Test 3 Saunders NCLEX questions

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 are 20 to 36 seconds. Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the client's activated partial thromboplastin time would be considered therapeutic if it was 60 seconds.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? 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/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

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

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

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? 1.Apples 2.Pears 3.Bananas 4. Cranberries

3 Rationale: Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, fresh oranges, mangos, nectarines, papayas, and prunes.

A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if the client's PVCs continued to exhibit which finding? 1.Occur in pairs 2.Appear to be multifocal 3.Fall on the second half of the T wave 4.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 is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1.Weighing the diapers 2.Inserting a Foley catheter 3.Comparing intake with output 4.Measuring the amount of water added to formula

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

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as daily prescribed medications. The nurse tells the client to report which finding as an indication that the medications are not having the intended effect? 1.Sudden increase in appetite 2.Weight gain of 2 to 3 lb in a few days 3.Increased urine output during the day 4.Cough accompanied by other signs of respiratory infection

2 Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy (Lasix). A cough resulting from respiratory infection does not necessarily indicate that heart failure is worsening.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1.Prone position 2.Knee-chest position 3.High Fowler's position 4.Reverse Trendelenburg's position

2 Rationale: Tetralogy of Fallot includes four defects-ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. If pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is left to right. If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation. All other options will not improve systemic arterial oxygen saturation.

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

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

A nurse is caring for a client with unstable ventricular tachycardia. The nurse should instruct the client to take which action, if prescribed, during an episode of ventricular tachycardia? 1.Lie down flat in bed. 2.Remove any metal jewelry. 3.Breathe deeply, regularly, and easily. 4.Inhale deeply and cough forcefully every 1 to 3 seconds.

4 Rationale: Restorative coughing techniques are sometimes used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. The other options will not assist in terminating the dysrhythmia.

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. Option 2 will not decrease the heart rate. Additionally, the pulse should be taken more frequently than each shift.

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

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

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse immediately would assess which item based on priority? 1.Anxiety level of the client and family 2.Presence of a Medic-Alert card for the client to carry 3.Knowledge of restrictions of 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.

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

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. Options 3 and 4 indicate an increase in fluid volume. Although the BP will decrease, it is not the earliest indicator.

The nurse notes that a client's cardiac rhythm shows absent P waves and no PR interval. 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 may be absent. There is no PR interval, and the QRS duration usually is normal and constant. 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 seconds in duration, and the QRS interval is 0.06 to 0.10 seconds in duration

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The P waves and QRS complexes 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 interprets 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.

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching? 1."Quiet activities are allowed." 2."The child should play inside for now." 3."Visitors are not allowed for 1 month." 4."The regular schedule for naps is resumed."

3 Rationale: Visitors without signs of any infection are allowed to visit the child. The mother should be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge. Options 1, 2, and 4 are accurate instructions regarding activity following heart surgery.

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

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

The nurse is monitoring a client who is taking propranolol (Inderal LA). Which assessment data indicates a potential serious complication associated with this medication? 1.The development of complaints of insomnia 2.The development of audible expiratory wheezes 3.A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication 4.A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minute after two doses of the medication

2 Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. b-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

A client who had surgery 3 days earlier is receiving heparin sulfate by subcutaneous injection every 12 hours. In planning for the client's morning care, the priority nursing intervention is which action? 1.Allow the client to sit only at the bedside. 2.Assist the client to shave using an electric razor. 3.Monitor the prothrombin time (PT) every 4 hours. 4.Tell the client that brushing the teeth is not allowed.

2 Rationale: Clients receiving heparin are at risk for bleeding. An electric razor rather than a straight blade razor is used for shaving. Options 1 and 3 are inappropriate and unnecessary nursing actions. It is not necessary to monitor laboratory values every 4 hours when the client is taking subcutaneous heparin. The PT is monitored when the client is taking warfarin (Coumadin).

A client's electrocardiogram shows that the atrial and ventricular rhythms are 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 AV block 4.First-degree atrioventricular (AV) block

2 Rationale: With atrial fibrillation, the atrial and ventricular rhythms are irregular and there are usually no discernible P waves. 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 monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply. 1.Tremors 2.Diarrhea 3.Irritability 4.Blurred vision 5.Nausea and vomiting

2, 4, 5Rationale: Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL.

The clinic nurse is providing instructions to a client with hypertension who will be taking captopril (Capoten). 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 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 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.

A hospitalized client with coronary artery disease complains of substernal chest pain. After assessing the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes the client states, "My chest still hurts." Which actions should the nurse take? Select all that apply. 1.Call a Code Blue. 2.Contact the client's family. 3.Assess the client's pain level. 4.Check the client's blood pressure. 5.Contact the health care provider (HCP). 6.Administer a second nitroglycerin, 0.4 mg, sublingually.

3,4,6 Rationale: The usual guidelines for administering nitroglycerin tablets for chest pain to a hospitalized client include administering one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. If the client does not obtain relief after taking a third dose of nitroglycerin, the HCP is notified. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a Code Blue. Additionally it is not necessary to contact the client's family unless he or she has requested this.

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

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

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

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

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

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

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

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

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1.Anxiety 2.A temper tantrum 3.A hypercyanotic episode 4.The need for immediate health care provider (HCP) notification

3 Rationale: Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate HCP notification is not required unless other appropriate nursing interventions are unsuccessful. Options 1 and 2 are unrelated to tetralogy of Fallot.

A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the initial action by the nurse? 1.Place the infant in a prone position. 2.Call a code and notify the supervisor. 3.Place the infant in a knee-chest position. 4.Contact the respiratory therapy department.

3 Rationale: If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia. Therefore, options 1, 2, and 4 are incorrect.

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

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

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

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

A client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. In formulating a response, the nurse understands that this effect occurs because of the client's primary need for which increased cardiac response? 1.Pulse rate 2.Cardiac index 3.Cardiac output 4.Stroke volume

3 Rationale: The client's symptoms are the direct result of the body's attempt to meet the metabolic demands generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital organs of the body. With exercise, these demands increase, and the heart must beat faster (increased heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output for body surface area.

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

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

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1.Bananas 2.Broccoli 3.Antacids 4.Cantaloupe

3 Rationale: The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.

The home health nurse is visiting a client who has had a prosthetic valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care after this surgery? 1."I need to count my pulse every day." 2."I have to do deep breathing exercises every 2 hours." 3."I threw away my straight razor and bought an electric razor." 4."I have to go to the bathroom frequently because of my medication."

3Rationale: Prosthetic valves require long-term anticoagulation to prevent clots from forming on the "foreign" tissue implanted in the client's body. Anticoagulation therapy requires clients to avoid any trauma or potential means of causing bleeding, such as the use of straight razors. Counting pulse, deep breathing exercises, and going to the bathroom frequently are not specifically related to postoperative care after prosthetic valve replacement.

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1."The child may return to school in 1 week." 2."The child will not be able to return to school during this academic year." 3."The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4."The child may return to school in 3 weeks but needs to go half-days for the first few days."

4 Rationale: After heart surgery, the child may return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months. Options 1, 2, and 3 are incorrec

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

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

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

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

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 demand pacemaker fires only when needed and should therefore discharge only when no electrical activity is occurring in the client's own heart.

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 admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1.Regular insulin 2.Glipizide (Glucotrol) 3.Repaglinide (Prandin) 4.Metformin (Glucophage)

4 Rationale: Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.

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

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

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

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

A client is admitted to the hospital with a diagnosis of aortic regurgitation. The nurse plans care for the client, knowing that the failure of the aortic valve to close completely allows blood to flow retrograde through which structures? 1.Aorta to left ventricle 2.Left ventricle to left atrium 3.Right ventricle to right atrium 4.Pulmonary artery to right ventricle

1 Rationale: The aortic valve separates the aorta from the left ventricle. Options 2, 3, and 4 describe the mitral, tricuspid, and pulmonic valves, respectively.

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 has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instructions? 1."A balance of rest and exercise is important." 2."I can apply lotion or powder to the incision if it is itchy." 3."Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4."Large crowds of people need to be avoided for at least 2 weeks after surgery."

2 Rationale: The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is experiencing which rhythm? 1.Sinus tachycardia 2.Ventricular fibrillation 3.Ventricular tachycardia 4.Premature ventricular contractions (PVCs)

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. Sinus tachycardia has a recognizable P wave and QRS. Ventricular tachycardia is a regular pattern of wide QRS complexes. PVCs appear as irregular beats within a rhythm. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.

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

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

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

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

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.

A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes action, knowing that this level could ultimately lead to which complication? 1.Stroke 2.Cardiac arrest 3.High blood pressure 4.Urinary stone formation

2 Rationale: The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move back during repolarization. Depolarization is responsible for cardiac contraction. Options 1 and 3 are unrelated to calcium levels. Elevated calcium levels can lead to urinary stone formation. The nurse would take action and contact the health care provider when a calcium level is abnormal.

A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin (Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about this information? 1.Normal, because of the client's age 2.Abnormal, requiring further assessment 3.Normal, as a result of the effects of digoxin 4.Normal, because this is the reason the client is receiving digoxin

2 Rationale: The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the health care provider. Digoxin increases the strength and contraction of the heart; it is not used to treat low heart rates. If a low heart rate is noted in a client taking digoxin, the medication is withheld and the health care provider is notified. Options 1, 3, and 4 are incorrect interpretations because the heart rate of 52 beats/min is not normal.

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 is wearing a nasal cannula delivering oxygen at 2 L/min. 2.The client's digoxin (Lanoxin) has been withheld for the last 48 hours. 3.The defibrillator has the synchronizer turned on and is set at 50 joules (J). 4.The client has received an intravenous dose of a conscious sedation medication.

1 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 50 to 100 J. The client typically receives a dose of an intravenous sedative or antianxiety agent.

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

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

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

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

The nurse has provided self-care activity instructions to a client after insertion of an automatic internal cardioverter-defibrillator (AICD). The nurse determines that further instruction is needed if the client makes which statement? 1."I can perform activities such as swimming, driving, or operating heavy equipment as I need to." 2."I need to avoid doing anything that could involve rough contact with the AICD insertion site." 3."I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cutoff on the AICD." 4. "I should keep away from electromagnetic sources such as transformers, large electrical generators, metal detectors, and I shouldn't lean over running motors."

1 Rationale: Post discharge instructions typically include avoiding tight clothing or belts over AICD insertion sites; rough contact with the AICD insertion site; and electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert health care providers (HCP) or dentists to the presence of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a HCP regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment

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

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

The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding? 1.A normal finding 2.Indicative of atrial flutter 3.Indicative of atrial fibrillation 4.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. Options 2, 3, and 4 are incorrect.

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

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

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

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

A client is admitted to the hospital with a diagnosis of mitral stenosis. The narrowing of this valve will impede circulation of blood through which structures? 1.Left ventricle to aorta 2.Left atrium to left ventricle 3.Right atrium to right ventricle 4.Right ventricle to pulmonary artery

2 Rationale: The mitral valve separates the left atrium from the left ventricle. Options 1, 3, and 4 describe the aortic, tricuspid, and pulmonic valves, respectively

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

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

A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block? 1.Presence of Q waves 2.Tall, peaked T waves 3.Prolonged PR interval 4.Widened QRS complex

3 Rationale: A prolonged PR interval indicates 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 ECG taken during a pain episode is intended to capture ischemic changes, which also include ST-segment elevation or depression.

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? 1.Chloride level of 98 mEq/L 2.Sodium level of 135 mEq/L 3.Potassium level of 6.8 mEq/L 4.Magnesium level of 1.6 mEq/L

3 Rationale: Hyperkalemia can cause tall, peaked or tented T waves on the ECG. Levels of potassium 5.0 mEq/L or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels.

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

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

The nurse is evaluating a client's cardiac rhythm strip to determine if there is proper function of the VVI mode pacemaker. Which denotes proper functioning? 1.Spikes precede all P waves and QRS complexes. 2.There are consistent spikes before each P wave. 3.Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. 4. Spikes occur before all QRS complexes regardless of intrinsic ventricular activity.

3 Rationale: When a pacemaker is operating in the VVI mode, pacemaker spikes will be observed before the QRS complex if the client does not have their own intrinsic beat; therefore options 1, 2, and 4 are incorrect.

A client is scheduled for a cardiac catheterization using a radiopaque dye. Which assessments are most critical before the procedure? 1.Intake and output 2.Height and weight 3.Allergy to iodine or shellfish 4.Baseline peripheral pulse rates

3Rationale: A cardiac catheterization requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is a concern, and the presence of allergies must be assessed before the procedure. Although the remaining options are accurate, they are not the most critical pre-procedure assessments.

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."

Rationale: 2 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.

During assessment of a client newly diagnosed with hypertension, the nurse recognizes that which is a common occurrence? 1.Be asymptomatic 2.Be short of breath 3.Have visual disturbances 4.Have frequent nosebleeds

1 Rationale: Hypertensive clients often have no symptoms until target organ involvement, which happens with very high blood pressure. This is why it is often noted as the "silent killer." Options 2, 3, and 4 are incorrect because those clinical manifestations occur with severely high hypertension.

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

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

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

1,35 Rationale: Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

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? 1.50 to 100 joules 2. 150 to 300 joules 3. 300 to 350 joules 4. 350 to 400 joules

1Rationale: For cardioversion procedures, the defibrillator is charged to the energy level prescribed by the HCP. Countershock usually is started at 50 to 100 joules. Options 2, 3, and 4 are incorrect.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? 1.Prevents blue (tet) spells 2.Maintains adequate cardiac output 3.Maintains an adequate hormonal level 4.Maintains the position of the great arteries

2 Rationale: A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output. The remaining options are incorrect. In addition, tet spells occur in tetralogy of Fallot, not in transposition of the great arteries.

A nurse is assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. The nurse plans care with the understanding that the heart normally sends out how many liters of blood per minute to the body? 1. 2 L/min 2. 5 L/min 3. 10 L/min 4. 15 L/min

2 Rationale: The cardiac cycle consists of contraction and relaxation of the heart muscle. The heart normally sends out about 5 L of blood every minute to the body. Therefore, options 1, 3, and 4 are incorrect.

The health care provider has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? 1.Questions the client about allergies to iodine or shellfish 2.Has the client sign an informed consent form for an invasive procedure 3.Tells the client that the procedure is painless and takes 30 to 60 minutes 4.Keeps the client on nothing-by-mouth (NPO) status for 2 hours before the procedure

3 Rationale: Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client.

A nurse employed in a cardiac unit determines that which client is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)? 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 three episodes of cardiac arrest unrelated to myocardial infarction

3 Rationale: An AICD detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are 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.

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1.Severe bradycardia 2.Asymptomatic findings 3.Bluish discoloration of the skin 4.Higher than normal body weight

3 Rationale: The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Options 1 and 2 are inaccurate findings. Many children with a left-to-right shunt may remain asymptomatic. Option 4 is incorrect because these children usually have lower than normal body weight.

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

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

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

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

A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further research on the anatomy and physiology of the heart? 1."The coronary arteries branch from the aorta." 2."The coronary arteries supply the heart muscle with blood." 3."The left coronary artery provides blood for the left atrium and the left ventricle." 4."The left coronary artery supplies the right atrium and right ventricle with blood."

4 Rationale: The left coronary artery divides into the anterior descending artery and the circumflex artery, providing blood for the left atrium and left ventricle. The right coronary artery supplies the right atrium and right ventricle. Options 1, 2, and 3 are correct.

A client with rapid-rate atrial fibrillation asks a nurse why the health care provider is going to perform carotid sinus massage. Which is a correct explanation? 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 2, 3, and 4 are incorrect descriptions of this procedure.

The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse? 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 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.Precipitating factors, such as infection 4.Blood pressure and oxygen saturation

4 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, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

A client taking an angiotensin-converting enzyme (ACE) inhibitor to treat hypertension calls the clinic nurse and reports that he has a dry, nonproductive cough that is very bothersome. The nurse should respond by making which statement? 1.The medication may need to be changed. 2.The cough must be the start of a respiratory infection. 3.The medication needs to be taken with large amounts of water to prevent the cough. 4.This sometimes happens, and the client will need to take a cough medication with each dose of medication.

1 Rationale: An ACE inhibitor is used to treat hypertension or heart failure. An adverse effect of ACE inhibitors is a characteristic dry, nonproductive cough. This can be quite bothersome to a client, and the medication may need to be changed. The cough is reversible with discontinuation of therapy. Options 2, 3, and 4 are incorrect.

The home care nurse has given instructions to a client who is beginning therapy with digoxin (Lanoxin). The nurse determines a need for further teaching of the instructions if the client makes which statement? 1."If I miss a dose, I should just take two the next day." 2."I shouldn't change brands without asking the health care provider first." 3."I should call the health care provider if my daily pulse rate is under 60 or over 100." 4."The pills should be kept in their original container so they don't get mixed up with my other medicines."

1 Rationale: Client teaching should include taking the dose exactly as prescribed each day. If the client misses a dose and more than 12 hours goes by, that dose should be omitted, and only the next scheduled dose should be taken; the client should not double-dose. The HCP should be consulted before changing brands because the bioavailability of another preparation of the medication may be different. A daily pulse check is necessary, and the client should know the parameters for which the health care provider (HCP) should be called. Clients are advised not to mix digoxin in pill boxes with other medications.

A client in the hospital emergency department who received nitroglycerin for chest pain has obtained relief but now complains of a headache. The nurse should interpret that this client is most likely experiencing which condition? 1.An expected medication side effect 2.An allergic reaction to nitroglycerin 3.An early sign of tolerance to the medication 4.A warning that the medication should not be used again

1 Rationale: Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol). The other options are incorrect interpretations.

A health care provider writes a prescription for lisinopril (Zestril) for a hospitalized client. The nurse caring for the client determines that the medication has been prescribed to treat which disorder? 1.Hypertension 2.Immune disorder 3.Venous insufficiency 4.Gastroesophageal reflux disorder

1 Rationale: Lisinopril (Zestril) is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat hypertension or heart failure. It is not used to treat immune disorder, venous insufficiency, or gastroesophageal reflux disorder.

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

1 Rationale: Medication should not be mixed with food, because this method of administration would not ensure that the child received the prescribed dose. The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Additionally, the parents should be instructed that if a dose is missed and is not identified until 4 or more hours later, the dose should not be administered. If more than one dose is missed, the health care provider (HCP) needs to be notified.

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates the client needs additional education? 1."It is important that I limit protein intake." 2."I need to maintain a regular exercise program." 3."I understand that I need to avoid adding salt to foods." 4."It is important that I begin reducing and then maintaining weight."

1 Rationale: Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.

A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3 mEq/L and is complaining of anorexia. The health care provider prescribes determination of the serum digoxin level to rule out digoxin toxicity. The nurse checks the results, knowing that which value is the therapeutic serum level (range) for digoxin? 1. 0.5 to 2 ng/mL 2. 1.2 to 2.8 ng/mL 3. 3.0 to 5.0 ng/mL 4. 3.5 to 5.5 ng/mL

1 Rationale: Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. The ranges in the remaining options are incorrect.

Atenolol (Tenormin) has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching? 1."I need to rise slowly from a lying to a sitting position." 2."If I feel that my heart rate is too low, I should stop the medication." 3."It will take 1 to 2 weeks before my blood pressure becomes controlled." 4."I should avoid tasks that require alertness until I know how the medication will affect my body."

2 Rationale: Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. The client should not abruptly stop the medication. Abrupt withdrawal may result in sweating, palpitations, headache, and tremulousness and may precipitate heart failure or myocardial infarction in a client with cardiac disease. Abrupt withdrawal can also cause rebound hypertension. A pulse rate of 60 or below should be reported to the client's health care provider. Options 1, 3, and 4 are correct client statements.

The nurse has given a client information about the use of nitroglycerin sublingual tablets. The client has a prescription for PRN use if chest pain occurs. Which client statement indicates an understanding of this medication? 1."It's best to keep this medication in a shirt pocket close to the body." 2."I need to discard unused tablets 6 to 9 months after the bottle is opened." 3."I will avoid using the medication until the chest pain actually begins and gets worse." 4."I can take aspirin for any headache that occurs when I first start taking the nitroglycerin."

2 Rationale: Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that could trigger chest pain. Tablets should be discarded 6 to 9 months after opening the bottle (expiration date on the bottle should always be checked), and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is very unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or purse. Headache often occurs with early use and diminishes in time. Acetaminophen (Tylenol), rather than aspirin (acetylsalicylic acid), may be used to treat headache.

A client with nausea and bradycardia is admitted to a medical unit. The family hands a nurse a small white envelope labeled "heart pill." The envelope is sent to the pharmacy and it is found to be digoxin (Lanoxin). A family member states, "That health care provider doesn't know how to take care of my family." Which statement would convey a therapeutic response by the nurse? 1."Don't worry about this. I'll take care of everything." 2."You are concerned your loved one receives the best care." 3."You're right! I've never seen them put pills in an envelope." 4."I think you're wrong. That health care provider (HCP) has been in practice more than 30 years."

2 Rationale: Option 2 is a therapeutic, nonjudgmental response. The statement reflects the family's concern but remains nonjudgmental. Option 1dismisses the family's concerns and disempowers the family. Option 3 creates doubt about the HCP's practice without actually knowing the circumstances. Option 4 is argumentative and nontherapeutic.

A client has recently begun medication therapy with propranolol (Inderal LA). The long-term care nurse should plan to notify the health care provider (HCP) if which assessment finding is noted? 1.Complaints of insomnia 2.Audible expiratory wheezes 3.Decrease in heart rate from 86 to 78 beats/min 4.Decrease in blood pressure from 162/90 to 136/84 mm Hg

2 Rationale: Propranolol (Inderal LA) is a beta-blocker. Audible expiratory wheezes could indicate bronchospasm, a serious adverse reaction. Beta blockers that are not cardioselective, such as propranolol, may induce this reaction, particularly in clients with chronic obstructive pulmonary disease (COPD) or asthma. Insomnia is a frequent mild side effect and should continue to be monitored. A normal decrease in heart rate and blood pressure is expected.

ntravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1.Vitamin K 2.Protamine sulfate 3.Potassium chloride 4.Aminocaproic acid (Amicar)

2 Rationale: The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Potassium chloride is administered for a potassium deficit. Aminocaproic acid is the antidote for thrombolytic therapy.

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

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

The nurse is providing medication information to a client who is beginning medication therapy with enalapril (Vasotec). The nurse should tell the client that which is an anticipated, although unpleasant, side effect of this medication? 1.Rapid pulse 2.Persistent dry cough 3.Increased blood pressure 4.Metallic taste in the mouth

2 Rationale: The principal side/adverse effects of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, are persistent cough, first-dose hypotension, and hyperkalemia. The medication is used to treat hypertension. A persistent dry cough is a harmless side effect, although it can be disturbing. If this side effect occurs and is troublesome, the health care provider should be notified so that the medication can be changed to a different one. A rapid pulse and metallic taste in the mouth are not side or adverse effects.

A home health nurse instructs a client about the use of a nitrate patch. The nurse should make which statement to the client to prevent client tolerance to nitrates? 1."Do not remove the patches." 2."Have a 12-hour 'no-nitrate' time." 3."Ensure a 24-hour 'no-nitrate' time." 4."Keep nitrates on 24 hours, then off 24 hours."

2 Rationale: To help prevent tolerance, clients need a 12-hour "no-nitrate" time, sometimes referred to as a pharmacological vacation away from the medication. The remaining options are incorrect.

The nurse has provided instructions to a client receiving enalapril maleate (Vasotec). Which statement by the client indicates a need for further instruction? 1."I need to rise slowly from a lying to sitting position." 2."I need to notify the health care provider if fatigue occurs." 3."I need to notify the health care provider (HCP) if a sore throat occurs." 4."I know that several weeks of therapy may be required for the full therapeutic effect."

2 Rationale: To reduce the hypotensive effect of this medication, the client is instructed to rise slowly from a lying to a sitting position and to permit the legs to dangle from the bed momentarily before standing. If fatigue occurs, it is not necessary to notify the HCP; the client is encouraged to pace activities. The client should report signs of a sore throat or fever to the HCP because these may indicate infection. The client should be notified that several weeks may be needed for the full therapeutic effect of blood pressure reduction. The client also should be instructed not to skip doses or discontinue the medication because severe rebound hypertension could occur.

A client with atrial fibrillation secondary to mitral stenosis is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium (Coumadin) 7.5 mg at 5:00 pm daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT) = 32 seconds; internationalized normalized ratio (INR) = 1.3. The nurse should plan to take which action based on the client's laboratory results? 1.Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2.Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. 3.Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4.Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate (Pradaxa) in place of warfarin sodium.

2 Rationale: When a client is receiving warfarin (Coumadin) for clot prevention due to atrial fibrillation, an INR of 2 to 3 is appropriate for most clients. Until the INR has achieved a therapeutic range the client should be maintained on a continuous heparin infusion with the aPTT ranging between 60 and 80 seconds. Therefore, the nurse should collaborate with the health care provider to obtain a prescription to increase the heparin infusion and to administer the warfarin as prescribed.

A client admitted to the hospital is taking atenolol (Tenormin). The nurse monitors the client for which sign or symptom of an adverse effect of the medication? 1.Nausea 2.Diaphoresis 3.Hypotension 4.Tachycardia

3 Rationale: Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Adverse effects include profound bradycardia or hypotension. Options 1, 2, and 4 are not adverse effects of this medication. Nausea and diaphoresis are side effects of the medication.

Atenolol (Tenormin) has been prescribed for a client, and the client asks the nurse about the side effects of the medication. What should the nurse tell the client is an occasional side effect of this medication? 1.Dry skin 2.Flushing 3.Decreased libido 4.Increased blood pressure

3 Rationale: Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Frequent side effects include hypotension manifested as dizziness, nausea, diaphoresis, headache, cold extremities, fatigue, and constipation or diarrhea. Occasional side effects include insomnia, flatulence, urinary frequency, and impotence or decreased libido. Options 1, 2, and 4 are not side effects of this medication.

The nurse has given a client the prescribed dose of intravenous hydralazine (Apresoline). The nurse evaluates the effectiveness of the medication by monitoring which client parameter? 1.Pulse rate 2.Urine output 3.Blood pressure 4.Potassium level

3 Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. It is a vasodilator medication that decreases afterload. The blood pressure needs to be monitored. Options 1, 2, and 4 are unrelated to the use of this medication.

A client's total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching? 1.The client should maintain the current dietary regimen but increase activity level. 2.Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. 3.The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. 4.The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen.

3 Rationale: In the absence of documented cardiovascular disease, the desired goal is to have the total cholesterol level lower than 200 mg/dL. A desired LDL-C level for all individuals is lower than 100 mg/dL, and a desirable HDL-C level is higher than 40 mg/dL. Because the client's levels are outside the range for all three values to a significant degree, the client is at high risk for developing cardiovascular disease and requires teaching on risk factor reduction.

Lisinopril (Prinivil) has been prescribed for a client. What should the nurse instruct the client to do? 1.Take the medication with food only. 2.Discontinue the medication if nausea occurs. 3.Rise slowly from a reclining to a sitting position. 4.Expect to note a full therapeutic effect immediately.

3 Rationale: Lisinopril is an angiotensin-converting enzyme inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a reclining to a sitting position and to dangle the legs from the bed for a few moments before standing to reduce the hypotensive effect. It is not necessary to take the medication with food. If nausea occurs, the client should drink a noncola carbonated beverage and eat salted crackers or dry toast. A full therapeutic effect may be achieved in 1 to 2 weeks.

The nurse has completed medication administration that included a nitroglycerin. Within minutes, the client is complaining of a headache. Which is the priority nursing action at this time? 1.Evaluate pupil response. 2.Place the client on the left side. 3.Administer the prescribed analgesic. 4.Notify the health care provider (HCP) immediately.

3 Rationale: Nitroglycerin causes vasodilation. The major side effect of nitroglycerin is a headache that can be alleviated by an analgesic. It is an expected response to the medication, and the health care provider (HCP) does not need to be notified. Placing the client on the left side will not alleviate the headache. There is no indication for the need to evaluate pupil response.

A client with cardiac disease has begun taking propranolol (Inderal LA), and the nurse provides information to the client about the medication. The nurse should tell the client to contact the health care provider (HCP) if which symptoms develop? 1.Insomnia and headache 2.Nausea and constipation 3.Night cough and dyspnea 4.Drowsiness and nightmares

3 Rationale: Propranolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, antidysrhythmic, and antimigraine medication. It may precipitate heart failure or myocardial infarction in clients with cardiac disease. Signs of heart failure include dyspnea (particularly on exertion or lying down), night cough, peripheral edema, and distended neck veins. If signs of heart failure occur, the HCP should be notified. Options 1, 2, and 4 identify side effects of this medication that do not warrant HCP notification if they occur.

The nurse is reviewing the assessment findings for a client who has been taking spironolactone (Aldactone) for treatment of hypertension. Which, if noted in the client's record, would indicate that the client is experiencing an adverse effect related to the medication? 1.Client complaint of dry skin 2.A potassium level of 3.5 mEq/L 3.A potassium level of 5.8 mEq/L 4.Client complaint of constipation

3 Rationale: Spironolactone (Aldactone) is a potassium-retaining diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.

In reviewing the medication records of the following group of clients, the nurse determines that which client would be at greatest risk for developing hyperkalemia? 1.Client receiving bumetanide 2.Client receiving furosemide (Lasix) 3.Client receiving spironolactone (Aldactone) 4.Client receiving hydrochlorothiazide (HCTZ)

3 Rationale: Spironolactone is a potassium-sparing diuretic and competes with aldosterone at receptor sites in the distal tubule, resulting in excretion of sodium, chloride, and water and retention of potassium and phosphate. Use of the medications furosemide, bumetanide, and hydrochlorothiazide could result in hypokalemia.

A home health care nurse is visiting an older client at home. Furosemide (Lasix) is prescribed for the client and the nurse teaches the client about the medication. Which statement, if made by the client, indicates the need for further teaching? 1."I will sit up slowly before standing each morning." 2."I will take my medication every morning with breakfast." 3."I need to drink lots of coffee and tea to keep myself healthy." 4."I will call my health care provider (HCP) if my ankles swell or my rings get tight."

3 Rationale: Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration. Sitting up slowly prevents postural hypotension. Taking the medication at the same time each day improves compliance. Because furosemide is a diuretic, the morning is the best time to take the medication so as not to interrupt sleep. Notification of the HCP is appropriate if edema is noticed in the hands, feet, or face or if the client is short of breath.

A nurse is auscultating a 56 year old adult client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/minute. Which action should the nurse take? 1.Withhold the digoxin, and reevaluate the heart rate in 4 hours. 2.Administer half the prescribed dose to avoid a further decrease in heart rate. 3.Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. 4.Administer the digoxin. The heart rate would be considered normal because of the client's age.

3 Rationale: The normal heart rate is 60 to 100 beats/min in an adult. If the nurse notes a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output so this would also be assessed.

The nurse is planning to administer hydrochlorothiazide to a client. The nurse understands that which is a concern related to the administration of this medication? 1.Hypouricemia, hyperkalemia 2.Increased risk of osteoporosis 3.Hypokalemia, hyperglycemia, sulfa allergy 4.Hyperkalemia, hypoglycemia, penicillin allergy

3 Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

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. 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, then option 4 would be the next choice, along with contacting the health care provider.

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. Options 1, 2, and 4 are incorrect.

The nurse is preparing to administer furosemide (Lasix) 40 mg by intravenous (IV) injection (IV push) to a client. The nurse should administer the medication over which time period? 1. 10 seconds 2. 30 seconds 3. 1 minute 4. 5 minutes

3 Rationale: When furosemide is administered by IV injection, each 40 mg or fraction thereof should be given over a 1- to 2-minute period. Options 1 and 2 identify administration times that are too rapid and could cause adverse effects. Option 4 is too slow of a time period for administration and may affect effectiveness of the IV medication.

A health care provider writes a prescription for digoxin (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is most important to be sure to implement which measure? 1.Count the radial and carotid pulses every morning. 2.Check the blood pressure every morning and evening. 3.Stop taking the medication if the pulse is faster than 100 beats/min. 4. Withhold the medication, and call the health care provider if the pulse is slower than 60 beats/min.

4 Rationale: An important component of taking digoxin is monitoring the pulse rate; however, it is not necessary for the client to take both radial and carotid pulses. It is also unnecessary for the client to check the blood pressure every morning and evening because the medication does not directly affect blood pressure. It is most important for the client to know the guidelines related to withholding the medication and calling the health care provider. The client should not stop taking the medication

Diltiazem (Cardizem) is prescribed for a client with Prinzmetal's variant angina. The nurse should plan care, knowing that this medication works by which method? 1.Increasing the heart rate 2.Constricting peripheral arteries 3.Increasing sinoatrial (SA) and atrioventricular (AV) conduction 4.Inhibiting calcium movement across cell membranes of cardiac and smooth muscle

4 Rationale: Diltiazem is a calcium channel blocker that inhibits calcium movement across cell membranes of cardiac and smooth muscle. It dilates coronary arteries and peripheral arteries and arterioles. Diltiazem decreases the heart rate and slows SA and AV conduction.

The nurse has a prescription to give a client a scheduled dose of digoxin (Lanoxin). Prior to administering the medication, the nurse should assess for which manifestations that could indicate digoxin toxicity? 1.Dyspnea, edema, and palpitations 2.Chest pain, hypotension, and paresthesias 3.Constipation, dry mouth, and sleep disorder 4.Double vision, loss of appetite, and nausea

4 Rationale: Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Other signs of digoxin toxicity include bradycardia, visual alterations (such as green and yellow vision, or seeing spots or halos), confusion, vomiting, diarrhea, decreased libido, and impotence. The other options are incorrect because they do not identify manifestations of digoxin toxicity.

A male client is on enalapril (Vasotec) for the treatment of hypertension. The nurse teaches the client that he should seek emergent care if he experiences which adverse effect? 1.Nausea 2.Insomnia 3.Dry cough 4.Swelling of the tongue

4 Rationale: Enalapril is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side, not adverse effects of the medication

client receives education regarding self-administration of enoxaparin (Lovenox) on discharge to home. The client complains, "I feel as if the health care provider is discharging me too soon if I still have to take injections at home." What is the best nursing response? 1."Are you not happy about going home?" 2."Do you want to stay in the hospital forever?" 3."You'll have to take that up with the health care provider." 4."Research shows that it is best for clients to administer this medication at home rather than stay in the hospital."

4 Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin that can be administered without the usual activated partial thromboplastin time testing that is required with the use of heparin. Options 1 and 2 devalue the client's feelings. Option 3 places the client's feelings on hold.

The nurse is administering a dose of intravenous hydralazine (Apresoline) to a client. The nurse should ensure that which item is in place before injecting the medication? 1.Central line 2.Foley catheter 3.Pulse oximeter 4.Blood pressure cuff

4 Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse should be monitored frequently after administration, so a blood pressure cuff is one of the items to have in place. Options 1, 2, and 3 are not necessary.

Hydrochlorothiazide (HydroDIURIL) has been prescribed for a client. The nurse contacts the health care provider to verify the prescription if which condition is noted in the assessment data? 1.Hypertension 2.Allergy to eggs 3.Nephrotic syndrome 4.Allergy to sulfonamides

4 Rationale: Hydrochlorothiazide is a diuretic and antihypertensive medication that is used to treat mild to moderate hypertension, edema associated with heart failure, and nephrotic syndrome. The medication is a sulfonamide derivative. A contraindication to the use of this medication is a history of hypersensitivity to sulfonamides. The conditions noted in options 1, 2, and 3 are not contraindications for the use of this medication.

A client with angina pectoris has been given a new prescription for nitroglycerin transdermal patches. The client indicates an understanding of how to use this medication administration system by making which statement? 1."I need to wait until the next day to apply a new patch if it falls off." 2."I need to alternate daily dosage times to prevent tolerance to the medication." 3."I need to place the patch in the area of a skin fold to promote better adherence." 4."I need to apply the patch in the morning and leave it in place for 12 to 14 hours as directed."

4 Rationale: Nitroglycerin is a coronary vasodilator used for coronary artery disease. The client should apply a new patch each morning and leave it in place for 12 to 14 hours in accordance with health care provider directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client does not need to wait to apply a new patch if it falls off because the medication is released continuously in small amounts through the skin. The client should avoid placing the patch in skin folds or excoriated areas.

A client with hypertension has begun taking spironolactone (Aldactone). The nurse teaches the client to limit intake of which food? 1.Rice 2.Salad 3.Oatmeal 4.Citrus fruits

4 Rationale: Spironolactone (Aldactone) is a potassium-retaining diuretic that causes hyperkalemia as the principal adverse effect. Clients are instructed to restrict their intake of potassium-rich foods, such as citrus fruits and bananas. The other foods listed are appropriate to include in the diet.

The nurse is working with a client receiving an intravenous heparin sodium drip. The nurse should review which laboratory study to determine the therapeutic effect of heparin for the client? 1.Bleeding time 2.Thrombin time 3.Prothrombin time (PT) 4.Partial thromboplastin time (PTT)

4 Rationale: The PTT will assess the therapeutic effect of heparin, and the PT is one test that will assess for the therapeutic effect of warfarin (Coumadin). Bleeding time and thrombin time are hematological studies that may be prescribed for clients with coagulopathy or other disorders.

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

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

A client is seen in the clinic complaining of anorexia and nausea. The health care provider suspects that the client may be experiencing digoxin toxicity. While waiting for test results to become available, the nurse should assess the client for which sign or symptom that would support a diagnosis of digoxin toxicity? 1.Edema 2.Chest pain 3.Constipation 4.Photophobia

4 Rationale: The most common early manifestations of digoxin toxicity are gastrointestinal disturbances such as anorexia, nausea, and vomiting and neurological disturbances such as fatigue, headache, weakness, drowsiness, confusion, and nightmares. Visual disturbances such as photophobia, light flashes, halos around bright objects, and yellow or green color perception also may occur.

A 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 sodium level of 145 mEq/L 2.Serum chloride level of 98 mEq/L 3.Serum calcium level of 10 mg/dL 4.Serum potassium level of 2.8 mEq/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.

A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), which laboratory result should the nurse review as the priority? 1.Sodium level 2.Digoxin level 3.Creatinine level 4.Potassium level

4 Rationale: The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias

The nurse has a prescription to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the prescription if the client has a history of allergy to which item? 1.Iodine 2.Shellfish 3.Penicillin 4.Sulfa drugs

4 Rationale: Thiazide diuretics, such as hydrochlorothiazide, are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. A sulfa allergy must be communicated to the pharmacist, health care provider, nurse, and other health care providers. The other options are not contraindications for administering the medication.

Atenolol (Tenormin) 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 β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-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.

A nurse is collecting data from a client and notes that the client is taking atenolol (Tenormin). What has this medication been prescribed to treat? 1.Hypertension 2.Ulcerative colitis 3.Rheumatoid arthritis 4.Second-degree heart block

1 Rationale: Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It is used to treat conditions such as hypertension and angina pectoris. It is not used to treat the conditions noted in options 2, 3, and 4. Additionally, its use is contraindicated in the client with heart block greater than first degree.

A hospitalized client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin, gr 1/4 sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure remains stable, the nurse should take which action next? 1.Administer another nitroglycerin tablet. 2.Administer 10 L of oxygen via nasal cannula. 3.Call for a 12-lead electrocardiogram (ECG) to be performed. 4.Wait an additional 5 minutes, and then give a second nitroglycerin tablet.

1 Rationale: Nitroglycerin tablets are usually prescribed one every 5 minutes PRN for chest pain for the hospitalized client, up to a total dose of three tablets. The nurse should administer the second tablet. The client with known angina pectoris should have low-flow oxygen at a rate of 1 to 3 L/min via nasal cannula. A 12-lead ECG would be done if prescribed by standing protocol or by individual health care provider prescription.

The health care provider (HCP) writes a prescription for atenolol (Tenormin) for a client who was admitted to the hospital. The nurse contacts the HCP to verify the prescription if which finding is noted in the assessment data? 1.Temperature is 100.1° F. 2.Apical heart rate is 48 beats/min. 3.Blood pressure is 138/82 mm Hg. 4.Pedal pulses are bounding and strong.

2 Rationale: Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. Contraindications to the medication include severe bradycardia, cardiac failure, cardiogenic shock, and heart block greater than first degree. Options 1, 3, and 4 are not contraindications to this medication.

Atenolol (Tenormin) has been prescribed for a hospitalized client. The nurse should check which item before administering this medication? 1.Pedal pulses 2.Apical heart rate 3.Most recent potassium level 4.Most recent electrolyte levels

2 Rationale: Atenolol is a β-adrenergic blocker that is used as an antihypertensive, antianginal, and antidysrhythmic. It blocks β-adrenergic receptors in cardiac tissue and produces the therapeutic effects of slowing the heart rate, decreasing cardiac output, decreasing blood pressure, and decreasing myocardial oxygen demand. The nurse should check the client's apical heart rate and blood pressure immediately before administering the medication. If the heart rate is 60 beats/min or lower or if the systolic blood pressure is less than 90 mm Hg, the medication is withheld and the health care provider is contacted. Options 1, 3, and 4 are unrelated to the administration of this medication.

A client with heart disease is taking digoxin (Lanoxin) and complains of having no appetite, and experiencing diarrhea and blurry vision. The nurse notes that the client's serum potassium (K) level is 3.0 mEq/L. Based on analysis of the data, what might the nurse expect to note when reviewing the digoxin level results? 1.Digoxin level of 1.8 ng/mL 2.Digoxin level higher than 2 ng/mL 3.Digoxin level lower than 0.5 ng/mL 4.Digoxin level of 0 ng/mL because of diarrhea

2 Rationale: When a client is taking digoxin, digoxin toxicity is a concern. The therapeutic digoxin level is 0.5 to 2 ng/mL. Anorexia, diarrhea, and visual disturbances are symptoms of digoxin toxicity. In addition, a low serum potassium level potentiates the risk for digoxin toxicity. This client's potassium level is low at 3.0 mEq/L. The client's complaints are indicative of digoxin toxicity. Therefore the only correct choice is option 2.

The home care nurse instructs a client on how to administer enoxaparin (Lovenox) subcutaneously. Which statement, if made by the client, indicates an understanding of how to administer this medication? 1."I need to hold my skin flat before I put the needle into my skin." 2."I need to massage the skin with the alcohol wipe after I give the injection." 3."A syringe that has a small ⅝-inch needle is used to administer the injection." 4."I need to pull back on the syringe and aspirate before pushing the medication into my skin."

3 Rationale: A subcutaneous injection of enoxaparin is performed using the same technique as for a heparin injection. The client should use a 25- to 27-gauge, ⅝-inch needle to prevent hematoma formation at the injection site. The client should be taught to bunch the skin rather than placing it flat. The client should not aspirate before injecting the medication and should not massage the area after injection.

The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication? 1.Blood urea nitrogen 2.Cholesterol level 3.Potassium level 4.Creatinine level

3 Rationale: Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication.

A client receiving total parenteral nutrition (TPN) has a history of heart failure. The health care provider has prescribed furosemide (Lasix) 40 mg by mouth daily to prevent fluid overload. Which laboratory value should the nurse monitor to identify the presence of an adverse effect from this medication? 1.Sodium 2.Glucose 3.Potassium 4.Magnesium

3 Rationale: Furosemide is a potassium-losing diuretic, and insufficient replacement of potassium may lead to hypokalemia. Although the sodium, glucose, and magnesium levels may be monitored, these laboratory values are not specific to administering furosemide.

The nurse has been given a medication prescription to administer intravenous (IV) hydralazine (Apresoline). The nurse obtains which priority piece of equipment needed for use during administration of this medication? 1.Pulse oximetry 2.Cardiac monitor 3.Noninvasive blood pressure cuff 4.Nonrebreather oxygen face mask

3 Rationale: Hydralazine is an antihypertensive medication used for moderate to severe hypertension. Because the blood pressure and pulse should be monitored frequently after administration, a noninvasive blood pressure cuff should be obtained. The other options are not priority items specific to the use of this medication.

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

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

Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL; serum magnesium, 1.2 mg/dL; serum potassium, 4.1 mEq/L; serum creatinine, 0.9 mg/dL. Which result should alert the nurse that the client is at risk for digoxin toxicity? 1.Serum calcium level 2.Serum potassium level 3.Serum creatinine level 4.Serum magnesium level

4 Rationale: An increased risk of toxicity exists in clients with hypercalcemia, hypokalemia, hypomagnesemia, hypothyroidism, and impaired renal function. The calcium, creatinine, and potassium levels are all within normal limits. The normal range for magnesium is 1.6 to 2.6 mg/dL and the results in the correct option are reflective of hypomagnesemia

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

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

A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action? 1.Withhold the medication. 2.Administer the medication. 3.Double-check the apical heart rate and administer the medication. 4.Check the blood pressure and respirations and administer the medication.

1 Rationale: Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider. Therefore, options 2, 3, and 4 are incorrect actions; it would be harmful to administer the medication.

A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter? 1.Limiting both movement and abduction of the left arm 2.Limiting both movement and abduction of the right arm 3.Assisting the client to get out of bed and ambulate with a walker 4.Having the physical therapist do active range-of-motion exercises to the right arm

2 Rationale: In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Therefore, options 1, 3, and 4 are incorrect.

The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

2 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.

Which locations is the correct position for the V1 lead when performing a 12-lead electrocardiogram? 1.Fourth intercostal space left sternal border 2.Fourth intercostal space right sternal border 3.Fifth intercostal space left midaxillary line 4.Fifth intercostal space left midclavicular line

2 Rationale: The correct location for the V1 electrode is the fourth intercostal space right sternal border. Therefore, options 1, 3, and 4 are incorrect.

A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse should respond with which statement? 1."The work of breathing is increased when the client is anemic." 2."Blood flows more slowly when the hemoglobin or hematocrit is low." 3."The body has to work harder to fight infection in the presence of anemia." 4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."

4 Rationale: Oxygen is required to meet the metabolic needs of the body. With decreased hemoglobin, such as in iron deficiency anemia, the oxygen-carrying capacity of the blood is less than normal. The client feels the effects of this change as fatigue. Options 1, 2, and 3 are incorrect.

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse most 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, presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.

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

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

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

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

The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1.Pallor 2.Hyperactivity 3.Exercise intolerance 4.Gastrointestinal disturbances

3 Rationale: Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

A 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 who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. A nurse exercising nearby is correct when the nurse cautions him to check the pulse on only one side, primarily for which reason? 1.It is unnecessary to use both hands. 2.The client could occlude the trachea. 3.The heart rate and blood pressure could drop. 4.Feeling dual pulsations may lead to an incorrect measurement.

3Rationale: Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope. Although the information in options 1, 2, and 4 may be correct, these are not the primary reasons

A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? 1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure

4 Rationale: Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, options 1, 2, and 3 are incorrect.

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

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

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 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 options 2, 3, and 4 are correct statements.

A client with myocardial infarction is experiencing new, multiform premature ventricular contractions (PVCs). Knowing that the client is allergic to lidocaine hydrochloride, the nurse plans to have which medication available for immediate use? 1.Procainamide 2.Digoxin (Lanoxin) 3.Verapamil (Calan SR) 4.Metoprolol (Lopressor)

1 Rationale: Procainamide is an antidysrhythmic that may be used to treat ventricular dysrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac glycoside; verapamil is a calcium-channel blocking agent; metoprolol is a β-adrenergic blocking agent.

nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by which problem? 1.Chronic fatigue 2.Poor oxygenation 3.Poor sucking ability 4.Consistent sucking on the fingers

2 Rationale: The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. Options 1, 3, and 4 are unrelated to this occurrence.

The postmyocardial 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 Foley 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 Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore allergies to iodine and shellfish are not a concern.

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. The nurse should plan to allow for which client activity? 1.Strict bed rest for 24 hours after transfer 2.Bathroom privileges and self-care activities 3.Ad lib activities because the client is monitored 4. Unsupervised hallway ambulation with distances under 200 feet

2 Rationale: On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Strict bedrest is unnecessary and can be harmful and promote emboli. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/min. 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 interpret this rhythm? 1.Sinus tachycardia 2.Sinus dysrhythmia 3.Sinus bradycardia 4.Normal sinus rhythm

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

2 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.