NURSE333333333 CARDIAC
A nurse and nursing student are caring for a client with coronary heart disease and providing information about the disease process to the client. When client care is completed, the student asks the nurse what things stimulate the heart to beat faster. The correct response would be which of the following? a) "Anything that stimulates the sympathetic nervous systerm (positive chronotropy)" b) "Hypothyroidism" c) "Beta-adrenergic blocking agents" d) "Anything that stimulates the parasympathetic nervous system (negative chronotropy)"
"Anything that stimulates the sympathetic nervous systerm (positive chronotropy)" Correct Explanation: Stimulation of the sympathetic nervous system increases heart rate. Parasympathetic stimulation reduces heart rate. Administration of beta-adrenergic blocking agents decreases stimulation of the sympathetic nervous system and subsequently heart rate.
A nurse working in the clinic is seeing a client who has just been prescribed a new medication for hypertension. The client asks why hypertension is sometimes called the "silent killer." The nurse's correct response is which of the following? a) "Hypertension is difficult to diagnose." b) "Hypertension often causes no pain." c) "Hypertension often causes no symptoms." d) "Hypertension often kills early in the disease process."
"Hypertension often causes no symptoms." Correct Explanation: Hypertension is sometimes called the "silent killer" because people with it are often symptom free. Physical examination may reveal no abnormalities other than elevated blood pressure. People with hypertension may remain asymptomatic for many years. The usual consequences of prolonged, uncontrolled hypertension are myocardial infarction, heart failure, renal failure, strokes, and impaired vision. Pain is not usually an issue, but that is not why hypertension is called the "silent killer." Hypertension is easily diagnosed by taking a series of blood pressure readings.
The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? a) "The client is in shock because your loved one is not responding and brain dead." b) "The client is in shock because all peripheral blood vessels have massively dilated." c) "The client is in shock because the heart is unable to circulate the body fluids." d) "The client is in shock because the blood volume has decreased in the system."
"The client is in shock because the blood volume has decreased in the system." Correct Explanation: Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.
· A nurse is caring for a client who has HF and a prescription for Digoxin 125mcg PO daily. Available is Digoxin PO 0.25mg/tablet. How many tablets should the nurse administer per dose?
0.5 tablet
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. A client is now receiving an I.V. infusion of heparin sodium at 1,200 units/hour. The dilution is 25,000 units/500 mL. How many milliliters per hour will this client receive? mL/hour
24 Correct Explanation: First, calculate how many units are in each milliliter of the medication: 25,000 units/500 mL = 50 units/1 mL. Next, calculate how many milliliters the client receives per hour: 1,200 units/1 hour divided by 50 units/1 mL. So 1,200 units/1 hour X 1 mL/50 units = 24 mL/hour.
Fill in the blank (with a number) question - Enter the answer in the space provided. Your answer should contain only numbers and, if necesary, a decimal point. The nurse is assessing a client who is at risk for cardiac tamponade from chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if his blood pressure is 108/82 mm Hg?
26 Correct Explanation: Pulse pressure is the difference between systolic and diastolic pressures. Normally, systolic pressure exceeds diastolic pressure by approximately 40 mm Hg. Narrowed pulse pressure, a difference of less than 30 mm Hg, is a sign of cardiac tamponade.
· A nurse is preparing to infuse a 250ml unit of packed RBC's over 2hrs. The drop factor of the manual IV tubing is 15gtts/ml. Drops per minute?
31gtts/min
The rapid response team has been called to manage an unwitnessed cardiac arrest in a client's hospital room. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is: a) 12 to 15 minutes. b) 4 to 6 minutes. c) 8 to 10 minutes. d) 1 to 2 minutes.
4 to 6 minutes. Correct Explanation: After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain damage is almost certain. To prevent permanent brain damage, it is important to begin CPR promptly after a cardiopulmonary arrest.
· A nurse is preparing to administer Digoxin to a 6-month old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?
90bpm
Automatacity
ABILITY TO DO THINGS WITH OUT NEEDING TO OCCUPY SPACE IN THE MIND, AN AUTOMATIC RESPONCE OR PATTERN
The nurse is assessing a client who has been admitted with impaired arterial circulation in the lower extremities due to diabetes mellitus. Which of the following would be expected findings? a) Capillary refill in the toes within 3 seconds b) Absence of dorsalis pedis pulse, coolness, and decreased sensation in the feet c) Redness, inflammation, and sharp pain with calf muscle contraction d) Edema and coolness in the ankles and feet
Absence of dorsalis pedis pulse, coolness, and decreased sensation in the feet Explanation: This choice is the most accurate description of an interference with arterial circulation. The dorsalis pedis is one of the most peripheral pulses, its absence along with coolness indicates compromised arterial flow. Impaired blood flow will also affect the nervous status in the foot, resulting in decreased sensation. Capillary refill in 2 seconds is normal; edema and coolness is more an indication of venous impairment; inflammation and calf pain likely indicate a thrombophlebitis.
A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, it is important for the nurse to a) Administer the prescribed enoxaparin (Lovenox). b) Monitor partial thromboplastin (PTT) time. c) Encourage a diet high in vitamin K. d) Have the client limit physical activity.
Administer the prescribed enoxaparin (Lovenox). Explanation: Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered.
The nurse is caring for clients on a telemetry unit. Which nursing consideration best represents concerns of altered rhythmic patterns of the heart? a) Altered patterns frequently produce neurological deficits. b) Altered patterns frequently turn into life-threatening arrhythmias. c) Altered patterns frequently affect the heart's ability to pump blood effectively. d) Altered patterns frequently cause a variety of home safety issues.
Altered patterns frequently affect the heart's ability to pump blood effectively. Explanation: The best representation of a nursing concern related to a cardiac arrhythmia is the inability of the heart to fill the chambers and eject blow flow efficiently. Lack of an efficient method to circulate blood and bodily fluids produces a variety of complications such as tissue ischemia, pulmonary edema, hypotension, decreased urine output, and impaired level of consciousness. The other options can occur with dysrhythmias, but the cause stemming from the altered pattern is the best answer.
· Nurse is assessing an older client who is receiving Digoxin. The nurse should recognize that which of the following findings is a manifestation of Digoxin toxicity?
Anorexia
· Nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a HR?
Apex of heart
· A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Assess apical pulse for a full minute
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. The client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first: a) Assess color and temperature of the left leg. b) Encourage the client to change her position. c) Administer pain medication. d) Assess for edema in the left leg.
Assess color and temperature of the left leg. Explanation: The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Administering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data.
An ultrasonic Doppler is used for a) Aiding palpation of diastolic blood pressure b) Auscultating a pulse that is difficult to palpate c) Aiding palpation of pulse and rhythm d) Auscultating diastolic blood pressure
Auscultating a pulse that is difficult to palpate Correct Explanation: A Doppler device can be used to detect a pulse that is not easily palpable.
· Nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary restrictions?
Beans
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions would be appropriate for the nurse to give the client for promoting circulation to the extremities? a) Use a heating pad to promote warmth. b) Massage calf muscles if pain occurs. c) Participate in a regular walking program. d) Keep the extremities elevated slightly.
Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and resume activity when pain subsides. With arterial disease, extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. To avoid burns, heating pads should not be used by anyone with impaired circulation. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.
Which of the following is a term used to describe the splitting or separating of fused cardiac valve leaflets? a) Valvuloplasty b) Annuloplasty c) Chordoplasty d) Commissurotomy
Commissurotomy is the splitting or separating of fused cardiac valve leaflets. Annuloplasty is a repair of a cardiac valve's outer ring. Chordoplasty is repair of the stringy, tendinous fibers that connect the free edges of the atrioventricular valve leaflets to the papillary muscle. Valvuloplasty is a repair of a stenosed or regurgitant cardiac valve by commissurotomy, annuloplasty, leaflet repair, or chordoplasty.
The nurse identifies which of the following symptoms as a manifestation of right-sided heart failure (HF)? a) Reduction in forward flow b) Accumulation of blood in the lungs c) Reduction in cardiac output d) Congestion in the peripheral tissues
Congestion in the peripheral tissues Correct Explanation: Right-sided HF, failure of the right ventricle, results in congestion in the peripheral tissues and the viscera and causes systemic venous congestion and a reduction in forward flow. Left-sided HF refers to failure of the left ventricle; it results in pulmonary congestion and causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? a) Document the findings and recheck the client in 1 hour. b) Encourage the client to perform isometric leg exercise to improve circulation in his legs. c) Contact the physician and report the findings. d) Slow the I.V. fluid to prevent any more swelling at the puncture site.
Contact the physician and report the findings. Correct Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take? a) Slow the I.V. fluid to prevent any more swelling at the puncture site. b) Document the findings and recheck the client in 1 hour. c) Contact the physician and report the findings. d) Encourage the client to perform isometric leg exercise to improve circulation in his legs.
Contact the physician and report the findings. Correct Explanation: The client is probably developing a hematoma at the puncture site. The decreased pulses, swelling, and cool temperature in the leg are all classic signs that blood flow to that extremity is compromised. The nurse should notify the physician immediately to preserve the blood flow in the client's leg. Documenting findings and checking the client again in 1 hour, slowing the I.V. fluid, and encouraging the client to perform isometric leg exercises aren't appropriate actions for the nurse to take at this time.
The nurse is caring for a child with hemophilia who is actively bleeding from the leg. The nurse should apply: a) Ice bag with elevation of the leg twice a day. b) Direct pressure to the injured area continuously for 10 minutes. c) Direct pressure, checking every few minutes to see if the bleeding has stopped. d) Ice to the injured leg area several times a day.
Direct pressure to the injured area continuously for 10 minutes. Explanation: For the child with hemophilia who is actively bleeding, the nurse should apply direct pressure to the injured area for 10 minutes continuously along with elevating the leg. The continuous application of direct pressure aids in stopping the bleeding. Elevating the leg reduces blood flow to the area, thereby minimizing the extent of blood loss. Although ice will cause local vasoconstriction and slow the bleeding, applying continuous direct pressure is essential.
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry-red in color? a) Milia b) Nevi c) Xanthelasma d) Hemangioma
Hemangioma Correct Explanation: Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of the aging of the skin or a lipid disorder. Nevi are freckles.
The client returns to the nursing unit following an open reduction with internal fixation of the right hip. Nursing assessment findings include temperature 100.8 degrees Farenheit, heart rate 112 beats per minute, respiratory rate 28 breaths per minute, and blood pressure 86/58. There is no urine in the Foley catheter collection bag. The nurse interprets these findings as indicating which of the following complications? a) Atelectasis b) Urinary retention c) Osteomyelitis d) Hypovolemic shock
Hypovolemic shock Correct Explanation: Indicators of hypovolemic shock include a heart rate greater than 100 beats per minute, a blood pressure less than 90/60 mm Hg, and urine output less than 30 ml per hour.
A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms? a) Cardiac disease b) Impaired cerebral circulation c) Diabetes insipidus d) Hypertension
Impaired cerebral circulation Correct Explanation: TIAs result from impaired blood circulation in the brain, which can be caused by atherosclerosis and arteriosclerosis, cardiac disease, or diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by cardiac disease. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by diabetes. The symptoms of a TIA are the result of impaired blood circulation in the brain, which may have been caused by hypertension.
Which of the following is the most important postoperative assessment parameter for patients undergoing cardiac surgery? a) Inadequate tissue perfusion b) Mental alertness c) Blood glucose level d) Activity intolerance
Inadequate tissue perfusion Correct Explanation: The nurse must assess the patient for signs and symptoms of inadequate tissue perfusion, such as a weak or absent pulse, cold or cyanotic extremities, or mottling of the skin. Although the nurse does assess blood sugar and mental status, tissue perfusion is the higher priority. Assessing for activity intolerance, while important later in the recovery period, is not essential in the immediate postoperative period for patients undergoing cardiac surgery.
· Nurse is providing discharge teaching to a client who has a new prescription for Verapamil for angina. Which of the following instructions should the nurse include?
Inc. your daily intake of dietary fiber
A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking? a) Intermittent claudication b) Thromboangiitis obliterans c) Orthopnea d) Dyspnea
Intermittent claudication Correct Explanation: Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is the patient's subjective statement of difficulty breathing. Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger's disease.
A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? a) Use of antiembolytic stockings b) Keeping the legs in a neutral or dependent position c) Elevation of the legs above the heart d) Application of ace wraps from the toe to below the knees
Keeping the legs in a neutral or dependent position Correct Explanation: Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.
A patient is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The patient's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV Nitropress (nitroprusside). Upon assessment, which of the following patient findings requires immediate intervention by the nurse? a) Urine output of 40 cc/mL over the last hour b) Nausea and severe headache c) Left arm numbness and weakness d) Chest pain score of 3/10 (on a scale of 1 to 10)
Left arm numbness and weakness Explanation: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of left arm numbness and weakness may indicate the patient is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP and requires immediate interventions. A urine output of 40 mL/h is within normal limits. The other findings are likely caused by the hypertension and require intervention, but they do not require action as urgently as the neurologic changes.
· A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
MRI of chest
A 12-year-old client fractured her right leg while skiing and is undergoing an open reduction of the femur fracture. She returns to the orthopedic unit where you practice nursing with a cast in place. What is the rationale for frequently assessing her pedal pulses? a) Ensuring there wasn't nerve damage during surgery b) Making sure surgery was successful c) Maintaining adequate circulation d) Typical postoperative nursing management
Maintaining adequate circulation Correct Explanation: Circulation, sensation, and mobility of exposed fingers or toes must be assessed every 1 to 2 hours to ensure neurovascular status is not compromised.
· Nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?
Measure from heel to popliteal space
Which positioning strategy should be used for the patient diagnosed with hypovolemic shock? a) Prone b) Supine c) Modified Trendelenburg d) Semi-Fowler's
Modified Trendelenburg Correct Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood.
The nurse is assisting the physician with placing a ventricular assist device (VAD). Which assessment finding would confirm the successful implementation? a) Temperature within normal limits b) Pedal pulse stronger c) Respiratory rate decreased d) Heart rate increased
Pedal pulse stronger Correct Explanation: The ventricular assist device (VAD) is a medical mechanical device used to improve cardiac output and redistribute blood. The best evidence to confirm successful implementation is by identifying a strong pedal pulse in a lower extremity. Respiratory rate decreases as a client rests. Heart rate decreases when the tissues obtain the needed oxygen. The temperature within normal limits does not confirm successful implementation
· A nurse is caring for a client who is prescribed Warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of Warfarin?
PT
Assessment of the pulse amplitude is accomplished by which of the following? a) Palpating the flow of blood through an artery b) Auscultating the flow of blood through an artery c) Palpating the area of the left ventricle d) Auscultating the area of the left ventricle
Palpating the flow of blood through an artery Correct Explanation: The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction. It is assessed by the feel of the blood flowing through an artery.
When the nurse observes that the patient's systolic blood pressure is less than 80 to 90 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc per hour, the nurse recognizes that the patient is demonstrating which stage of shock? a) Compensatory b) Irreversible c) Refractory d) Progressive
Progressive Correct Explanation: In compensatory shock, the patient's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In progressive shock, the patient's skin appears mottled and mentation demonstrates lethargy. In refractory or irreversible shock, the patient requires complete mechanical and pharmacologic support.
A patient has been diagnosed with congestive heart failure. Which of the following is a cause of crackles heard in the bases of the lungs? a) Pulmonary congestion b) Mitral valve stenosis c) Heart palpitations d) Pulmonary hypertension
Pulmonary congestion Correct Explanation: Crackles heard in the bases of the lungs are a sign of pulmonary congestion. Heart palpitations are caused by tachydysrhythmias. Crackles heard in the bases of the lungs are not signs of pulmonary hypertension and mitral valve stenosis.
A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? a) Pulse is strong and remains despite moderate pressure. b) Pulse is strong, and light pressure causes it to disappear. c) Pulse is felt with difficulty and disappears with slight pressure. d) Pulse is felt easily, and moderate pressure causes it to disappear.
Pulse is felt with difficulty and disappears with slight pressure. Correct Explanation: Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure.
A nurse palpates the pulse of a patient and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent? a) Pulse rhythm b) Pulse rate c) Pulse deficit d) Pulse quality (amplitude)
Pulse quality (amplitude) Correct Explanation: Pulse quality/amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (4+). Pulse rates are measured in beats per minute. Pulse rhythm is the pattern of the pulsations and the pauses between them. The pulse deficit is the difference between the apical and radial pulse rates.
Which of the following is the most common symptom of a polyp? a) Diarrhea b) Rectal bleeding c) Abdominal pain d) Anorexia
Rectal bleeding Correct Explanation: The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: a) Control chest pain. b) Reduce coronary artery vasospasm. c) Control the arrhythmias associated with MI. d) Revascularize the blocked coronary artery.
Revascularize the blocked coronary artery. Correct Explanation: The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.
An elderly male client has been taking doxazosin (Cardura) 2 mg daily for 4 weeks for treatment of benign prostatic hypertrophy. The client reports feeling dizzy. The nurse should first: a) Take his blood pressure lying, standing, and sitting. b) Report the symptoms to the physician. c) Review his other medications. d) Test his urine for ketones.
Take his blood pressure lying, standing, and sitting. Explanation: Doxazosin is also used as an antihypertensive agent; the client may be experiencing orthostatic hypotension. Testing the urine for ketones would be appropriate if the client had diabetes mellitus. Because an adverse effect of doxazosin is orthostatic hypotension, the nurse should first take the client's blood pressure; later, she can review other mediations. The client's report of symptoms should be reported to the physician with the blood pressure readings.
· A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?
Take medication with orange juice to enhance absorption
Conductivity
The ability of an object to transfer heat or electricity to another object.
A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm? a) The blood pressure and pulse are within normal limits, but the client's skin color is pale and slightly diaphoretic. b) The client has been taking an antihypertensive for the past 3 years but forgot to take it today. c) The client reports feeling nauseated. d) The client reports increasing severe back pain.
The client reports increasing severe back pain. Correct Explanation: Increased severe back pain and increased irritation to nerves are indicative of a potential rupture of an aneurysm. The client would be hypertensive and present with tachycardia, so the other choices are not correct. Nausea, although possible, or a missed dose of medication, do not indicate potential rupture.
A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? a) The development of right-sided heart failure b) The development of left-sided heart failure c) The development of corpulmonale d) The development of chronic obstructive pulmonary disease (COPD)
The development of left-sided heart failure Correct Explanation: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Corpulmonale is a condition in which the heart is affected secondarily by lung damage.
Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: a) Control chest pain. b) Revascularize the blocked coronary artery. c) Reduce coronary artery vasospasm. d) Control the arrhythmias associated with MI.
The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood supply to the area.
· A nurse is caring for a client who is on Warfarin therapy for A Fib. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?
Vitamin K
EXCITABILITY
ability to respond to stimuli
· A nurse is providing teaching to a client about smoking cessation. Which of the following client statements indicates a need for further education?
o "I will test my ability to quit smoking by going to the bar where I used to smoke."
· A client with a hx or MI is prescribed Aspirin 325mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?
o Antiplatelet aggregate
· A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instruction should the nurse include in the teaching?
o Apply patch in the morning
· A nurse is providing teaching to a client who has stable angina and a new prescription for transdermal nitroglycerin. Which of the following instructions should the nurse include? Select all that apply.
o Apply the patch to a hairless area and rotate sites o Apply a new patch each morning o Remove patch for 10-12hrs daily
· A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? Select all that apply.
o Check peripheral pulses in the affected extremity o Keep client's hip and leg extended o Have client remain in bed up to 6hrs post op
· A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?
o Check the PT's vital signs
· A nurse is caring for a client who had congestive heart failure and is taking Digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
o Check vital signs
· A nurse is teaching a client who is Post Op following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? Select all that apply.
o Count your pulse for 1 min. each morning o Don't wear tight clothing over insertion area
· A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?
o Crushing the medication might cause you to have a stomachache or indigestion
· A nurse finds that a client didn't receive a scheduled dose of Lasix. Which of the following should the nurse include in the incident/variance report? Select all that apply
o Date of incident o Time client was to receive the medication o The client's vital signs
· A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload.
o Dyspnea o Jugular vein distention o Confusion
· Nurse is caring for a client who has thrombophlebitis and is receiving Heparin by continuous IV infusion. The client asks the nurse how long it will take for the Heparin to dissolve the clot. Which of the following responses should the nurse give?
o Heparin does not dissolve clots. It stops new clots from forming
· A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder?
o Hypercholesterolemia o Hypertension o Obesity o Smoking
· A nurse is teaching a client who takes Warfarin daily. Which of the following statements by the client indicates a need for further teaching?
o I have started taking ginger root to treat my joint stiffness
· A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.
o I must stop smoking o I need to monitor my weight o I am limiting my intake of fast foods
· A nurse is instruction a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?
o I will take my medications at the first sign of an attack
· A nurse is assessing a client who had fluid overload. Which of the following findings should the nurse expect? Select all that apply.
o Inc. HR o Inc. BP o Inc. RR
· A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?
o Increasing my intake of foods containing trans fatty acids can lower my risk.
· A nurse is assisting with obtaining an ECG for a client who has A Fib. Which of the following actions should the nurse take? Select all that apply.
o Inspect electrode pads o Instruct the client not to talk during the test
· Nurse in an emergency dept is assessing a client who is having a suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?
o Nausea o Tachycardia o Diaphoresis
· Nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipated which of the following orders when notifying the provider of this finding?
o Obtain a venous duplex ultrasound
· A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG trip should the nurse recognize as normal sinus rhythm?
o P wave falls before the QRS complex
· A nurse is caring for a male client who has peripheral vascular disease, takes dietary supplements and has a new prescription for Warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the Warfarin?
o Saw Palmetto o Glucosamine o Gingko Biloba
· A nurse is teaching a client who has a new prescription for Colesevelam to lower his low-density lipoprotein level. Which of the following instructions should the nurse include?
o Take medication 4hrs after other medications
· A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?
o Take one tablet at the first indication of chest pain
· A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and diaphoretic. Which of the following lab tests are used to diagnose a MI? Select all that apply
o Troponin I o Troponin T o CPK o Myoglobin
· A nurse is planning to teach a client about a low potassium diet. Which of the following foods should the nurse instruct the client to avoid?
o Yogurt o Orange Juice
A client with gestational hypertension is likely to exhibit: a) proteinuria, headaches, and vaginal bleeding. b) headaches, double vision, and vaginal bleeding. c) proteinuria, headaches, and double vision. d) proteinuria, double vision, and uterine contractions.
proteinuria, headaches, and double vision. Correct Explanation: A client with gestational hypertension typically complains of headache, double vision, and sudden weight gain. Additional findings include proteinuria. Vaginal bleeding and uterine contractions aren't associated with gestational hypertension.
