to dissolve thrombi that have already formed. 4.Thrombolytics have been proved to reverse all detrimental effects of heart attacks.

3 Rationale:Thrombolytics are most effective when started within 4 to 6 hours after symptom onset and act to dissolve or lyse existing thrombi that are causing a blockage. The remaining options are incorrect.

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1.Monitor for kidney failure. 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. 4.Have heparin sodium available.

3 Rationale:Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin may be administered after thrombolytic therapy, but the question is not asking about follow-up medications.

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 one indicate that the client will be successful in these areas.

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse correctly interpret this rhythm? 1.Asystole 2.Atrial fibrillation 3.Ventricular fibrillation 4.Ventricular tachycardia

3 Rationale:Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats/minute. The nurse determines that the client is experiencing which dysrhythmia? 1.Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions

3 Rationale:Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 seconds), and typically a rate between 140 and 180 impulses/minute. The rhythm is regular.

The nurse overhears a neurologist saying that a client has an aneurysm located in the circle of Willis. The nurse understands that which blood vessels are part of the circle of Willis? Select all that apply. 1.Basilar artery 2.Vertebral artery 3.Anterior cerebral artery 4.Internal carotid arteries 5.Posterior cerebral artery

3, 4, 5 Rationale:The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the anterior and middle cerebral arteries, posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, and anterior communicating branches. The basilar artery and vertebral artery are not part of the circle of Willis. Rather, they are part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the posterior inferior cerebellar artery and the spinal arteries.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3, 4, 5, 6 Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4 The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the health care provider's (HCP's) prescription and plans to allow which client position or activity following the procedure? 1. Bed rest in high Fowler's position 2. Bed rest with bathroom privileges only 3.Bed rest with head elevation at 60 degrees 4. Bed rest with head elevation no greater than 30 degrees

4 Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for 4 to 6 hours. The client is maintained on bed rest for 4 to 6 hours (time for bed rest may vary depending on the HCP's preference and on whether a vascular closure device was used) and the client may turn from side to side. The head is elevated no more than 30 degrees (although some HCPs prefer a lower position or the flat position) until hemostasis is adequately achieved.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

4 Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Stay very still. 2. Exhale very quickly. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

4 Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

The 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.

A client with myocardial infarction is experiencing new, multiform premature ventricular contractions and short runs of ventricular tachycardia. The nurse plans to have which medication available for immediate use to treat the ventricular tachycardia? 1.Digoxin 2.Verapamil 3.Acebutolol 4.Amiodarone

4 Rationale:Amiodarone is an antidysrhythmic that may be used to treat ventricular dysrhythmias. Digoxin is a cardiac glycoside; verapamil is a calcium channel-blocking agent; acebutolol is a beta-adrenergic blocking agent. Digoxin can be used to treat supraventricular dysrhythmias, but is inactive against ventricular dysrhythmias. Verapamil is used to slow the ventricular rate for a client with atrial fibrillation or atrial flutter, or to terminate supraventricular tachycardia. Acebutolol is a beta blocker used to treat dysrhythmias.

A registered nurse (RN) is orienting a new RN on the use of atorvastatin. Which statement by the new RN indicates that the teaching has been effective? 1."It is used in heart failure." 2."It helps to control hypertension." 3."It helps to reduce episodes of angina pectoris." 4."It is given to clients with hypercholesterolemia."

4 Rationale:Atorvastatin is a reductase inhibitor (HMG-CoA reductase inhibitor) that is used to treat hypercholesterolemia and hypertriglyceridemia. The statements made in the remaining options are incorrect.

The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? 1."If I feel an internal defibrillator shock, I should sit down." 2."I won't be able to have a magnetic resonance imaging test (MRI)." 3."My wife knows how to call the emergency medical services (EMS) if I need it." 4."I can stop taking my antidysrhythmic medicine now because I have a pacemaker."

4 Rationale:Clients with an ICD usually continue to receive antidysrhythmic medications after discharge from the hospital. The nurse should stress the importance of continuing to take these medications as prescribed. The nurse should provide clear instructions about the purposes of the medications, dosage schedule, and side effects or adverse effects to report. Clients should sit down if they feel an internal defibrillator shock. They cannot have an MRI because of the possible magnetic properties of the device. Also, knowledge of how to reach EMS is important.

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

4 Rationale: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.

A client who had coronary artery bypass surgery states to the home health nurse, "I 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 house cleaning."

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.

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 (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). 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 for CAD. Age 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.

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1.Before each P wave 2.Just after each P wave 3.Just after each T wave 4.Before each QRS complex

4 Rationale:If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted.

A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? 1."It will really hurt when the catheter is first put in." 2."I will receive general anesthesia for the procedure." 3."I will have to go to the operating room for this procedure." 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."

4 Rationale:It is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other preprocedure teaching points include the fact that the procedure is done in a darkened cardiac catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.

A client with chronic atrial fibrillation is being started on quinidine sulfate as maintenance therapy for dysrhythmia suppression, and the nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? 1."I will avoid chewing the tablets." 2."I will take the dose at the same time each day." 3."I will take the medication with food if my stomach becomes upset." 4."I will stop taking the prescribed anticoagulant after starting this new medication."

4 Rationale:Medication-specific teaching points for quinidine sulfate include to take the medication exactly as prescribed, not to chew the tablets, to take with food if stomach upset occurs, to wear a medical identification (e.g., MedicAlert) bracelet or tag, and to have periodic checks of heart rhythm and blood counts. The client should not stop taking a prescribed medication unless specifically told to do so by the health care provider.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1.Check vital signs. 2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to monitor for any rhythm change.

4 Rationale:Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change.

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse anticipate in this client if PVCs are occurring? 1.A P wave preceding every QRS complex 2.QRS complexes that are short and narrow 3.Inverted P waves before the QRS complexes 4.Premature beats followed by a compensatory pause

4 Rationale:PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, the presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.

A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if which finding is noted with regard to the PVCs? 1.They occur in pairs. 2.They appear to be multifocal. 3.They fall on the second half of the T wave. 4.They decrease to a frequency of less than 6 per minute.

4 Rationale:PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client's cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias.

The nurse has completed an educational course covering first-degree heart block. Which statement by the nurse indicates that teaching has been effective? 1."Presence of Q waves indicates first-degree heart block." 2."Tall, peaked T waves indicate first-degree heart block." 3."Widened QRS complexes indicate first-degree heart block." 4."Prolonged, equal PR intervals indicates first-degree heart block."

4 Rationale:Prolonged and equal PR intervals indicate first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An electrocardiogram (ECG) taken during a pain episode is intended to capture ischemic changes, which also include ST segment elevation or depression.

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 1.Measure the heart rate on the rhythm strip. 2.Administer prescribed nitroglycerin tablets. 3.Obtain a 12-lead electrocardiogram immediately. 4.Auscultate the client's apical pulse and obtain a blood pressure.

4 Rationale:Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although measuring the heart rate on the rhythm strip and obtaining a 12-lead electrocardiogram may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure.

A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1.Limiting oral and intravenous fluids 2.Measuring the client's pulse each shift 3.Providing the client with short, frequent walks 4.Eliminating sources of caffeine from meal trays

4 Rationale:Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Measuring the pulse each shift will not decrease the heart rate. In addition, the pulse should be taken more frequently than each shift.

The 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 blockage is located in which area? 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.

The home health nurse visits a client recovering after an episode of cardiogenic shock secondary to an anterior myocardial infarction (MI) 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 (3.6 kg) since discharge." 3."I take an antacid when I experience epigastric pain." 4."I have planned periods of rest at 10:00 a.m. and 3:00 p.m. daily."

4 Rationale:The client recovering from an episode of cardiogenic shock secondary to an MI will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated MI. 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 (3.6 kg) is significant and should be reported to the health care provider, at which point follow-up should occur.

The nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? 1.Serum chloride level of 98 mEq/L (98 mmol/L) 2.Serum sodium level of 145 mEq/L (145 mmol/L) 3.Serum calcium level of 10.5 mg/dL (2.75 mmol/L) 4.Serum potassium level of 2.8 mEq/L (2.8 mmol/L)

4 Rationale:The nurse should check the client's serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart. The values noted in the remaining options are normal.

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1.Anxiety level of the client and family 2.Presence of a MedicAlert card for the client to carry 3.Knowledge of restrictions on postdischarge physical activity 4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver

4 Rationale:The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.

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. The statements in the remaining options are incorrect.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority? 1.Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4.Confirm that the rhythm is actually ventricular fibrillation.

4 Rationale:Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.

A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the nurse anticipate will be prescribed? 1. Administer digoxin. 2. Defibrillate the client. 3. Continue to monitor the client. 4. Prepare for transcutaneous pacing

4. Prepare for transcutaneous pacing. Rationale: Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm becomes a concern when the client becomes symptomatic. Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the client delays necessary intervention.