Week 2

The healthcare provider orders mannitol 72 gm infusion over 24 hours. The nurse plans to set the infusion pump for how many grams per hour? 1 gm 2 gm 3 gm 4 gm

3 gm

Match the terms and descriptors: Amount of blood pumped out of the heart in 1 minute.

A. Cardiac Output.

14. A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?

Administers bisphosphonates as prescribed.

Match the terms and descriptors: Force that returns blood to the heart.

C. Systemic Filling Pressure.

A patient has reported a 2-kg (4.4-lb) weight gain over the past 3 days. Which factor should the nurse question? a. Protein intake b. Potassium intake c. Calorie intake d. Sodium intake

D Sodium intake

Match the terms and descriptors: Force with which the ventricles of the heart contract.

D. Stroke Volume.

A patient has received a medication that constricts the blood vessels. What effect will this have on the blood pressure? Will decrease Will be elevated Will stay the same Will fluctuate wildly

Will be elevated

Which patient would the nurse expect to have the highest risk for postural hypotension? A.A patient who is prescribed a drug that acts primarily on the arterioles B.A patient who is prescribed a drug that blocks the renin-angiotensin-aldosterone system C.A patient who is prescribed a drug that triggers the baroreceptor reflex D.A patient who is prescribed a drug that promotes venous vasodilation

•Answer: D D.A patient who is prescribed a drug that promotes venous vasodilation •Rationale: Postural (orthostatic) hypotension is caused by decreased venous return as a result of the pooling of blood in the veins, which can occur when a person assumes an erect posture. Drugs that dilate the veins intensify and prolong postural hypotension.

The nurse is teaching a group of nursing students about beta blockers. Which statement indicates a correct understanding? "Beta blockers increase myocardial contractility" "Beta blockers increase the patient's urine output" "Beta blockers increase dilation of the peripheral vessels" "Beta blockers decrease sympathetic stimulation of the heart"

"Beta blockers decrease sympathetic stimulation of the heart"

An unlicensed assistive personnel asks the nurse how the blood gets back to the heart. How should the nurse respond? "By way of two-way valves" "By way of the venous pump" "By way of dilation in the venous walls" "By way of the positive pressure in the right atrium"

"By way of the venous pump"

8. A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching?

"Call your primary health care provider for diarrhea."

After being taught about digoxin, which statement from the staff indicates more teaching is needed? "Digoxin has a positive inotropic effect" "Digoxin is a first-line drug for heart failure" "Digoxin when used by women may actually shorten life" "Digoxin can help with heart failure, but it does not prolong life"

"Digoxin is a first-line drug for heart failure"

The nurse is teaching a patient who has a new prescription for spironolactone [Aldactone]. Which statement by the patient indicates that the teaching was effective? "I will use salt substitutes to lower my sodium intake." "I will increase my intake of foods that are high in potassium." "I will call my doctor if I begin having menstrual irregularities." "I will take this medication at bedtime each evening."

"I will call my doctor if I begin having menstrual irregularities."

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching?

"I will weigh myself each morning before I eat or drink."

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply.

-Blood pressure -Pulse rate and quality -Urine output

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply.

-Calcium -Potassium

6. A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.)

-Calculate pulse pressure with each blood pressure reading. -Assess for pitting edema in dependent body areas. -Monitor trends in the client's daily weights. -Assist the client to change positions frequently. -Teach client and family how to read food labels for sodium.

7. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.)

-Hyperkalemia—salt substitutes -Hyponatremia—heart failure -Hypernatremia—hyperaldosteronism -Hypocalcemia—diarrhea -Hypokalemia—loop diuretics

4. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)

-Hypokalemia—muscle weakness with respiratory depression -Hypermagnesemia—bradycardia and hypotension -Hyponatremia—decreased level of consciousness -Hypomagnesemia—hyperactive deep tendon reflexes -Hypernatremia—weak peripheral pulses

1. A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.)

-Increased pulse rate -Distended neck veins -Skeletal muscle weakness -Visual disturbances

8. A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.)

-Potassium: 5.4 mEq/L (mmol/L): Dehydration -Osmolarity: 250 mOsm/L: Overhydration -Hematocrit: 68%: Dehydration -Magnesium: 0.8 mg/dL: Dehydration

3. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.)

-Reports of palpitations -Skeletal muscle weakness -Tall, peaked T waves on ECG

2. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.)

-Serum potassium level of 5.4 mEq/L (5.4 mmol/L) -Blood osmolality of 250 mOsm/kg (250 mmol/L)

5. After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.)

-Strong productive cough -Active bowel sounds

ANS: A Heart rate of 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.

1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: D Allergies to iodine-based agents Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.

10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: B Notify the primary health care provider before scheduling the MRI. The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but the nurse needs to notify the primary health care provider.

11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the primary health care provider before scheduling the MRI. c. Request lab for cardiac enzymes from the primary health care provider. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: A Compare the results with previous blood pressure readings. The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This client's blood pressure is at the upper range of acceptable, so the nurse would compare the client's current reading with those previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.

12. A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client's chart as the only action.

ANS: B Initiation of an external pacemaker The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.

13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

Sodium normal range

136-145 mEq/L

ANS: B "You should balance weight loss with consuming necessary nutrients." Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour?

15 mEq (mmol)

ANS: D "Use pillows to elevate your head and chest while you are sleeping." The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

15. A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response? a. "I will consult your primary health care provider to prescribe a sleep study." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."

ANS: C "What do you understand about what happened to you?" Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain. KEY: Coronary perfusion, Coping

16. A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The primary health care provider has prescribed an antacid every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"

The physician has ordered 1000 mL of D5NS to infuse over 6 hours. The IV tubing has a drop factor of 10 gtts/min. Calculate the flow rate in cc/mL and gtts/min. Round to the nearest whole number for each calculation: ___________ mL/hr; ___________ gtts/min

167 28

ANS: C "Tell me more about your concerns about the test." The nurse would discuss the client's feelings and concerns related to the cardiac catheterization. The nurse would not provide false hope or push the client's concerns off on the chaplain. The nurse would address support systems after addressing the client's current issue. KEY: Diagnostic examination, Anxiety

17. A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine test and the risk of death is very low." b. "Would you like to speak with a chaplain prior to test?" c. "Tell me more about your concerns about the test." d. "What support systems do you have to assist you?"

At 0900, the nurse hangs an IV of 1000 mL D5LR to infuse at 125 mL/hr. What time will the nurse need to hang a new bag of IV fluid? Provide your answer in military time: _____ hours.

1700

The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process? A) Diffusion B) Osmosis C) Active transport D) Filtration

A Diffusion

ANS: D Client who describes intense squeezing pressure across the chest. All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client 's chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction.

18. An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.

ANS: A Location A The aortic valve is auscultated in the second intercostal space just to the right of the sternum. The pulmonic valve would be heard in location B located in the second intercostal space just left of the sternum. The mitral valve would be heard in location D located in the fifth intercostal space at the apex of the heart. The tricuspid valve would be heard in location C located in the fifth intercostal space at the lower left of the sternal border.

19. A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

The healthcare provider orders furosemide [Lasix] 20 mg IV twice daily. The medication available is furosemide [Lasix] 10 mg/mL. How many mL will the nurse administer with each dose? 0.5 mL 1 mL 2 mL 4 mL

2 mL

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain

A Diminished deep tendon reflexes

ANS: D Pulse decreased from 100 to 80 beats/min. Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and better cardiac output.

2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min.

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia?

22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

In reviewing a patient's laboratory results, the nurse determines that the serum osmolality is within normal limits if the value is what? 198 mOsm/kg 238 mOsm/kg 287 mOsm/kg 327 mOsm/kg

287 mOsm/kg Normal serum osmolality is between 280 and 300 mOsm, with sodium the primary electrolyte involved in the determination of serum osmolality.

What would the nurse calculate the cardiac output to be when the client's heart rate is 68 beats/min and the stroke volume is 50 mL? A. 3400 L/min B. 4000 L/min C. 4400 L/min D. 4800 L/min

A 3400 L/min Cardiac output (CO), is the amount of blood pumped from the left ventricle each minute. CO depends on the relationship between heart rate (HR) and stroke volume (SV); it is the product of these two variables: CO = SV X HR i.e., 50 X 68 = 3400 mL/min.

The nurse correlates changes in peripheral resistance with constriction or dilation of what? A) Arterioles B) Arteries C) Venules D) Veins

A) Arterioles Changes in peripheral resistance are primarily determined by arterioles as opposed to arteries, veins, or venules.

A 58-year-old female with a family history of CAD is being seen for her annual physical exam. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. Which is the best response by the nurse? 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." 2. "The triglycerides are elevated and will not return to normal without these medications." 3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." 4. "The medications are not indicated since your lab values are all normal."

3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered." CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke.

ANS: C A 65-year-old woman with diabetes mellitus. Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease.

3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.

If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the old behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior

3. Rewarding the client whenever the acceptable behavior is performed. A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

Potassium normal range

3.5-5.0 mEq/L

ANS: C Assess the client's medications. Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.

4. A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.

The nurse prepares to infuse which intravenous solution in the patient with hypertonic dehydration? 0.9% normal saline Lactated Ringer's 3% sodium chloride 5% dextrose in water

5% dextrose in water Patients with hypertonic dehydration (contraction) have a higher solute-to-water ratio. The administration of a hypotonic fluid is indicated, and 5% dextrose in water is the only hypotonic fluid listed here. Normal saline at 0.9% and lactated Ringer's solution are isotonic, whereas 3% sodium chloride is hypertonic.

ANS: A "I get short of breath when I climb stairs." Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

5. An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."

ANS: B "My shoes fit tighter by the end of the day." Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

6. A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

ANS: C Fatigue and shortness of breath In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI.

7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm

A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

A Client with pancreatitis who has continuous nasogastric suctioning

ANS: C Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.

8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."

ANS: C Slurred speech and confusion A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.

9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."

A "Please roll onto your left side."

Which of the following is considered a first-line intravenous solution for a patient with hypovolemia? a) 0.9% NaCl (normal saline) b) 0.45% NaCl (½ normal saline) c) Dextran (a plasma expander) d) D5W (5% dextrose in water)

A 0.9% NaCl (normal saline)

Which client will the nurse consider to be at greatest risk for dehydration? a. A 75-year-old woman with chronic back pain b. A 25-year-old woman taking oral contraceptives c. A 75-year-old man who has a vitamin deficiency d. A 25-year-old man who has frequent esophageal reflux

A A 75-year-old woman with chronic back pain

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

A Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg

Which of the following would the nurse expect to be included in the plan of care for a patient receiving total parenteral nutrition (TPN)? a. Blood sugar levels are checked on a routine basis b. Maintaining NPO status c. Hourly urine output d. Vital signs every 4 hours

A Blood sugar levels are checked on a routine basis

Which assessment is most important for the nurse to perform on a client whose serum potassium level is 2.0 mEq/L (mmol/L)? a. Checking pulse oximetry b. Measuring blood pressure c. Listening to bowel sounds in all four quadrants d. Observing the ECG for flat T-waves

A Checking pulse oximetry

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders? A) Cimetidine B) Maalox C) Potassium chloride elixir D) Furosemide

A Cimetidine

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

A Depth of respirations

An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient's chart. Which laboratory value causes the nurse the most concern? a. Elevated creatinine clearance b. Elevated serum potassium level c. Normal blood glucose level d. Low levels of low-density lipoprotein (LDL) cholesterol

A Elevated creatinine clearance Hydrochlorothiazide should not be given to patients with severe renal impairment; therefore, an elevated creatinine clearance would cause the most concern. Thiazide diuretics are potassium-wasting drugs and thus may actually improve the patient's potassium level. Thiazides may elevate the serum glucose level in diabetic patients. Thiazides increase LDL cholesterol; however, this patient's levels are low, so this is not a risk.

You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration? A) Extravasation of the medication B) Discomfort to the patient C) Blanching at the site D) Hypersensitivity reaction to the medication

A Extravasation of the medication

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? a. Furosemide [Lasix] b. Hydrochlorothiazide [HydroDIURIL] c. Mannitol [Osmitrol] d. Spironolactone [Aldactone]

A Furosemide [Lasix] Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows severe signs of congestive heart failure with respiratory distress and pulmonary edema and needs immediate mobilization of fluid. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because their diuretic effects are less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur.

patient is brought to the emergency department (ED) by paramedics after a bystander saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP, 138/84 mm Hg; pulse, 135 beats/min, regular and strong; respiratory rate, 22 breaths/min; temperature, 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect? a) Hypomagnesemia b) Hyypocalcemia c) Hyperkalemia d) Hypernatremia

A Hypomagnesemia

You are the nurse evaluating a newly admitted patient's laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)? A) Increased serum sodium B) Decreased serum potassium C) Decreased hemoglobin D) Increased platelets

A Increased serum sodium

Which body fluid lies in the spaces between the body cells? a) Interstitial b) Intracellular c) Intravascular d) Transcellular

A Interstitial

The student nurse is reviewing a patient's laboratory reports. Which of the following results should be reported to the primary care provider? a) Na+ = 126 mEq/L b) K+ = 3.8 mEq/L c) Ca2+ = 9.2 mg/dL d) Mg2+ = 1.8 mg/dL

A Na+ = 126 mEq/L

A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously? A) Never, because it rapidly enters red blood cells, causing them to rupture. B) When the patient is severely dehydrated resulting in neurologic signs and symptoms C) When the patient is in excess of calcium and/or magnesium ions D) When a patients fluid volume deficit is due to acute or chronic renal failure

A Never, because it rapidly enters red blood cells, causing them to rupture.

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period? a. Plasma volume osmolarity increases; blood pressure increases b. Plasma volume osmolarity decreases; blood pressure increases c. Plasma volume osmolarity increases; blood pressure decreases d. Plasma volume osmolarity decreases; blood pressure decreases

A Plasma volume osmolarity increases; blood pressure increases

Which sign or symptom indicates to the nurse that treatment for a client's hypokalemia is effective? a. Reports having a bowel movement daily. b. ECG shows an inverted T wave. c.Fasting blood glucose level is 106 mg/dL. d. Two lb weight gain during the past week.

A Reports having a bowel movement daily.

The nurse has begun an infusion of fresh frozen plasma (FFP). Which symptom indicates an allergic reaction to the FFP? a. Respirations: 30/min b. Urine output: 50 mL/hr c. Heart rate: 62 beats/min d. Temperature: 39 C (102.2 F)

A Respirations: 30/min

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. Anarterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg,HCO3 = 24 mm Hg. What does the ABG reflect? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Metabolic acidosis

A Respiratory acidosis

Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia? a. Shortened QT-interval b. Absent P wave c. Prominent U wave d, Inverted T waves

A Shortened QT-interval

You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patient's labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults? A) Substantially reduced renal function B) Acute kidney injury C) Decreased cardiac output D) Alterations in ratio of body fluids to muscle mass

A Substantially reduced renal function

Which activity is important to include in the plan of care for a client with a peripherally inserted central catheter (PICC)? a. Use sterile technique when changing the PICC dressing. b. Change the IV tubing every 72 hours. c. Take blood pressure in the arm with the PICC line. d. Use only macrodrip tubing with IV infusions through the PICC line.

A Use sterile technique when changing the PICC dressing.

A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol [Osmitrol]. The nurse knows that this is given to: a. reduce intracranial pressure. b. reduce renal perfusion. c. reduce peripheral edema. d. restore extracellular fluid.

A reduce intracranial pressure. Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid from the brain into the blood. Mannitol can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid.

Before administering which class of drugs would the nurse always check the client's heart rate? A. Beta blockers B. Diuretics C. Anticoagulants D. Nonsteroidal anti-inflammatories

A Beta blockers An increase in circulating catecholamines (e.g., epinephrine and norepinephrine) usually causes an increase in HR and contractility. Many cardiovascular drugs, particularly beta blockers, block this sympathetic (fight or flight) pattern by decreasing the HR. The nurse would check to be sure that the heart rate was not too slow before administering a beta blocker.

Which is the most common and normal response by a client to a cardiovascular illness? A. Denial B. Fear C. Loss of control D. Depression

A Denial A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the inter-disciplinary plan of care.

Which statement best describes the functional capability of a client who is categorized as New York Heart Association Class II? A. Ordinary physical activity results in fatigue, palpitations, dyspnea, and anginal pain. B. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. C. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain. D. If any physical activity is undertaken, discomfort is increased.

A Ordinary physical activity results in fatigue, palpitations, dyspnea, and anginal pain. With regard to physical activity, the New York Heart Association Functional Classification of Cardiovascular Disability describes the four classes as follows: Class I, ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain; Class II, ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain; Class III, less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain; and Class IV, if any physical activity is undertaken, dis-comfort is increased.

What is the best technique for assessing a client's right lower leg for arterial insufficiency? A. Palpate the peripheral arteries using a head-to-toe approach with side-to side comparison. B. Check all pulse points in the right leg in dependent and supine positions. C. Palpate the major arteries including the femoral, and observe for pallor. D. Use a Doppler to find the dorsalis pedis and posterior tibial pulses in the right leg.

A Palpate the peripheral arteries using a head-to-toe approach with side-to side comparison. Assessment of arterial pulses provides information about vascular integrity and circulation. For clients with suspected or actual vascular disease, major peripheral pulses should be assessed for presence or absence, amplitude, con-tour, rhythm, rate, and equality. Palpate the peripheral arteries in a head-to-toe approach with a side-to-side comparison.

Which client has an abnormal heart sound? A. S3 in a 54-year-old B. S1 in a 45-year-old C. S2 in a 38-year-old D. S3 in a 25-year-old

A S3 in a 54-year-old An S3 gallop in clients older than 35 years is considered abnormal and represents a decrease in left ventricular compliance. It can be detected as an early sign of heart failure or as a ventricular septal defect. An S3 heart sound is most likely to be a normal finding in those younger than 35 years. S1 and S2 are both nor-mal heart sounds.

Which laboratory value test elevation does the nurse consider most significant in the diagnosis of a client's myocardial infarction (MI)? A. Troponin T and I B. Myoglobin C. Highly sensitive C-reactive protein D. Creatinine kinase MB

A Troponin T and I Troponin is a myocardial muscle protein re-leased into the bloodstream with injury to myocardial muscle. Troponins T and I are not found in healthy clients, so any rise in values indicates cardiac necrosis or acute MI. Before the development of highly sensitive troponin levels, providers relied on creatinine kinase (CK), its isoenzyme (CK-MB), and myoglobin to assist with diagnosis of acute myocardial infarction. Highly sensitive C-reactive protein (hsCRP) has been the most studied marker of inflammation.

7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?

A 34 year old who is NPO and receiving rapid intravenous DW5 infusions

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?

A 76 year old who is cognitively impaired.

The nurse correlates which hemodynamic effect with the release of natriuretic peptides? A) Decreased preload B) Decreased afterload C) Increased peripheral resistance D) Increased vascular permeability

A) Decreased preload Natriuretic peptides decrease blood volume (through the action of aldosterone) and increase venous capacitance. Both of these actions result in reduced preload.

The nurse should notify the healthcare provider immediately about which patient? A patient who takes digoxin [Lanoxin] 0.125 mg orally daily with a serum digoxin level of 0.8 ng/mL A patient who takes digoxin [Lanoxin] 0.25 mg orally daily with a serum potassium level of 4.0 mEq/L A patient who takes oral lisinopril [Zestril] 5 mg daily and digoxin [Lanoxin] 0.125 mg daily with a serum digoxin level of 0.5 ng/mL A patient who takes oral spironolactone [Aldactone] 25 mg daily and enalapril [Vasotec] 5 mg daily with a serum potassium level of 5.5 mEq/L

A patient who takes oral spironolactone [Aldactone] 25 mg daily and enalapril [Vasotec] 5 mg daily with a serum potassium level of 5.5 mEq/L

The nurse recognizes that sympathetic tone to the heart results in what? A) Increased heart rate B) Increased vasodilation C) Decreased cardiac output D) Decreased peripheral resistance

A) Increased heart rate Sympathetic innervation results in increased heart rate and myocardial contractility. Parasympathetic stimulation results in decreased heart rate and reduced cardiac output.

Which American Heart Association guidelines would the nurse teach a client to fight obesity and improve cardiovascular health? Select all that apply. A. Don't consume more calories than you can use in a day. B. Consume foods that contain vitamins, minerals, and fiber. C. Choose foods that are healthy and low in calories. D. Avoid gas-producing vegetables such as cabbage or broccoli. E. Eat vegetables, fruit, and whole-grain foods. F. For calcium, choose whole milk dairy products.

A, B, C, E A. Don't consume more calories than you can use in a day. B. Consume foods that contain vitamins, minerals, and fiber. C. Choose foods that are healthy and low in calories. E. Eat vegetables, fruit, and whole-grain foods. The American Heart Association provides guidelines to combat obesity and improve car-diac health, including ingesting more nutrient-rich foods that have vitamins, minerals, fiber, and other nutrients but are low in calories. To get the necessary nutrients, teach clients to choose foods such as vegetables, fruits, unre-fined whole-grain products, and fat-free (not whole milk) dairy products most often. Also teach clients to not eat more calories than they can burn every day. Vegetables such as cabbage and broccoli are good sources of nutrients.

The nurse is reassessing a patient 1 hour after administering a vasodilator to treat hypertension. Assessment findings include BP 116/70 mm Hg (down from 145/88 mm Hg), pulse 88 (up from 80 beats/min), and respirations 22 (up from 20). What should the nurse do? (Select all that apply.) A. Continue collecting additional assessment data. B. Document the findings. C. Explain orthostatic BP precautions. D. Page the prescriber STAT. E. Raise all four bed side rails for safety. F. Reassess the vital signs within 1 hour.

A, B, C, F. A. Continue collecting additional assessment data. B. Document the findings. C. Explain orthostatic BP precautions. F. Reassess the vital signs within 1 hour.

Drugs that can be used to lower BP decrease venous resistance by doing what? (Select all that apply.) A. Dilating veins. B. Reducing right arterial pressure. C. Reducing volume of blood. D. Stimulating auxiliary muscle pumps.

A, B, C. A. Dilating veins. B. Reducing right arterial pressure. C. Reducing volume of blood.

Which techniques would the medical/surgical nurse use when inspecting a client's precordium? Select all that apply. A. Look at the chest from the side, at a right angle, and downward over areas of the precordium where vibrations are visible. B. Note any movement over the aortic, pulmonic, and tricuspid areas. C. Use percussion over the heart area to determine its size. D. Observe for the location of the point of maximal impulse (PMI) and note any shift. E. Palpate the areas over the aortic, pulmonic, and tricuspid valves. F. Listen to the heart sounds in a systematic order.

A, B, D A. Look at the chest from the side, at a right angle, and downward over areas of the precordium where vibrations are visible. B. Note any movement over the aortic, pulmonic, and tricuspid areas. D. Observe for the location of the point of maximal impulse (PMI) and note any shift. Inspect the chest from the side, at a right angle, and downward over areas of the precordium where vibrations are visible. Cardiac motion is of low amplitude, and sometimes the inward movements are more easily detected by the naked eye. Note any prominent pulses. Movement over the aortic, pulmonic, and tricuspid areas is abnormal. Pulses in the mitral area (the apex of the heart) are considered normal and are referred to as the apical impulse, or the point of maximal impulse (PMI). The PMI should be located at the left fifth intercostal space (ICS) in the midclavicular line. If it appears in more than one ICS and has shifted lateral to the mid-clavicular line, the client may have left ventricular hypertrophy. Palpation and percussion are usually not performed by medical/surgical nurses. Listening to the heart sounds would be part of auscultation assessment.

Which instructions would the nurse give the LVN/LPN monitoring a client after cardiac catheterization by radial artery approach? Select all that apply. A. Monitor the client's vital signs every 15 minutes for 1 hour. B. Assess the insertion site for bloody drainage or hematoma. C. Keep the client in bed for at least 6 hours. D. Assess peripheral pulses and skin temperature and color with every vital sign check. E. Monitor intake and output. F. Provide oral fluids for adequate contrast excretion.

A, B, D, E, F A. Monitor the client's vital signs every 15 minutes for 1 hour. B. Assess the insertion site for bloody drainage or hematoma. D. Assess peripheral pulses and skin temperature and color with every vital sign check. E. Monitor intake and output. F. Provide oral fluids for adequate contrast excretion. All options except C are correct for safe recovery of the client after a cardiac catheterization. Keeping the client in bed for more than 2 hours is not necessary when the radial approach is used for the test.

Which assessment data would the nurse expect for a client diagnosed with angina? Select all that apply. A. Pain relieved at rest B. Sudden onset of pain C. Intermittent pain relieved by sitting upright D. Substernal pain that may spread across chest, back, and arms E. Sharp, stabbing pain that is moderate to severe F. Pain that usually lasts less than 15 minutes

A, B, D, F A. Pain relieved at rest B. Sudden onset of pain D. Substernal pain that may spread across chest, back, and arms F. Pain that usually lasts less than 15 minutes Angina pain is usually sudden in onset, in response to exertion, emotion, or extremes in temperature. It is usually located on the left side of chest without radiation but can be substernal and may spread across the chest and the back and/or down the arms. It usually lasts less than 15 minutes and is relieved with rest, nitrate administration, or oxygen therapy. See Table 30.1 in the text.

Besides having diuretic effects for patients with congestive heart failure, thiazides are also used to treat what? (Select all that apply.) a. Diabetes insipidus b. Hepatic failure c. Increased intracranial pressure d. Intraocular pressure e. Postmenopausal osteoporosis

A, B, E a. Diabetes insipidus b. Hepatic failure e. Postmenopausal osteoporosis Thiazide diuretics have the paradoxical effect of reducing urine output in patients with diabetes insipidus. They can also be used to mobilize edema associated with liver disease. They promote tubular reabsorption of calcium, which may reduce the risk of osteoporosis in postmenopausal women. Mannitol is used to treat edema that causes increased intracranial pressure and intraocular pressure.

Match the terms and descriptors: Where stimulation of heartbeat originates.

J. Sinoatrial Node.

Which cardiovascular assessment changes would the nurse expect in an older client? Select all that apply. A. Presence of murmurs B. Atrial dysrhythmias C. Fewer premature ventricular contractions D. Very short QT interval on ECG E. Increased dizziness F. Positive orthostatic blood pressure

A, B, E, F A. Presence of murmurs B. Atrial dysrhythmias E. Increased dizziness F. Positive orthostatic blood pressure Calcification of heart valves can cause murmurs. Pacemaker cells decrease in number which can lead to atrial dysrhythmias and in-creased (not fewer) premature ventricular con-tractions. The size of the left ventricle increases which can lead to widened QRS complexes and longer (not shorter) QT intervals. Baroreceptors become less sensitive which can lead to positive orthostatic blood pressure and dizziness as well as fainting.

What possible causes would the nurse consider when assessing a client and finding a hyperkinetic pulse? Select all that apply. A. Sepsis B. Sedentary lifestyle C. Pain D. Fever E. Anxiety F. Thyrotoxicosis

A, C, D, E, F A. Sepsis C. Pain D. Fever E. Anxiety F. Thyrotoxicosis A hyperkinetic pulse is a large, "bounding" pulse caused by an increased ejection of blood. It occurs in clients with a high cardiac output (e.g., with exercise [not sedentary], sepsis, or thyrotoxicosis) and in those with increased sympathetic system activity (e.g., with pain, fever, or anxiety).

Which may be causes of a client's pericardial friction rub? Select all that apply. A. Myocardial infarction B. Pulmonary edema C. Cardiac tamponade D. Infection E. Inflammation F. Thoracotomy

A, C, D, E, F A. Myocardial infarction C. Cardiac tamponade D. Infection E. Inflammation F. Thoracotomy A pericardial friction rub originates from the pericardial sac and occurs with the movements of the heart during the cardiac cycle. They are usually transient and are a sign of inflammation, infection, or infiltration. They may be heard in clients with pericarditis resulting from MI, cardiac tamponade, or post-thoracotomy. Pulmonary edema is not a cause of a pericardial friction rub.

Which mechanisms regulate and mediate blood pressure? Select all that apply. A. Kidneys B. Gastrointestinal system C. Autonomic nervous system D. Respiratory system E. Endocrine system F. Carbon dioxide elimination

A, C, E A. Kidneys C. Autonomic nervous system E. Endocrine system The three mechanisms that regulate and mediate blood pressure: the autonomic nervous system (ANS), which excites or inhibits sympathetic nervous system activity in response to impulses from chemoreceptors and baroreceptors; the kidneys, which sense a change in blood flow and activate the renin-angiotensin-aldosterone mechanism; and the endocrine system, which releases various hormones (e.g., catecholamine, kinins, serotonin, histamine) to stimulate the sympathetic nervous system at the tissue level.

Which statements about intravascular ultrasonography (IVUS) are accurate? Select all that apply. A. A flexible catheter with a miniature transducer is introduced at the distal tip to view the coronary arteries. B. Injection of a contrast dye through a catheter permits viewing the coronary arteries. C. The catheter has a transducer which emits sound waves that reflect off the plaque and the arterial wall to create an image of the blood vessel. D. The catheter is advanced through either the inferior or the superior vena cava and is guided by fluoroscopy. E. IVUS can be used in vessels as small as 2 mm to assess the nature of plaques or vessel condition following an intervention. F. The cardiologist advances the catheter against the blood flow from the femoral, brachial, or radial artery up the aorta, across the aortic valve, and into the left ventricle.

A, C, E A. A flexible catheter with a miniature transducer is introduced at the distal tip to view the coronary arteries. C. The catheter has a transducer which emits sound waves that reflect off the plaque and the arterial wall to create an image of the blood vessel. E. IVUS can be used in vessels as small as 2 mm to assess the nature of plaques or vessel condition following an intervention. Options A, C, and E are accurate about the intravascular ultrasonography (IVUS) procedure. Options B, D, and F are descriptions related to the usual cardiac catheterization procedure.

Which assessment factors for a 62-year-old client would the nurse recognize as modifiable risk factors for heart disease? Select all that apply. A. History of smoking B. Age C. Obesity D. Ethnic background E. Sedentary lifestyle F. Gender

A, C, E A. History of smoking C. Obesity E. Sedentary lifestyle Modifiable risk factors are personal lifestyle habits, including cigarette smoking, physical inactivity, obesity, and psychological variables. Nonmodifiable (uncontrollable) risk factors in-clude the client's age, gender, ethnic origin, and a family history of cardiovascular disease.

The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A, C, E, F A. "If you tend to get angry easily, then your risk for heart disease is higher." C. "Do not eat more calories on a daily basis that you are able to burn." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

A, C, E- a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.

A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

A, C, E- a. Total cholesterol: 280 mg/dL c. Triglycerides: 200 mg/dL e. Low-density lipoprotein cholesterol: 160 mg/dL A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

Which statements about the structure of the heart are accurate? Select all that apply. A. The heart normally pumps about 5 L of blood per minute. B. A muscular wall called the septum separates only the ventricles of the heart. C. The pericardium is a covering that protects the heart. D. The left ventricle pumps deoxygenated blood to the lungs. E. The right ventricle pumps blood into the aorta and systemic arterial system. F. Coronary artery blood flow occurs primarily during diastole.

A, C, F A. The heart normally pumps about 5 L of blood per minute. C. The pericardium is a covering that protects the heart. F. Coronary artery blood flow occurs primarily during diastole. Options A, C, and F are accurate. The septum separates the atria and the ventricles. The right ventricle pumps deoxygenated blood to the pulmonary artery and lungs, while the left ventricle pumps blood to the aorta and the systemic arterial system.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

A,B,C- a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the clients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

A,B,E,F a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness f. Visual disturbances Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.

A- Compare the results with previous pulmonary artery pressure readings. Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.

A nurse assesses a client who had an MI and is hypotensive. Which additional assessment finding should the nurse expect? a. HR 120 beats/min b. Cool, clammy skin c. O2 sat 90% d. RR 8 breaths/min

A- HR 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month

A- I get short of breath when I climb stairs Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

A- Location A The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

Which intravenous (IV) fluid would be most appropriate for treating isotonic volume contraction? A. 0.9% sodium chloride B. 5% dextrose and water C. 0.225% sodium chloride D. 3% sodium chloride and water

A. 0.9% sodium chloride Isotonic volume contraction occurs when sodium and water are lost in isotonic proportions. It may be caused by vomiting, diarrhea, kidney disease, and/or misuse of diuretics. In this situation, volume is replenished with isotonic solutions, such as normal saline (0.9% sodium chloride).

What are the primary regulatory systems of arterial pressure? (Select all that apply.) A. Autonomic nervous system B. Renin-angiotensin-aldosterone system C. Renal system D. Pulmonary system E. P450 enzyme system

A. Autonomic nervous system B. Renin-angiotensin-aldosterone system C. Renal system Arterial pressure is regulated primarily by the autonomic nervous system (provides short-term tone and control), the renin-angiotensin-aldosterone system (constriction and volume), and the renal system (long-term volume control).

A patient receiving a vasodilator that has a high incidence of orthostatic hypotension. Before administering the medication and after the patient has rested supine for 10 minutes, the nurse assesses the BP and pulse. Results are BP 145/80 mm Hg, P 68 beats/min. The nurse assists the patient to stand, ensuring safety, and after 1 minute reassesses the BP and pulse. Which reading would be of most concern to the nurse? A. BP 110/70 mm Hg, pulse 92 beats/min. B. BP 126/70 mm Hg, pulse 78 beats/min. C. BP 134/70 mm Hg, pulse 72 beats/min. D. BP 140/82 mm Hg, pulse 70 beats/min.

A. BP 110/70 mm Hg, pulse 92 beats/min.

The nurse is researching a drug. The handbook states that it decreases afterload. Before the nurse administers this medication to a patient, which assessment would be most critical? A. BP for hypotension. B. Pulse for tachycardia. C. Respirations for tachycardia. D. Temperature for fever.

A. BP for hypotension.

The nurse is assessing a patient who is receiving medication for acute HF. Which assessment would be a priority to report to the prescriber? A. Cough with frothy sputum. B. Expiratory wheezes of bronchi and bronchioles. C. Pulse 100 beats/min. D. Respirations 25/min.

A. Cough with frothy sputum.

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period?

A. Plasma volume osmolarity increases; blood pressure increases

Which acid-base imbalance is caused by retention of CO2 secondary to hypoventilation? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Respiratory acidosis results from retention of CO2 secondary to hypoventilation. Reduced CO2 exhalation raises plasma pCO2, which in turn causes plasma pH to fall.

When providing discharge teaching for a patient who has been prescribed furosemide [Lasix], it is most important for the nurse to include which dietary items to prevent adverse effects of furosemide [Lasix] therapy? A.Oranges, spinach, and potatoes B.Baked fish, chicken, and cauliflower C.Tomato juice, skim milk, and cottage cheese D.Oatmeal, cabbage, and bran flakes

A.Oranges, spinach, and potatoes

Match the terms and descriptors: Stimulation of these receptors decreases heart rate.

K. Muscarinic Receptors.

Which of the following statements would be considered incorrect when transfusing packed red blood cells (RBCs)? (Select all that apply.) a. Adjust the infusion rate to ensure unit is infused within 6 hours. b. Begin an infusion of D5W prior to the packed RBCs. c. Obtain baseline vital signs, including temperature and pulse oximetry. d. Verify the patient ID and blood unit number with another nurse prior to administration

AB a. Adjust the infusion rate to ensure unit is infused within 6 hours. b. Begin an infusion of D5W prior to the packed RBCs.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance?(Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

ABCEF a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

ABE a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes e. A 76-year-old who is prescribed antacids

Which of the following findings would indicate effectiveness of fluid replacement for a patient admitted with dehydration? (Select all that apply.) a. Blood urea nitrogen - 18 mg/dL b. Pulse - 82 c. Blood pressure - 140/90 d. Urine specific gravity - 1.033 e. 24-hour fluid balance - +200

ABE a. Blood urea nitrogen - 18 mg/dL b. Pulse - 82 e. 24-hour fluid balance - +200

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs andsymptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

ABEF a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness f. Visual disturbances

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia Flaccid paralysis with respiratory depression b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness c. Hyponatremia Decreased level of consciousness d. Hypercalcemia Positive Trousseaus and Chvosteks signs e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension

AC Hypokalemia Flaccid paralysis with respiratory depression Hyponatremia Decreased level of consciousness

Which assessment findings will the nurse consider as possible causes for a client to have a serum potassium level of 6.3 mE/L (mmol/L)? (Select all that apply.) a. Management of hypertension with an angiotensin converting enzyme inhibitor b. Presence of chronic kidney disease c. Vegan diet d. Excessive use of salt substitute e. Daily therapy with a potassium-sparing diuretics f. Past history of hepatitis A

ACD a. Management of hypertension with an angiotensin converting enzyme inhibitor c. Vegan diet d. Excessive use of salt substitute

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach as client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply.) a. Red meat b. Cereal c. Citrus fruit d. Salt substitutes e. Eggs f. Bread

ACD a. Red meat c. Citrus fruit d. Salt substitutes

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently f. Teach client and family how to read food labels for sodium.

ACDEF a. Calculate pulse pressure with each blood pressure reading c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently f. Teach client and family how to read food labels for sodium.

You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply. A) Milk B) Beef C) Poultry D) Green vegetables E) Liver

ACE A) Milk C) Poultry E) Liver

Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

AD A. Calcium D. Potassium

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration inolder adults. What factors contribute to this phenomenon? Select all that apply. A) Decreased kidney mass B) Increased conservation of sodium C) Increased total body water D) Decreased renal blood flow E) Decreased excretion of potassium

ADE A) Decreased kidney mass D) Decreased renal blood flow E) Decreased excretion of potassium

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? Select all that apply. A. Blood pressure B. Deep tendon reflexes C. Hand-grip strength D. Pulse rate and quality E. Skin turgor F. Urine output

ADF A. Blood pressure D. Pulse rate and quality F. Urine output

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

AEF a. Reports of palpitations e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min

ANS: 31 drops/min

5. An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."

ANS: A "I get short of breath when I climb stairs." Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."

ANS: A "I get short of breath when I climb stairs." Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

What teaching will the nurse provide to a client who says, "Smoking doesn't hurt my heart"? A."Smoking increases risks for heart disease." B."Lungs are the only organ damaged by smoking." C."The impact of smoking is only on the heart." D."Are you worried about smoking?"

ANS: A "Smoking increases risks for heart disease." Cigarette smoking is a major risk factor for CVD, specifically coronary artery disease (CAD) and peripheral vascular disease (PVD).

A patient with a history of hypertension is admitted for a procedure. If the patient's arterial pressure decreases, which clinical manifestation would the nurse expect to see? a. Decreased heart rate b. Increased heart rate c. Decreased blood pressure d. Syncope

ANS: B b. Increased heart rate When arterial pressure decreases, the vasoconstrictor center causes constricition of nearly all the arterioles, leading to an increase in the peripheral resistant, constriction of vein, increasing venous return and subsequent acceleration of the heart rate.

A patient with hypertension is admitted to the hospital. On admission the patient's heart rate is 72 beats per minute, and the blood pressure is 140/95 mm Hg. After administering an antihypertensive medication, the nurse notes a heart rate of 85 beats per minute and a blood pressure of 130/80 mm Hg. What does the nurse expect to occur? a.A decrease in the heart rate back to baseline in 1 to 2 days b.An increase in the blood pressure within a few days c.An increase in potassium retention in 1 to 2 days d.A decrease in fluid retention within a week

ANS: A A decrease in the heart rate back to baseline in 1 to 2 days When blood pressure drops, the baroreceptors in the aortic arch and carotid sinus sense this and relay information to the vasoconstrictor center of the medulla; this causes constriction of arterioles and veins and increased sympathetic impulses to the heart, resulting in an increased heart rate. After 1 to 2 days, this system resets to the new pressure, and the heart rate returns to normal. The blood pressure will not increase when this system resets. Increased potassium retention will not occur. Over time, the body will retain more fluid to increase the blood pressure.

12. A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client's chart as the only action.

ANS: A Compare the results with previous blood pressure readings. The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This client's blood pressure is at the upper range of acceptable, so the nurse would compare the client's current reading with those previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.

A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client's chart as the only action.

ANS: A Compare the results with previous blood pressure readings. The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This client's blood pressure is at the upper range of acceptable, so the nurse would compare the client's current reading with those previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.

8. An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient's chart. Which laboratory value causes the nurse the most concern? a. Elevated creatinine clearance b. Elevated serum potassium level c. Normal blood glucose level d. Low levels of low-density lipoprotein (LDL) cholesterol

ANS: A Elevated creatinine clearance Hydrochlorothiazide should not be given to patients with severe renal impairment; therefore, an elevated creatinine clearance would cause the most concern. Thiazide diuretics are potassium-wasting drugs and thus may actually improve the patient's potassium level. Thiazides may elevate the serum glucose level in diabetic patients. Thiazides increase LDL cholesterol; however, this patient's levels are low, so this is not a risk. PTS: 1 DIF: Cognitive Level: Application REF: pp. 452-453

1. A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? a. Furosemide [Lasix] b. Hydrochlorothiazide [HydroDIURIL] c. Mannitol [Osmitrol] d. Spironolactone [Aldactone]

ANS: A Furosemide [Lasix] Furosemide, a potent diuretic, is used when rapid or massive mobilization of fluids is needed. This patient shows severe signs of congestive heart failure with respiratory distress and pulmonary edema and needs immediate mobilization of fluid. Hydrochlorothiazide and spironolactone are not indicated for pulmonary edema, because their diuretic effects are less rapid. Mannitol is indicated for patients with increased intracranial pressure and must be discontinued immediately if signs of pulmonary congestion or heart failure occur. PTS: 1 DIF: Cognitive Level: Application REF: pp. 450-452 | pp. 452-453 | pp. 452-454

1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: A Heart rate of 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.

A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: A Heart rate of 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later.

19. A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

ANS: A Location A The aortic valve is auscultated in the second intercostal space just to the right of the sternum. The pulmonic valve would be heard in location B located in the second intercostal space just left of the sternum. The mitral valve would be heard in location D located in the fifth intercostal space at the apex of the heart. The tricuspid valve would be heard in location C located in the fifth intercostal space at the lower left of the sternal border.

Individuals who have plaque lining their arteries experience an increase in vessel resistance. The nurse should assess for which reaction that is the body's attempt to compensate? A. Peripheral edema. B. Rise in blood pressure (BP). C. Shifting of point of maximal impulse (PMI). D. Slowing of heart rate.

B. Rise in blood pressure (BP).

A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug? a. Decreased stroke volume b. Increased stroke volume c. Decreased myocardial contractility d. Increased myocardial contractility

ANS: A a. Decreased stroke volume constrictions of arterioles increases the load against which the heart must pump to eject blood. increased constrictions of arterioles would decreased. no increased stroke volume of the heart. myocardial contractility is determined by the sympathetic nervous system acting through beta-adrenergic receptors in the myocardium.

A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to: a.ask for assistance when getting out of bed. b.expect bradycardia for a few days. c.notify the provider if headache occurs. d.report shortness of breath.

ANS: A ask for assistance when getting out of bed. A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects.

A nurse is assessing a patient who has heart failure. The patient complains of shortness of breath, and the nurse auscultates crackles in both lungs. The nurse understands that these symptoms are the result of: a.decreased force of ventricular contraction. b.increased force of ventricular contraction. c.decreased ventricular filling. d.increased ventricular filling.

ANS: A decreased force of ventricular contraction. In the failing heart Starling's law breaks down, and the force of contraction no longer increases in proportion to the amount of ventricular filling. The result is the backup of blood into the lungs and the symptoms of shortness of breath and crackles caused by fluid. Increased ventricular contraction would not result in a backup of blood into the lungs. Changes in ventricular filling are not the direct cause of this symptom.

6. A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol [Osmitrol]. The nurse knows that this is given to: a. reduce intracranial pressure. b. reduce renal perfusion. c. reduce peripheral edema. d. restore extracellular fluid.

ANS: A reduce intracranial pressure. Mannitol is an osmotic diuretic that is used to reduce intracranial pressure by relieving cerebral edema. The presence of mannitol in blood vessels in the brain creates an osmotic force that draws edematous fluid from the brain into the blood. Mannitol can also be used to increase renal perfusion. It can cause peripheral edema and is not used to restore extracellular fluid. PTS: 1 DIF: Cognitive Level: Application REF: p. 455

. A patient is taking a drug that interferes with venous constriction. The nurse will tell the patient to: a. ask for assistance when getting out of bed. b. expect bradycardia for a few days. c. notify the provider if headache occurs. d. report shortness of breath

ANS: A a. ask for assistance when getting out of bed. A drop in venous pressure reduces venous return to the heart, and as blood pools in the extremities, orthostatic hypotension can occur. Patients taking drugs that reduce venous constriction should be cautioned to ask for assistance when getting out of bed. Bradycardia, headache, and shortness of breath are not expected effects

7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

ANS: A A 34 year old who is NPO and receiving rapid intravenous D5W infusions. Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Sodium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

12. A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

ANS: A Assess the client's respiratory rate, rhythm, and depth. In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

The nurse is preparing to insert an IV catheter with an intermittent infusion device (IID) into an elderly woman for medication administration. Which of the following considerations would be incorrect? a. Insert the IV catheter into nondominant hand/arm. b. Use a 16- or 18-gauge over-the-needle catheter. c. Release the tourniquet before attaching the IID. d. Flush the IID with 2 to 3 mL normal saline after insertion.

B Use a 16- or 18-gauge over-the-needle catheter.

A nurse is caring for a patient who is receiving a drug that causes constriction of arterioles. The nurse expects to observe which effect from this drug? a.Decreased stroke volume b.Increased stroke volume c.Decreased myocardial contractility d.Increased myocardial contractility

ANS: A Decreased stroke volume Constriction of arterioles increases the load against which the heart must pump to eject blood. Increased constriction of arterioles would decrease, not increase, the stroke volume of the heart. Myocardial contractility is determined by the sympathetic nervous system, acting through beta1-adrenergic receptors in the myocardium.

9. A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

ANS: A Depth of respirations A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient with hypertension is admitted to the hospital. On admission the patient's heart rate is 72 beats per minute, and the blood pressure is 140/95 mm Hg. After administering an antihypertensive medication, the nurse notes a heart rate of 85 beats per minute and a blood pressure of 130/80 mm Hg. What does the nurse expect to occur? a. A decrease in the heart rate back to baseline in 1 to 2 days b. An increase in the blood pressure within a few days c. An increase in potassium retention in 1 to 2 days d. A decrease in fluid retention within a week

ANS: A a. A decrease in the heart rate back to baseline in 1 to 2 days When blood pressure drops, the baroreceptors in the aortic arch and carotid sinus sense this and relay information to the vasoconstrictor center of the medulla; this causes constriction of arterioles and veins and increased sympathetic impulses to the heart, resulting in an increased heart rate. After 1 to 2 days, this system resets to the new pressure, and the heart rate returns to normal. The blood pressure will not increase when this system resets. Increased potassium retention will not occur. Over time, the body will retain more fluid to increase the blood pressure

A nurse is assessing a patient with heart failure. The patient complains of shortness of breath, and the nurse auscultates crackles in both lungs. The nurse understands that these symptoms are the result of: a. decreased force of ventricular contraction. b. increased force of ventricular contraction. c. decreased ventricular filling. d. increased ventricular filling

ANS: A a. decreased force of ventricular contraction. In the failing heart Starling's law breaks down, and the force of contraction no longer increases in proportion to the amount of ventricular filling. The result is the backup of blood into the lungs and the symptoms of shortness of breath and crackles caused by fluid. Increased ventricular contraction would not result in a backup of blood into the lungs. Changes in ventricular filling are not the direct cause of this symptom

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.

ANS: A Compare the results with previous pulmonary artery pressure readings Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

ANS: A Heart rate of 120 beats/min When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month

ANS: A I get short of breath when I climb stairs. Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

ANS: A Location A The aortic valve is auscultated in the second intercostal space just to the right of the sternum.

A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

ANS: A, C, E a. Total cholesterol: 280 mg/dL c. Triglycerides: 200 mg/dL e. Low-density lipoprotein cholesterol: 160 mg/dL A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for renal protection. Hydration would continue after the procedure. The client would be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

1. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

ANS: A, B, C a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for renal protection. Hydration would continue after the procedure. The client would be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous catheter are not required for the procedure and would only increase the client's risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter

ANS: A, B, C a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the clients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.

4. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

ANS: A, B, C, E, F a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.) a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old who is prescribed antacids

ANS: A, B, E a. A 36-year-old who is malnourished b. A 42-year-old with uncontrolled diabetes e. A 76-year-old who is prescribed antacids Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxidebased or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

1. Besides having diuretic effects for patients with congestive heart failure, thiazides are also used to treat what? (Select all that apply.) a. Diabetes insipidus b. Hepatic failure c. Increased intracranial pressure d. Intraocular pressure e. Postmenopausal osteoporosis

ANS: A, B, E a. Diabetes insipidus b. Hepatic failure e. Postmenopausal osteoporosis Thiazide diuretics have the paradoxical effect of reducing urine output in patients with diabetes insipidus. They can also be used to mobilize edema associated with liver disease. They promote tubular reabsorption of calcium, which may reduce the risk of osteoporosis in postmenopausal women. Mannitol is used to treat edema that causes increased intracranial pressure and intraocular pressure. PTS: 1 DIF: Cognitive Level: Analysis REF: pp. 452-453 | p. 455

1. A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

ANS: A, B, E, F a. Increased pulse rate b. Distended neck veins e. Skeletal muscle weakness f. Visual disturbances Signs and symptoms of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding. DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

ANS: A, C, D, E, F a. Calculate pulse pressure with each blood pressure reading. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium. Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

6. A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade f. Dysrhythmias

ANS: A, C, E a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of left-sided heart catheterizations.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade f. Dysrhythmias

ANS: A, C, E a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of left-sided heart catheterizations.

4. A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

ANS: A, C, E a. Total cholesterol: 280 mg/dL (7.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

ANS: A, C, E a. Total cholesterol: 280 mg/dL (7.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L) A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

ANS: A, C, E a. Thrombophlebitis c. Pulmonary embolism e. Cardiac tamponade Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.

4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.) a. Electrocardiogram changes b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness

ANS: A, D, E a. Electrocardiogram changes d. Paralytic ileus e. Skeletal muscle weakness Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.

3. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

ANS: A, E, F a. Reports of palpitations e. Skeletal muscle weakness f. Tall, peaked T waves on ECG Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

9. A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching? a. "I can expect improvement within a few hours after taking this drug." b. "I need to stop taking potassium supplements." c. "I should use salt substitutes to prevent toxic side effects." d. "I should watch closely for dehydration."

ANS: B "I need to stop taking potassium supplements." Spironolactone is a potassium-sparing diuretic used to counter the potassium-wasting effects of hydrochlorothiazides. Patients taking potassium supplements are at risk for hyperkalemia when taking this medication, so they should be advised to stop the supplements. Spironolactone takes up to 48 hours to have effects. Salt substitutes contain high levels of potassium and are contraindicated. Spironolactone is a weak diuretic, so the risk of dehydration is not increased. PTS: 1 DIF: Cognitive Level: Application REF: pp. 452-454

6. A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

ANS: B "My shoes fit tighter by the end of the day." Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

ANS: B "My shoes fit tighter by the end of the day." Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."

ANS: B "You should balance weight loss with consuming necessary nutrients." Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."

ANS: B "You should balance weight loss with consuming necessary nutrients." Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

11. The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

ANS: B Assess the client's lung sounds every 2 hours. All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Overhydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

A patient with a history of hypertension is admitted for a procedure. If the patient's arterial pressure decreases, which clinical manifestation would the nurse expect to see? a.Decreased heart rate b.Increased heart rate c.Decreased blood pressure d.Syncope

ANS: B Increased heart rate When arterial pressure decreases, the vasoconstrictor center causes constriction of nearly all arterioles, leading to an increase in peripheral resistance, constriction of veins, increasing venous return, and subsequent acceleration of the heart rate. A decrease in arterial pressure would not cause a decrease in the heart rate or blood pressure, nor would it cause syncope.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

ANS: B Initiation of an external pacemaker The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.

13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

ANS: B Initiation of an external pacemaker The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.

11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the primary health care provider before scheduling the MRI. c. Request lab for cardiac enzymes from the primary health care provider. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: B Notify the primary health care provider before scheduling the MRI. The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but the nurse needs to notify the primary health care provider.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the primary health care provider before scheduling the MRI. c. Request lab for cardiac enzymes from the primary health care provider. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: B Notify the primary health care provider before scheduling the MRI. The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but the nurse needs to notify the primary health care provider.

3. After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

ANS: B "I will weigh myself each morning before I eat or drink." One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day. DIF: Analyzing TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Dehydration, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

4. A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain.

ANS: B Anxious client who has tachypnea. Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

ANS: B Assess client further for fall risk. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.

ANS: B Connect the client to a cardiac monitor. This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Calcium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The nurse knows that which organ is primarily responsible for maintaining fluid volume and osmolality? A. Liver B. Kidneys C. Blood vessels D. Heart

B. Kidneys The kidneys are responsible for maintaining and regulating volume and osmolality.

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.

ANS: B Document the finding. The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

ANS: B Initiation of an external pacemaker The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day

ANS: B My shoes fit tighter by the end of the day. Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

ANS: B Notify the health care provider before scheduling the MRI. The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet b. You should balance weight loss with consuming necessary nutrients c. A nutritionist will provide you with information about your new diet d. If you exercise more frequently, you wont need to change your diet

ANS: B You should balance weight loss with consuming necessary nutrients Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

A client has recently been admitted with a diagnosis of coronary artery disease (CAD). What lab assessment finding requires nursing interventions? (Select all that apply.) A.Cholesterol 120 mg/dL B.Triglycerides 168 mg/dL C.HDLs 40 mg/dL D.CRP 0.8 mg/dL E. Lipids 100 mg/dL

ANS: B, C B.Triglycerides 168 mg/dL C.HDLs 40 mg/dL Triglycerides that are elevated signal increased risk for CAD and would be anticipated in a client diagnosed with CAD. Low HDL values indicate an increased risk for CAD and would be anticipated in a client with CAD. The other values are normal values. These values would likely be elevated in a client with CAD.

7. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

ANS: B, C, D, E, F b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

8. A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

ANS: B, C, D, F b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration f. Magnesium: 0.8 mg/dL: Dehydration In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

ANS: B, C, E b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

ANS: B, C, E b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

ANS: B, C, E b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptomsindigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome

7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

ANS: B, D b. Use a draw sheet to reposition the client in bed. d. Provide nonslip footwear for the client to use when out of bed. Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.

5. A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: B, D, E b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, would be performed. Beta blockers are often held prior to the procedure as they lower the heart rate and may result in inaccurate results.

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

ANS: B, D, E b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, would be performed. Beta blockers are often held prior to the procedure as they lower the heart rate and may result in inaccurate results.

3. A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor f. Oxygen saturation 93% on room air

ANS: B, D, E b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding hematoma signifies bleeding. Rhythm changes on the monitor are a known complication. These findings would require prompt action. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The oxygen saturation is slightly low but not critical and there is no baseline to compare it to.

In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm?

Pulse rate and rhythm

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor f. Oxygen saturation 93% on room air

ANS: B, D, E b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding hematoma signifies bleeding. Rhythm changes on the monitor are a known complication. These findings would require prompt action. The client's blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours. The oxygen saturation is slightly low but not critical and there is no baseline to compare it to.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.)

ANS: B, D, E b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination. Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

ANS: B, D, E b. Serum potassium of 2.9 mEq/L d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.

2. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

ANS: B, E b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg) Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

A nurse is teaching a nursing student how blood can return to the heart when pressure in the venous capillary beds is very low. Which statement by the student indicates a need for further teaching? a."Constriction of small muscles in the venous wall increases venous pressure." b."Negative pressure in the left atrium draws blood toward the heart." c."Skeletal muscles relax to allow the free flow of blood." d."Venous valves help prevent the backflow of blood."

ANS: C "Skeletal muscles relax to allow the free flow of blood." Skeletal muscle contraction, along with one-way venous valves, helps create an "auxiliary" venous pump that helps drive blood toward the heart. Constriction of small muscles in venous walls helps increase venous pressure. Negative pressure in the left atrium sucks blood toward the heart. Valves, which are one-way, work with the contraction of skeletal muscles to create a venous pump.

A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine test and the risk of death is very low." b. "Would you like to speak with a chaplain prior to test?" c. "Tell me more about your concerns about the test." d. "What support systems do you have to assist you?"

ANS: C "Tell me more about your concerns about the test." The nurse would discuss the client's feelings and concerns related to the cardiac catheterization. The nurse would not provide false hope or push the client's concerns off on the chaplain. The nurse would address support systems after addressing the client's current issue.

17. A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine test and the risk of death is very low." b. "Would you like to speak with a chaplain prior to test?" c. "Tell me more about your concerns about the test." d. "What support systems do you have to assist you?"

ANS: C "Tell me more about your concerns about the test." The nurse would discuss the client's feelings and concerns related to the cardiac catheterization. The nurse would not provide false hope or push the client's concerns off on the chaplain. The nurse would address support systems after addressing the client's current issue. KEY: Diagnostic examination, Anxiety

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The primary health care provider has prescribed an antacid every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"

ANS: C "What do you understand about what happened to you?" Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain.

16. A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The primary health care provider has prescribed an antacid every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"

ANS: C "What do you understand about what happened to you?" Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client's misconception about recent pain and the cause of that pain. KEY: Coronary perfusion, Coping

3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.

ANS: C A 65-year-old woman with diabetes mellitus. Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease.

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.

ANS: C A 65-year-old woman with diabetes mellitus. Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease. Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular disease.

4. A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.

ANS: C Assess the client's medications. Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.

ANS: C Assess the client's medications. Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However, the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent.

8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."

ANS: C Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."

ANS: C Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the client's problem.

Which action will the nurse take when having difficulty auscultating the first heart sound, S1? A.Listen at the heart base B.Assess only for higher pitched sounds. C.Direct the client to lay on his or her left side. D.Have the client hold their breath while auscultation takes place

ANS: C Direct the client to lay on his or her left side. If the nurse is having difficulty hearing the heart sounds, ask the client to lean forward or roll to his or her left side. This will make the sounds more audible for auscultation.

7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm

ANS: C Fatigue and shortness of breath In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI.

A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm

ANS: C Fatigue and shortness of breath In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not known to be specific symptoms for women having and MI.

2. A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.5 mEq/L d. Sodium level of 140 mEq/L

ANS: C Potassium level of 3.5 mEq/L This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient's serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient's serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it may improve with diuresis. PTS: 1 DIF: Cognitive Level: Application REF: pp. 450-451

7. A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom? a. Frequent nocturia b. Headaches c. Ringing in the ears d. Urinary retention

ANS: C Ringing in the ears Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus, dizziness, or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect. PTS: 1 DIF: Cognitive Level: Application REF: pp. 450-451

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

ANS: C Slurred speech and confusion A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.

9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

ANS: C Slurred speech and confusion A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may not be significant.

3. A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? a. Bumetanide [Bumex] b. Furosemide [Lasix] c. Spironolactone [Aldactone] d. Hydrochlorothiazide [HydroDIURIL]

ANS: C Spironolactone [Aldactone] Spironolactone is a non-potassium-wasting diuretic; therefore, if the patient has a serum potassium level of 6 mEq/L, indicating hyperkalemia, an order for this drug should be questioned. Bumetanide, furosemide, and hydrochlorothiazide are potassium-wasting diuretics and would be appropriate to administer in a patient with hyperkalemia. PTS: 1 DIF: Cognitive Level: Application REF: p. 454

A patient is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing: a. cardiac afterload. b. cardiac preload. c. myocardial contractility. d. venous return

ANS: C c. myocardial contractility. Beta1-adrenergic agents help increase the heart's stroke volume by increasing myocardial contractility. Cardiac afterload is determined primarily by the degree of peripheral resistance caused by constriction of arterioles; increasing afterload would decrease stroke volume. Beta1-adrenergic agents do not affect afterload. Cardiac preload is the amount of stretch applied to the cardiac muscle before contraction and is determined by the amount of venous return. Beta1-adrenergic agents do not affect cardiac preload. Venous return is determined by the systemic filling pressure and auxiliary muscle pumps and is not affected by beta1-adrenergic agents

8. A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

ANS: C "Call your primary health care provider for diarrhea." One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Sodium imbalances, Health teaching MSC: Client Needs Category: Health Promotion and Maintenance

1. A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure.

ANS: C A 76 year old who is cognitively impaired. Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration. DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

10. A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

ANS: C Prepare to administer dextrose 20% and 10 units of regular insulin IV push. A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

13. A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

ANS: C Sets the IV pump to deliver 30 mEq of potassium an hour. IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

The most toxic antiarrhythmic agent is Digoxin (Lanoxin) Lidocaine (Xylocaine) Amiodarone (Cordarone) Quinidine (Cardioqiun)

Amiodarone (Cordarone)

A nurse is teaching a nursing student how blood can return to the heart when pressure in the venous capillary beds is very low. Which statement by the student indicates a need for further teaching? a. "Constriction of small muscles in the venous wall increases venous pressure." b. "Negative pressure in the left atrium draws blood toward the heart." c. "Skeletal muscles relax to allow the free flow of blood." d. "Venous valves help prevent the backflow of blood

ANS: C c. "Skeletal muscles relax to allow the free flow of blood." Skeletal muscle contraction, along with one-way venous valves, help create an "auxiliary" venous pump that helps drive blood toward the heart. Constriction of small muscles in venous walls helps increase venous pressure. Negative pressure in the left atrium sucks blood toward the heart. Valves, which are one-way, work with the contraction of skeletal muscles to create a venous pump

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

ANS: C A 45-year-old American Indian woman with diabetes mellitus The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.

ANS: C Assess the clients medications. Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.

ANS: C Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

ANS: C Disorientation and confusion In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

ANS: C Slurred speech and confusion A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority.

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?

ANS: C Tell me more about your concerns about the surgery. The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: D Allergies to iodine-based agents Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?

ANS: C What do you understand about what happened to you? Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the clients misconception about recent pain and the cause of that pain.

5. After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

ANS: C, D c. Strong productive cough d. Active bowel sounds A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working. DIF: Understanding TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Potassium imbalances MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

15. A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response? a. "I will consult your primary health care provider to prescribe a sleep study." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."

ANS: D "Use pillows to elevate your head and chest while you are sleeping." The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response? a. "I will consult your primary health care provider to prescribe a sleep study." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."

ANS: D "Use pillows to elevate your head and chest while you are sleeping." The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: D Allergies to iodine-based agents Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take priority for client safety.

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.

ANS: D Client who describes intense squeezing pressure across the chest. All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client 's chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction.

18. An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.

ANS: D Client who describes intense squeezing pressure across the chest. All clients who have chest pain would be assessed more thoroughly. To determine which client would be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the client 's chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets worse with inspiration, and cramping pain are not usually associated with myocardial infarction.

2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min.

ANS: D Pulse decreased from 100 to 80 beats/min. Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and better cardiac output.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min.

ANS: D Pulse decreased from 100 to 80 beats/min. Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow for better filling and better cardiac output.

Which acid-base imbalance is caused by hyperventilation? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis Respiratory alkalosis is produced by hyperventilation. Deep and rapid breathing increases CO2 loss, which in turn lowers the pCO2* of blood, and thereby increases pH. * pCO2 is the partial pressure of carbon dioxide in blood.

5. A patient with hypertension is taking furosemide [Lasix] for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient? a. Bumetanide [Bumex] b. Chlorothiazide [Diuril] c. Hydrochlorothiazide [HydroDIURIL] d. pironolactone [Aldactone]S

ANS: D pironolactone [Aldactone]S Spironolactone is used in conjunction with furosemide because of its potassium-sparing effects. Furosemide can contribute to hypokalemia, which can increase the risk of fatal dysrhythmias, especially with digoxin administration. The other diuretics listed are all potassium-wasting diuretics. PTS: 1 DIF: Cognitive Level: Application REF: pp. 450-452 | pp. 452-453 | pp. 452-454

14. A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

ANS: D Administers bisphosphonates as prescribed. Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Calcium imbalances MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

16. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

ANS: D Dangle the client on the bedside before ambulating. An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

ANS: D Decreased orthostatic changes when standing The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Fluid and electrolyte imbalances, Dehydration MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

ANS: D Grilled chicken breast with glazed carrots Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium. DIF: Applying TOP: Integrated Process: Teaching/Learning KEY: Fluid and electrolyte imbalances, Sodium imbalances MSC: Client Needs Category: Health Promotion and Maintenance

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

ANS: D A 58-year-old male who describes his pain as intense stabbing that spreads across his chest All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

ANS: D Allergies to iodine-based agents Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

ANS: D Pulse decreased from 100 beats/min to 80 beats/min Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.

ANS: D Use pillows to elevate your head and chest while you are sleeping. The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

A patient has reduced cardiac output. Which compensatory response would the nurse expect to occur in this patient? Shrinkage of cardiac muscle Excretion of water and blood volume Suppression of the sympathetic nervous system (SNS) Activation of the renin-angiotensin-aldosterone system (RAAS)

Activation of the renin-angiotensin-aldosterone system (RAAS)

A patient's serum digoxin level is noted to be 0.5 ng/mL. Which action by the nurse is appropriate? Notify the provider. Administer an antidote. Hold the ordered dose of digoxin. Administer the ordered dose of digoxin

Administer the ordered dose of digoxin

Which of the following client is at greatest risk for digital toxicity? A 25 year old client with congenital heart disease A 50 year old client with CHF A 60 year old client after myocardial infarction An 80 year old client with CHF

An 80 year old client with CHF

The nurse is preparing to administer a daily dose of digoxin [Lanoxin]. What is the priority nursing intervention? Check blood pressure Palpate the pedal pulses Assess for Homans' sign Analyze heart rate and rhythm

Analyze heart rate and rhythm

The nurse is caring for a patient with heart failure. Which drug classification should the nurse recognize as the cornerstone of therapy? Cardiac glycosides Sympathomimetics Direct renin inhibitors Angiotensin-converting enzyme inhibitors

Angiotensin-converting enzyme inhibitors

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume status

Ans: D Fluid volume status A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?

Anxious client who has tachypnea.

Dobutamine (Dobutrex) improves cardiac output and is indicated for use in all of the following conditions except Septic shock Congestive heart failure Arryhthmias Pulmonary congestion

Arrhythmias

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?

Assess client further for fall risk.

11. The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

Assess the client's lung sounds every 2 hours.

12. A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Assess the client's respiratory rate, rhythm, and depth.

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm?

Assess the client's response to the Chvostek test

The nurse recognizes that magnesium sulfate is contraindicated in patients with which cardiac abnormality? Bradycardia Sick sinus syndrome Atrioventricular block Ventricular tachycardia

Atrioventricular block Elevated magnesium levels can suppress conduction of impulses through the atrioventricular (AV) node. Therefore, magnesium is contraindicated in the treatment of patients with a history of AV block.

A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching? a. "I can expect improvement within a few hours after taking this drug." b. "I need to stop taking potassium supplements." c. "I should use salt substitutes to prevent toxic side effects." d. "I should watch closely for dehydration."

B "I need to stop taking potassium supplements." Spironolactone is a potassium-sparing diuretic used to counter the potassium-wasting effects of hydrochlorothiazides. Patients taking potassium supplements are at risk for hyperkalemia when taking this medication, so they should be advised to stop the supplements. Spironolactone takes up to 48 hours to have effects. Salt substitutes contain high levels of potassium and are contraindicated. Spironolactone is a weak diuretic, so the risk of dehydration is not increased.

Which statement made by the client on the way to the catheterization laboratory requires immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."

B "I was nervous last night, but I still remembered to take my warfarin."

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol)mEq (mmol) D. 20 mEq (mmol)

B 15 mEq (mmol)

About how many mL will the nurse record as having been replaced for a client with dehydration initially weighed 142 lb (64.5 kg) and now weighs 156 lb (70.9 kg) after 2 days of rehydration therapy? a. 3000 b. 6300 c. 9300 d. 7000

B 6300

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia? a. A 26 year old with hyperparathyroidism b. A 70 year old who has alcoholism and malnutrition c. A 40 year old taking tetracycline for an infection d. A 35 year old athlete taking NSAIDs for joint pain

B A 70 year old who has alcoholism and malnutrition

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the patient's mobility when selecting a site. C) Have the patient briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes.

B Consider potential effects on the patient's mobility when selecting a site.

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? A. Asking about the use of sugar substitutes. B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease

B Determining what drugs are taken daily

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit? A) Diarrhea B) Dilute urine C) Increased muscle tone D) Joint pain

B Dilute urine

A nurse in the emergency department is caring for an adult patient with numerous draining wounds from gunshots. The patient's pulse rate has increased from 100 to 130 beats/min over the past hour. For which imbalance should the nurse assess symptoms? a. Respiratory acidosis b. Extracellular fluid volume deficit c. Metabolic alkalosis d. Intracellular fluid volume excess

B Extracellular fluid volume deficit

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect? A) Hypophosphatemia B) Hypocalcemia C) Hypermagnesemia D) Hyperkalemia

B Hypocalcemia

Which physiologic mechanism helps to ensure venous return despite low pressure in the venules? A. Positive pressure in the right atrium B. Negative pressure in the right atrium C. Vasodilation in the periphery D. Cardiac muscle relaxation

B. Negative pressure in the right atrium The three mechanisms that help ensure venous return are negative pressure in the right atrium, constriction of veins, and the combination of venous valves and contraction of skeletal muscles.

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response? A) I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup. B) Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids. C) It is normal to be a little confused following surgery, and it is safe not to urinate at night. D) If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

B Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patient's admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly? A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia. D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

B Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.

Which assessment finding on a client with hypervolemia indicates to the nurse that the client's condition may be worsening? a. Nose and ears have a slightly yellow-tinged appearance. b. Neck veins are now distended in the sitting position. c. Breath sounds can be heard in the right lower lung lobe. d. Weight is unchanged from that obtained yesterday

B Neck veins are now distended in the sitting position.

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport

B Osmosis and osmolality

A patient with an excessive alcohol intake has a reduced amount of antidiuretic hormone (ADH). Which symptom is the patient likely to exhibit? a. Dysuria b. Polyuria c. Oliguria d. Hematuria

B Polyuria

A patient is in respiratory distress. The provider has ordered arterial blood gases (ABGs). The results are the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. How should the nurse interpret the ABGs? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

B Respiratory alkalosis

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room.The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware thathyperventilation is the most common cause of which acidbase imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances

B Respiratory alkalosis

A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members ofthe nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis? A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C) The kidneys react rapidly to compensate for imbalances in the body. D) The kidneys regulate the bicarbonate level in the intracellular fluid.

B The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6 mg/dL; and Cl- = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. Why should the nurse question the order for digoxin 0.25 mg orally daily? a) Based on the digoxin level, the dose may need to be increased. b) The patient is at risk for an elevated digoxin level at this time. c) Digoxin and furosemide should never be taken together. d) The nurse should not be concerned about the order as written.

B The patient is at risk for an elevated digoxin level at this time.

Which statement by a client to the nurse indicates an understanding of cigarette usage related to cardiovascular risks? A. "I don't smoke as much as I used to and I'm down to half a pack a day." B. "I need to be completely cigarette-free for at least 3 years." C. "I started smoking a few years ago but I plan to quit in a year or two." D. "I smoke to relax like when I go out with friends or when I drink."

B "I need to be completely cigarette-free for at least 3 years." Three to four years after a client has stopped smoking, his or her CVD risk appears to be similar to that of a person who has never smoked. The client is still smoking in the other responses and is still at risk for CVD.

What is the best advice the nurse would give to a client with moderate-to-severe cramping sensation in their legs or buttocks associated with an activity such as walking? A. "Elevating the affected extremity may help relieve the pain." B. "Resting or lowering the affected extremity can relieve the pain." C. "Placing a nitroglycerine tablet under your tongue may relieve the pain." D. "Losing some weight can take pressure off the extremity and relieve the pain."

B "Resting or lowering the affected extremity can relieve the pain." Clients who report a moderate-to-severe cramping sensation in their legs or buttocks associated with an activity such as walking have intermittent claudication related to decreased arterial tissue perfusion. Resting or lowering the affected extremity to decrease tissue demands or to enhance arterial blood flow usually relieves claudication pain. Leg pain that results from prolonged standing or sitting is related to venous insufficiency from either incompetent valves or venous obstruction. Elevating the extremity may relieve this pain. Nitroglycerine is given to relieve angina. Weight loss will not relieve the pain of intermittent claudication.

Which instruction would the nurse give a client who is to have an exercise electrocardiography test? A. "Someone must drive you home because of sedative effects of the medications." B. "Wear comfortable loose-fitting clothes and supportive, rubber-soled shoes." C. "Avoid smoking or drinking alcohol for at least a week before the test." D. "Do not eat or drink anything after midnight."

B "Wear comfortable loose-fitting clothes and supportive, rubber-soled shoes." Clients are advised to wear comfortable, loose clothing and rubber-soled, supportive shoes. Instruct the client to get plenty of rest the night before the procedure. He or she may have a light meal 2 hours before the test but should avoid smoking or drinking alcohol or caffeine-containing beverages on the day of the test. Usually cardiovascular drugs such as beta blockers or calcium channel blockers are withheld on the day of the test to allow the heart rate to increase during the stress portion of the test. Sedation drugs are not given with this test.

What is the correct technique for the nurse to use to check a client's lower extremities using the ankle-brachial index? A. Blood pressure in the legs is measured with the client supine; then the client stands for 5 minutes and blood pressure is measured in the arms. B. A blood pressure cuff is applied to the lower extremities and the systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. C. The dorsalis pedis and posterior tibial pulses are manually palpated and compared bilaterally for strength and equality and compared to a standard index. D. A blood pressure cuff is applied to the lower extremities to observe for an exaggerated decrease in systolic pressure of more than 10 mm Hg during inspiration.

B A blood pressure cuff is applied to the lower extremities and the systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The ankle-brachial index (ABI) can be used to assess the vascular status of the lower extremities. A BP cuff is applied to the lower extremity just above the malleolus. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses to obtain the ABI. Normal values for the ABI are 1.00 or higher because BP in the legs is usually higher than BP in the arms.

When the nurse assesses a client in the clinic for a physical examination and finds decreased skin temperature, what does this most likely indicate? A. Renal failure B. Arterial insufficiency C. Anemia D. Central cyanosis

B Arterial insufficiency Decreased blood flow results in decreased skin temperature. It is lowered in several clinical conditions, including heart failure, peripheral vascular disease, and shock. It can be assessed for symmetry by touching different areas of the body with the dorsal (back) surface of the hand or fingers.

What does the nurse suspect when assessing a client at risk for CVD who states, "my right foot turns very dark red when I sit too long and when I put my foot up, it turns pale?" A. Central cyanosis B. Arterial insufficiency C. Peripheral cyanosis D. Venous insufficiency

B Arterial insufficiency Rubor (dusky redness) that replaces pallor in a dependent foot suggests arterial insufficiency. Central cyanosis involves decreased oxygenation of the arterial blood in the lungs and appears as a bluish tinge of the conjunctivae and the mucous membranes of the mouth and tongue. Peripheral cyanosis occurs when blood flow to the peripheral vessels is decreased by peripheral vasoconstriction. Venous insufficiency is a result of prolonged venous hypertension that stretches and damages the valves which can lead to backup of blood, edema, and decreased tissue perfusion.

Which medications will the nurse expect the cardiologist to put on hold before an exercise stress test? A. Acetaminophen and bronchodilator B. Atenolol and diltiazem C. Vitamins and iron D. Colace and aspirin

B Atenolol and diltiazem Usually cardiovascular drugs such as beta blockers (e.g., atenolol) or calcium channel blockers (e.g., cardizem) are withheld on the day of the test to allow the heart rate to increase during the stress portion of the test. The drugs listed in options A, C, and D do not generally affect heart rate.

Which exercise regimen would the nurse teach an older adult is best to meet guidelines for physical fitness to promote heart health? A. Golfing for 4 hours once a week B. Brisk walk for 20 to 30 minutes each day C. Bike ride for 6 hours every Saturday D. Running for 15 minutes twice a week

B Brisk walk for 20 to 30 minutes each day In the United States the recommended exercise guidelines are: 150 minutes of moderate exercise or 75 minutes of vigorous exercise per week (or a combination of the two) plus completing muscle-strengthening exercises at least 2 days per week. Regular physical activity (not just once a week) promotes cardiovascular fit-ness and produces beneficial changes in blood pressure and levels of blood lipids and clotting factors.

Which statement best defines the cardiovascular concept of preload? A. Amount of resistance the ventricles must overcome to eject blood through the semilunar valves and into the peripheral blood vessels B. Degree of myocardial fiber stretch at the end of diastole and just before the heart contracts C. The volume of blood ejected each minute by the heart D. Force of blood exerted against the vessel walls

B Degree of myocardial fiber stretch at the end of diastole and just before the heart contracts The stretch imposed on the muscle fibers results from the volume contained within the ventricle at the end of diastole. Preload is determined by the amount of blood returning to the heart from both the venous system (right heart) and the pulmonary system (left heart) (left ventricular end-diastolic [LVED] volume). Option A describes the concept of afterload. Option C describes the concept of cardiac output and Option D is the definition of blood pressure.

Which action does the nurse perform to pre-vent kidney toxicity when caring for a client after cardiac catheterization? A. Assess pedal pulses every 15 minutes. B. Provide intravenous and oral fluids for 12 to 24 hours. C. Check the catheterization site every hour for 8 hours. D. Keep the catheterized extremity straight for 6 hours.

B Provide intravenous and oral fluids for 12 to 24 hours. Contrast-induced renal dysfunction can result from vasoconstriction and the direct toxic effect of the contrast agent on the renal tubules. Hydration pre-and post-study helps eliminate or minimize contrast-induced renal toxicity.

For which pathophysiological conditions can a normal healthy heart adapt to maintain perfusion to the body tissues? A. Menses and gastroesophageal reflux disease B. Stress and infection C. Kidney stones and peripheral vascular disease D. Bleeding and shortness of breath

B Stress and infection The healthy heart can adapt to various pathophysiologic conditions (e.g., stress, infections, hemorrhage) to maintain perfusion to the various body tissues.

The nurse correlates which of these hemodynamic changes with the administration of a drug that decreases peripheral resistance? A) Increased preload B) Decreased afterload C) Decreased cardiac output D) Increased myocardial contractility

B) Decreased afterload Afterload is the pressure against which the heart must pump. Drugs that decrease peripheral resistance will cause a decrease in afterload and a corresponding increase in cardiac output.

The nurse understands that the administration of drugs that lower arterial pressure will trigger the baroreceptor reflex, resulting in what? A) Postural hypotension B) Reflex tachycardia C) Urinary retention D) Vasodilation

B) Reflex tachycardia When drugs are administered that lower arterial pressure, the baroreceptor reflex is stimulated by activation of baroreceptors in the aortic arch and carotid bodies, which results in reflex tachycardia.

In administering medications that affect blood flow, the nurse recognizes that the most important determinant of resistance to blood flow is what? A) Heart rate B) Vessel diameter C) Blood viscosity D) Myocardial contractility

B) Vessel diameter Blood flow is affected by the size of blood vessels (length and diameter) and blood viscosity. Blood vessel diameter has the greatest effect on blood flow and changes as a result of vasoconstriction and vasodilation.

The ________ reflex maintains arterial pressure at a consistent, predetermined level. A) atrioventicular B) baroreceptor C) circumflex D) diastolic

B) baroreceptor The baroreceptor reflex works to maintain arterial pressure. When arterial pressure decreases, arterioles and veins vasoconstrict and heart rate increases to reestablish arterial pressure. Drugs that lower the arterial pressure trigger the baroreceptor reflex.

Which questions would the nurse ask a client when a client is admitted reporting chest pain? Select all that apply. A. "How do you feel about the chest pain?" B. "How long does the pain last and how often does it occur?" C. "Where does the pain occur and what does it feel like?" D. "Have you had other symptoms that occur with the chest pain and what are they?" E. "What activities were you doing when the pain occurred?" F. "Is this episode of chest pain different from other episodes you have had?"

B, C, D, E, F B. "How long does the pain last and how often does it occur?" C. "Where does the pain occur and what does it feel like?" D. "Have you had other symptoms that occur with the chest pain and what are they?" E. "What activities were you doing when the pain occurred?" F. "Is this episode of chest pain different from other episodes you have had?" If pain is present, ask whether it is different from any other episodes of pain. Ask the client to describe which activities he or she was doing when it first occurred, such as sleeping, arguing, or running (precipitating factors). If possible, the client should point to the area where the chest pain occurred (location) and describe if and how the pain radiated (spread). In addition, ask how the pain feels and whether it is sharp, dull, or crushing (quality of pain). To understand the severity of the pain, ask the client to grade it from 0 to 10, with 10 indicating severe pain (intensity). He or she may also re-port other signs and symptoms that occur at the same time (associated symptoms), such as dyspnea, diaphoresis (excessive sweating), nausea, and vomiting. Other factors that need to be addressed are those that may have made the chest pain worse (aggravating factors) or less intense (relieving factors). Asking how the client feels about the pain should be part of the psychosocial assessment.

Which triad of symptoms would the nurse assess for in a woman at risk for cardiovascular disease? Select all that apply. A. Severe chest pain B. Feeling of abdominal fullness C. Chronic fatigue despite adequate rest D. Extremity pain E. Dyspnea or inability to catch her breath F. Intermittent claudication

B, C, E B. Feeling of abdominal fullness C. Chronic fatigue despite adequate rest E. Dyspnea or inability to catch her breath Some clients, especially women, do not experience pain in the chest but, instead, feel discomfort or indigestion. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feelings of an "inability to catch my breath" (dyspnea) are also common in heart disease.

Which questions would the nurse ask to assess a client's nicotine dependence? Select all that apply. A. "What brand of cigarettes do you smoke?" B. "Do you smoke even when you are ill?" C. "How soon after you wake up in the morning do you smoke?" D. "What happened the last time you tried to quit smoking?" E. "Do you wake up in the middle of the night to smoke?" F. "Do you find it difficult not to smoke in places where smoking is prohibited?"

B, C, E, F B. "Do you smoke even when you are ill?" C. "How soon after you wake up in the morning do you smoke?" E. "Do you wake up in the middle of the night to smoke?" F. "Do you find it difficult not to smoke in places where smoking is prohibited?" Determine nicotine dependence by asking questions such as: How soon after you wake up in the morning do you smoke?; Do you wake up in the middle of the night to smoke?; Do you find it difficult not to smoke in places where smoking is prohibited?; and Do you smoke even when you are ill?

Which client serum lipid tests suggest an increased risk for cardiovascular disease (CVD)? Select all that apply. A. HDL 65 mg/dL B. LDL 170 mg/dL C. Triglycerides 185 mg/dL D. Total cholesterol 175 mg/dL E. VLDL 39 mg/dL F. Total cholesterol 250 mg/dL

B, C, E, F B. LDL 170 mg/dL C. Triglycerides 185 mg/dL E. VLDL 39 mg/dL F. Total cholesterol 250 mg/dL See Laboratory Profile Cardiovascular Assessment Box in text. This box lists the normal results and states which lipid results increase the risk for CVD. The desired ranges for lipids are: Total cholesterol less than 200 mg/dL; Triglycerides between 40 and 160 mg/dL for men and between 35 and 135 mg/dL for women; HDL more than 45 mg/dL for men; more than 55 mg/dL for women ("good" cholesterol); and LDL less than 130 mg/dL; VLDL is 7-32 mg/dL or 0.18-0.83 mmol/L (SI units). A fasting blood sample for the measurement of serum cholesterol levels is preferable to a non-fasting sample.

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

B, C, E- b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptoms indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.

Which statements about blood pressure are accurate? Select all that apply. A. The right ventricle of the heart generates the greatest amount of blood pressure. B. Diastolic blood pressure is primarily determined by the amount of peripheral vasoconstriction. C. Systolic blood pressure is the amount of pressure or force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart. D. Diastolic pressure is the highest pressure generated during contraction of the ventricles. E. To maintain adequate blood flow through the coronary arteries, mean arterial pressure (MAP) must be at least 90 mm Hg. F. Paradoxical blood pressure is an exaggerated decrease in systolic pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle.

B, C, F B. Diastolic blood pressure is primarily determined by the amount of peripheral vasoconstriction. C. Systolic blood pressure is the amount of pressure or force generated by the left ventricle to distribute blood into the aorta with each contraction of the heart. F. Paradoxical blood pressure is an exaggerated decrease in systolic pressure by more than 10 mm Hg during the inspiratory phase of the respiratory cycle. The left ventricle generates the greatest amount of blood pressure. To maintain adequate blood flow through the coronary arteries, MAP must be at least 60 mm Hg. Systolic pressure is the highest pressure during contraction of the ventricles. Options B, C, and F are accurate.

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

B, D, E- b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination. Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.

Which actions by an older adult are likely to cause the experience of syncope? Select all that apply. A. Walking briskly for 20 minutes B. Turning the head C. Laughing D. Performing a Valsalva maneuver E. Rapidly swallowing fluids F. Shrugging the shoulders

B, D, F B. Turning the head D. Performing a Valsalva maneuver F. Shrugging the shoulders Syncope in an older adult may result from hypersensitivity of the carotid sinus bodies in the carotid arteries. Pressure applied to these arteries while turning the head, shrugging the shoulders, or performing a Valsalva maneuver (bearing down during defecation) may stimulate a vagal response and syncope. Walking, laughing, or swallowing fluids does not usually cause syncope in older adults.

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

B,D,E- b. Serum potassium of 2.9 mEq/L d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor In the first few hours post-procedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.

B- Document the finding. The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

B- Initiation of an external pacemaker The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day

B- My shoes fit tighter by the end of the day. Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

B- Notify the health care provider before scheduling the MRI. The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you won't need to change your diet.

B- You should balance weight loss with consuming necessary nutrients. Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.

Match the terms and descriptors: Constricts vessels and increases kidney water retention.

B. Aldosterone (renin-angiotensin-aldosterone system).

Which statements accurately reflect Starling's law as applied to a healthy heart? (Select all that apply.) A. When venous return increases, stroke volume decreases. B. The right and left ventricles pump the same amount of blood. C. Cardiac output is equal to the volume of blood delivered by the veins. D. When venous return increases, cardiac output increases. E. As cardiac muscle fibers increase in length, their contractile force decreases.

B. The right and left ventricles pump the same amount of blood. C. Cardiac output is equal to the volume of blood delivered by the veins. D. When venous return increases, cardiac output increases. Starling's law states that the force of ventricular contraction is proportional to muscle fiber length. Therefore, as muscle fibers increase in length, the force of the heart contraction increases. In this situation, the right and left ventricles pump the same amount of blood, and overall cardiac output is equivalent to the volume delivered by the veins. As venous return increases, stroke volume increases accordingly.

Which condition do the natriuretic peptides serve to protect the cardiovascular system? A. Hypovolemia B. Volume overload C. Myocardial infarction D. Hypotension

B. Volume overload Natriuretic peptides protect the cardiovascular system in the event of volume overload. They work by reducing blood volume and promoting the dilation of arterioles and veins.

A patient with heart failure who takes furosemide [Lasix] is diagnosed with bacterial pneumonia. Which medication, if ordered by the physician, should the nurse question? A.Ciprofloxacin [Cipro] B.Gentamicin [Garamycin] C.Amoxicillin [Amoxcil] Erythromycin [E-Mycin}

B.Gentamicin [Garamycin]

For a patient with a nursing diagnosis of Fluid Volume Deficit, the nurse is alert to which signs and symptoms? (Select all that apply.) a. Hypertension b. Flushed skin c. Dry mucous membranes d. Weak, thready pulse e. Pale yellow urine

BCD b. Flushed skin c. Dry mucous membranes d. Weak, thready pulse

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

BCDEF b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results arepaired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

BCDF b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration f. Magnesium: 0.8 mg/dL: Dehydration

A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.) a. Encourage oral fluid intake of at least 2 L/day. b. Use a draw sheet to reposition the client in bed. c. Strain all urine output and assess for urinary stones. d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side every 2 hours.

BD Use a draw sheet to reposition the client in bed. Provide nonslip footwear for the client to use when out of bed.

The patient is to receive potassium 20 mEq every morning. Which of the following orders would the nurse question? (Select all that apply.) a. Potassium 10 mEq capsules. Administer 2 capsules PO. b. Potassium 15 mEq/5 mL liquid. Administer 10 cc of liquid PO. c. Potassium 2 mEq/1 mL solution. Add 10 cc to 1000 cc Lactated Ringers; infuse at 50 mL/h. d. Potassium 5 mEq/1 mL solution. Administer 4 cc IV over 10 minutes.

BD b. Potassium 15 mEq/5 mL liquid. Administer 10 cc of liquid PO. d. Potassium 5 mEq/1 mL solution. Administer 4 cc IV over 10 minutes.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretionand release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

BE b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

The nurse is teaching a patient about the auxiliary venous pump to prevent blood clots. Which image should the nurse use in the teaching session? Pressure gradient (high--> low) Deep veins v superficial vein communication Blood flow to heart between open and closed valves Time difference in pulmonary circulation

Blood flow to heart between open and closed valves

A patient is prescribed digoxin for heart failure. The nurse instructs the patient to avoid consuming bran. What is the reason behind this instruction? Bran decreases digoxin absorption Bran and digoxin cause constipation Bran and digoxin cause urinary retention Bran increases the digoxin concentration in body

Bran decreases digoxin absorption

Which of the following drugs should be used only in situations in which the client can be very closely monitored, such as a critical care unit? Bretylium (Bretylol) Digoxin (Lanoxin) Quinidine (Cardioquin) Inderal (Propranolol)

Bretylium (Bretylol)

Beta blockers should be avoided in which of the following conditions? Bronchoconstriction Hypertension Angina Myocardial infarction

Bronchoconstriction

Epinephrine is used to treat cardiac arrest and status asthmaticus because of which of the following actions? Increased speed of conduction and gluconeogenesis Bronchodilation and increased heart rate, contractility, and conduction Increased vasodilation and enhanced myocardial contractility Bronchoconstriction and increased heart rate

Bronchodilation and increased heart rate, contractility, and conduction

The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation? A) Endocarditis B) Multiple myeloma C) Guillain-Barr syndrome D) Overdose of amphetamines

C Guillain-Barr syndrome

A physician has prescribed 1,000 ml of 0.9% NaCl (normal saline) over 4 hours for a hypovolemic patient. The drop (gtt) factor is 60. What would the nurse set the drip rate at? a) 75 gtt/min b) 100 gtt/min c) 250 gtt/min d) 500 gtt/min

C 250 gtt/min

After receiving the change-of-shift report, which client does the nurse assess first? a. 67 year old with nausea and vomiting who reports abdominal cramps. b. A 77 year old with normal saline infusing at 150 mL/hr with an average hourly urine output of 75 mL. c. A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg. d. A 45 year old with a nasogastric (NG) tube who has dry oral mucosa and reports feeling very thirsty.

C A 57 year old receiving IV diuretics whose blood pressure is 88/52 mm Hg.

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion? A) Leave one hand ungloved to assess the site. B) Cleanse the skin with normal saline. C) Ask the patient about allergies to latex or iodine. D) Remove excessive hair from the selected site.

C Ask the patient about allergies to latex or iodine.

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? A. Hold the next dose of the prescribed antidiarrheal drug B. Assess bowel sounds in all four abdominal quadrants C. Assess the client's response to the Chvostek test D. Increase the IV flow rate of the normal saline infusion

C Assess the client's response to the Chvostek test

Which assessment is most important for the nurse to perform on a client who is receiving IV magnesium sulfate? a. Monitoring 24-hour urine output b. Monitoring the serum calcium levels c. Assessing the blood pressure hourly d. Asking the client whether a headache is present

C Assessing the blood pressure hourly

A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond? a. Potatoes and avocados can be substituted for fruit. b. If you cook the fruit, the amount of potassium will be lower. c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in potassium.

C Berries, cherries, apples, and peaches are low in potassium.

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site? A) Leave the hair intact. B) Shave the area. C) Clip the hair in the area. D) Remove the hair with a depilatory.

C Clip the hair in the area.

Which assessment on an older client with some degree of dehydration will the nurse perform to determine whether the client is safe for independent ambulation? a. Ensuring that the most recent serum potassium level is above 3.5 mEq/L (mmol/L) b. Assessing for furrows on the tongue to determine dryness of oral mucous membranes c. Comparing blood pressure measurements in the lying, sitting, and standing positions d. Ensuring that the pulse rate obtained radially is within 2 beats/min of that obtained apically

C Comparing blood pressure measurements in the lying, sitting, and standing positions

Which of the following IV solutions is considered hypertonic? a. Lactated Ringers b. D5W c. D5 0.45% NS d. 0.9% normal saline

C D5 0.45% NS

What response does the nurse expect to see in the blood volume and blood osmolarity of a client whose secretion of aldosterone is abnormally low? a. Decreased blood volume; increased blood osmolarity b. Increased blood volume; decreased blood osmolarity c. Decreased blood volume; decreased blood osmolarity

C Decreased blood volume; decreased blood osmolarity

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following? A) Help distinguish hyponatremia from hypernatremia B) Help evaluate pituitary gland function C) Help distinguish reduced renal blood flow from decreased renal function D) Help provide an effective treatment for hypertension-induced oliguria

C Help distinguish reduced renal blood flow from decreased renal function

You are called to your patient's room by a family member who voices concern about the patient's status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patient's signs and symptoms? A) Hypocalcemia B) Hyponatremia C) Hyperchloremia D) Hypophosphatemia

C Hyperchloremia

The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate? A) Hypermagnesemia B) Hyponatremia C) Hypocalcemia D) Hyperkalemia

C Hypocalcemia

A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6 mg/dL; and Cl- = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. The nurse recognizes that these symptoms and diagnostic information are consistent with which of the following? a) Hypocalcemia b) Hypernatremia c) Hypokalemia d) Hypermagnesemia

C Hypokalemia

What effect does the nurse expect that an infusion of 200 mL of albumin will have immediately on a client's plasma osmotic and hydrostatic pressures? a.Decreased osmotic pressure; decreased hydrostatic pressure b. Decreased osmotic pressure; increased hydrostatic pressure c. Increased osmotic pressure; increased hydrostatic pressure d. Increased osmotic pressure; decreased hydrostatic pressure

C Increased osmotic pressure; increased hydrostatic pressure

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in patients over 70.

C Inelastic skin turgor is a normal part of aging.

The nurse is assessing the intravenous (IV) site in the right forearm and notices the area around it is cool, swollen, firm, and tender to touch. Which complication is most likely occurring? a. Infection b. Speed shock c. Infiltration d. Phlebitis

C Infiltration

You are making initial shift assessments on your patients. While assessing one patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload

C Infiltration

You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloricstenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since.Upon review of the mornings blood work, you notice that the patients potassium is below referencerange. You should recognize that the patient may be at risk for what imbalance? A) Hypercalcemia B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory acidosis

C Metabolic alkalosis

In reviewing the electrolytes of a client the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

C Pulse rate and rhythm

Which condition or symptom indicates to the nurse that the client's treatment for hyperkalemia is effective? a. Chvostek sign is negative. b. Respiratory rate is 22 breaths/min. c. Pulse rate is 76 beats/min and regular. d. Hematocrit is 42%.

C Pulse rate is 76 beats/min and regular.

What is the nurse's best action when auscultating S1 for a client is difficult? A. Ask the assistive personnel (AP) to do a 12-lead electrocardiogram (ECG). B. Auscultate with the bell of the stethoscope instead of the diaphragm. C. Have the client lean forward or roll to his or her left side. D. Instruct the client to take deep breaths and hold them for 5 seconds.

C Have the client lean forward or roll to his or her left side. When there is difficulty hearing heart sounds, have the client lean forward or roll to his or her left side. These actions move the heart closer to the chest wall and can facilitate hearing the heart sounds more clearly.

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.

C Read food labels to determine sodium content.

A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom? a. Frequent nocturia b. Headaches c. Ringing in the ears d. Urinary retention

C Ringing in the ears Patients taking furosemide should be advised that the risk of furosemide-induced hearing loss can be increased when other ototoxic drugs, such as gentamicin, are also taken. Patients should be told to report tinnitus, dizziness, or hearing loss. Nocturia may be an expected effect of furosemide. Headaches are not likely to occur with concomitant use of gentamicin and furosemide. Urinary retention is not an expected side effect.

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? A. Foot and ankle B. Forehead C. Sacrum D. Chest

C Sacrum

After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

C Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk

Which serum electrolyte value indicates to the nurse that the client has hypernatremia? a. Sodium 132 mEq/L (mmol/L) b. Potassium 3.5 mEq/L (mmol/L) c. Sodium 148 mEq/L (mmol/L) d. Potassium 5.3 mEq/L (mmol/L)

C Sodium 148 mEq/L (mmol/L)

The nurse is caring for a patient who needs to increase calcium in her diet but does not like milk. Which food should the nurse encourage the patient to consume? a. Cod b. Eggs c. Spinach d. Tomatoes

C Spinach

A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? a. Bumetanide [Bumex] b. Furosemide [Lasix] c. Spironolactone [Aldactone] d. Hydrochlorothiazide [HydroDIURIL]

C Spironolactone [Aldactone] Spironolactone is a non-potassium-wasting diuretic; therefore, if the patient has a serum potassium level of 6 mEq/L, indicating hyperkalemia, an order for this drug should be questioned. Bumetanide, furosemide, and hydrochlorothiazide are potassium-wasting diuretics and would be appropriate to administer in a patient with hyperkalemia.

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, Apatient in renal failure partially loses the ability to regulate changes in pH. What is the cause of thispartial inability? A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH. B) The kidneys buffer acids through electrolyte changes. C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH. D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

C The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.

A nurse is caring for an 80-year-old patient who is receiving bumetanide (a loop diuretic) for hypertension. The nurse notes that the patient admits to taking bisacodyl (Dulcolax) daily to stimulate her bowels. The nurse should assess the patient for possible symptoms of a. hypoglycemia. b. hypoparathyroidism. c. hypokalemia. d. hypocalcemia.

C hypokalemia.

For a patient in respiratory distress, the first arterial blood gases (ABGs) were: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. The ABGs were repeated the next morning. The new results are the following: pH = 7.47; PCO2 = 26 mmol/L; HCO3 = 20 mEq/L. The nurse recognizes that the values have changed and that the patient is now experiencing a) respiratory acidosis. b) metabolic alkalosis. c) partial compensation. d) complete compensation.

C partial compensation.

What is the client's pulse pressure when the nurse finds that his or her blood pressure is 148/86 mm Hg? A. 48 mm Hg B. 56 mm Hg C. 62 mm Hg D. 86 mm Hg

C 62 mm Hg The difference between the systolic and diastolic values is referred to as pulse pressure. 148 - 86 = 62 mm Hg.

What action does the nurse plan to take prior to a cardiac catheterization when a client states he or she has an allergy to seafood and iodine-containing dyes? A. Inform the cardiologist because the test must be delayed for a week. B. Prepare to administer anticoagulation therapy before the test. C. Administer an antihistamine and/or a steroid before the test. D. Instruct the client that the test will be conducted using noncontrast dye.

C Administer an antihistamine and/or a steroid before the test. Before the procedure, question the client about any history of allergy to iodine-based contrast agents. An antihistamine or steroid may be given to a client with a positive history or to prevent a reaction. The test does not need to be delayed and contrast dye is necessary to see any coronary artery blockages. Anticoagulants would not be given because that would cause bleeding.

What is the nurse's first action when the health care provider prescribes orthostatic blood pressure checks for a client? A. Wait for 1 minute before auscultating blood pressure while the client is sitting. B. Instruct the client to sit on the side of the bed before checking blood pressure. C. Measure the blood pressure after the client has been supine for 3 minutes. D. Tell the client to change positions rapidly between blood pressure checks.

C Measure the blood pressure after the client has been supine for 3 minutes. Postural (orthostatic) hypotension occurs when the BP is not adequately maintained while moving from a lying to a sitting or standing position. It is defined as a decrease of more than 20 mm Hg of the systolic pressure or more than 10 mm Hg of the diastolic pressure and a 10% to 20% increase in heart rate. To detect orthostatic changes in BP, first, measure the BP when the client is supine. After remaining supine for at least 3 minutes, the client changes position to sitting or standing. Normally systolic pressure drops slightly or remains unchanged as the client rises, whereas diastolic pressure rises slightly. After the position change, wait for at least 1 minute before auscultating BP and counting the radial pulse. The cuff should remain in the proper position on the client's arm. Observe and record any signs or symptoms of dizziness. If the client cannot tolerate the position change, return him or her to the previous position of comfort.

A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.5 mEq/L d. Sodium level of 140 mEq/L

C Potassium level of 3.5 mEq/L This patient has an irregular, rapid heartbeat that might be caused by a dysrhythmia. This patient's serum potassium level is low, which can trigger fatal dysrhythmias, especially in patients taking digoxin. Furosemide contributes to loss of potassium through its effects on the distal nephron. Potassium-sparing diuretics often are used in conjunction with furosemide to prevent this complication. This patient's serum glucose and sodium levels are normal and of no concern at this point, although they can be affected by furosemide. The oxygen saturation is somewhat low and needs to be monitored, although it may improve with diuresis.

Which tests will the nurse teach a client are routinely done for follow-up monitoring when the client is discharged with a prescription for warfarin? A. Complete blood count and platelet count B. Partial thromboplastin time (PTT) and serum potassium C. Prothrombin time (PT) and international normalized ratio (INR) D. Serum and urine electrolyte studies

C Prothrombin time (PT) and international normalized ratio (INR) are used when initiating and maintaining therapy with oral anticoagulants, such as sodium warfarin. They measure the activity of prothrombin, fibrinogen, and factors V, VII, and X. INR is the most reliable way to monitor anticoagulant status in warfarin therapy. The therapeutic ranges vary significantly based on the reason for the anticoagulation and the client's history. The normal INR is 0.8-1.1. An INR range of 2.0-3.0 is generally an effective therapeutic range for people taking warfarin.

What common assessment finding would the nurse expect to find in an older adult with cardiovascular disease? A. Lower leg swelling B. Pericardial friction rub C. S4 heart sound D. Change in point of maximal impulse (PMI) location

C S4 heart sound This question asks for a finding related to aging. An atrial gallop (S4) may be heard in clients with hypertension, anemia, ventricular hypertrophy, MI, aortic or pulmonic stenosis, and pulmonary emboli. It may also be heard with advancing age because of a stiffened ventricle. Edema, friction rubs, and PMI changes occur with CVD but are not just age related.

When a client is hypovolemic, which tissue reacts and sends fewer impulses to the CNS? A. Baroreceptors B. Central chemoreceptors C. Stretch receptors D. Kidney receptors

C Stretch receptors Stretch receptors in the vena cava and the right atrium are sensitive to pressure or volume changes. When a client is hypovolemic, stretch receptors in the blood vessels sense a reduced volume or pressure and send fewer impulses to the CNS. This reaction stimulates the sympathetic nervous system to increase the heart rate and constrict the peripheral blood vessels. Impulses from these baroreceptors inhibit the vasomotor center which results in a drop in BP. Central chemoreceptors in the respiratory center of the brain are also stimulated by hypercapnia (an increase in partial pressure of arterial carbon dioxide [Paco2]) and acidosis. The kidneys retain sodium and water so BP tends to rise because of fluid retention and activation of the renin-angiotensin-aldosterone mechanism.

Which statement about the peripheral vascular system is accurate? A. The velocity of blood flow depends on the diameter of the blood vessel lumen. B. The parasympathetic nervous system has the largest effect on blood flow to organs. C. Veins have valves that direct blood flow to the heart and prevent backflow. D. Blood flow decreases and blood tends to clot as the viscosity decreases.

C Veins have valves that direct blood flow to the heart and prevent backflow. Veins in the superficial and deep venous systems (except the smallest and the largest veins) have valves that direct blood flow back to the heart and prevent backflow. Skeletal muscles in the extremities provide a force that helps push the venous blood forward. Veins have the ability to accommodate large shifts in volume with minimal changes in venous pressure.

The nurse recognizes the action of natriuretic peptides as what? A) Increased preload B) Increased afterload C) Increased vasodilation D) Increased water retentio

C) Increased vasodilation Natriuretic peptides provide protection to the cardiovascular system by decreasing blood volume and facilitating arterial and venous dilation

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss?

The hematocrit is 52%.

The nurse recognizes that the primary factor responsible for blood return back to the right side of the heart is what? A) Constriction of smooth muscle in the venous wall B) Negative pressure in the right atrium C) Skeletal muscle contraction D) Arterial valves

C) Skeletal muscle contraction Pressure decreases progressively as blood flows through the circulatory system, with the pressure only 18 mm Hg when blood leaves the capillaries. Blood return to the heart is facilitated by negative pressure in the right atrium, which "sucks" blood toward the heart; smooth muscle constriction in the venous walls; and, most important, the combination of venous valves and skeletal muscle contraction that promotes venous pumping.

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

C- A 45-year-old American Indian woman with diabetes mellitus The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.

C- Assess the clients medications. Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.

C- Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

C- Disorientation and confusion In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

C- Slurred speech and confusion A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?

C- Tell me more about your concerns about the surgery The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue.

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?

C- What do you understand about what happened to you? Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the clients misconception about recent pain and the cause of that pain.

What does the nurse suspect when a client states "I get short of breath whenever I lie down for several hours?" A. Dyspnea on exertion B. Orthopnea C. Paroxysmal nocturnal dyspnea D. Fatigue

C. Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea (PND) develops after the client has been lying down for several hours. In this position, blood from the lower extremities is redistributed to the venous system, which increases venous return to the heart. A diseased heart cannot compensate for the increased volume and is ineffective in pumping the additional fluid into the circulatory system. Pulmonary congestion results, and the client awakens abruptly, often with a feeling of suffocation and panic. He or she sits upright and dangles the legs over the side of the bed to relieve the dyspnea. This sensation may last for 20 minutes. Dyspnea associated with activity is dyspnea on exertion. Orthopnea is dyspnea whenever a client lies flat and may require three to four pillows for sleep. Fatigue is a feeling of tiredness as a result of activity.

The nurse is caring for a patient receiving IV therapy with a 3% sodium chloride infusion at 75 mL/hr. The nurse should closely monitor for which adverse effect of treatment? A. Blood urea nitrogen of 22 mg/dL B. Tenting of the skin and dry mucous membranes C. Distended neck veins and ankle edema D. Sodium level of 140 mEq/L

C. Distended neck veins and ankle edema An IV solution of 3% sodium chloride is hypertonic and may cause fluid overload. Signs of volume overload include distended neck veins and ankle edema. The blood urea nitrogen level and sodium level are normal values. Tenting of the skin and dry mucous membranes indicate volume contraction, which would not be a likely adverse effect of this therapy.

A patient who is a chronic alcoholic is admitted to the hospital. Admission laboratory work reveals a magnesium level of 1.2 mEq/L. The prescriber orders intravenous magnesium sulfate in a 10% solution at a rate of 10 mL/min. What will the nurse do? a. Administer the IV dose as ordered and have calcium gluconate on hand. b. Administer the IV dose and make preparations for mechanical ventilation. c. Hold the IV dose until the infusion rate has been clarified with the provider. d. Request an order for renal function tests before administering the IV dose.

C. Hold the IV dose until the infusion rate has been clarified with the provider.

The nurse is caring for a patient receiving oral magnesium gluconate. Which symptom indicates a common adverse effect of this medication? A. Headache B. Wheezing C. Loose stools D. Urinary retention

C. Loose stools Diarrhea is a common side effect of magnesium supplementation. Other symptoms of excessive doses include neuromuscular blockade, atrioventricular (AV) heart block, and cardiac arrest.

Which acid-base imbalance is caused by chronic renal failure, loss of bicarbonate during severe diarrhea, or metabolic disorders that result in overproduction of lactic acid? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

C. Metabolic acidosis Principal causes of metabolic acidosis are chronic renal failure, loss of bicarbonate during severe diarrhea, and metabolic disorders that result in overproduction of lactic acid (lactic acidosis) or ketoacids (ketoacidosis). Metabolic acidosis may also result from poisoning by methanol and certain medications (eg, aspirin and other salicylates).

The nurse is preparing to administer IV potassium to a patient with hypokalemia. Which prescription is the most appropriate? A. Potassium chloride 30 mEq in 100 mL IV over 1 hour B. Potassium chloride 10 mEq in 100 mL IV over 30 minutes C. Potassium chloride 10 mEq in 100 mL IV over 1 hour D. Potassium chloride 10 mEq IV push over 1 minute

C. Potassium chloride 10 mEq in 100 mL IV over 1 hour IV potassium must be diluted (never given IV push) and infused slowly, at a rate no faster than 10 mEq/hr. Faster infusions of potassium can lead to cardiac toxicity.

A patient is prescribed spironolactone [Aldactone] for treatment of hypertension. Which foods should the nurse teach the patient to avoid? A.Baked fish B.Low-fat milk C.Salt substitutes D.Green beans

C.Salt substitutes

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

CD c. Strong productive cough d. Active bowel sounds

Which body areas are best for the nurse to use when assessing skin indications of hydration status for an older client? (Select all that apply.) a. Tops of the forearms b. Skin of the shins c. Skin of the forehead d. Skin over the abdomen e. Skin over the sternum f. Back of the hand

CDE c. Skin of the forehead d. Skin over the abdomen e. Skin over the sternum

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L) (Select all that apply.) a. Keeping the client NPO during drug treatment b. Pushing the drug as a bolus slowly over 5 minutes c. Using an IV controller to deliver the drug d. Checking IV access for blood return after the infusion e. Initiating the IV in a hand vein for rapid access f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

CF c. Using an IV controller to deliver the drug f. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution

A patient with hypomagnesemia is undergoing treatment with a continuous IV infusion of magnesium. Which supply does the nurse ensure is at the bedside of this patient? 10% glucose Sodium chloride Calcium gluconate Potassium chloride

Calcium gluconate Calcium gluconate is indicated in the treatment of hypermagnesemia, which can occur with continuous IV infusion of magnesium. Because hypermagnesemia causes neuromuscular blockade, these patients are at risk for paralysis of respiratory muscles. Calcium gluconate can counteract the neuromuscular blocking actions of magnesium.

Competitive antagonism of which of the following occurs at beta receptor sites? Catecholamines Adrenergic sites Acetylcholine Norepinephrine

Catecholamines

The nurse knows that diuretics mostly affect which function of the kidneys? Cleansing and maintenance of extracellular fluid volume Maintenance of acid-base balance Excretion of metabolic waste Elimination of foreign substances

Cleansing and maintenance of extracellular fluid volume

Following norepinephrine (Levophed) administration, it is essential to the nurse to assess Electrolyte status Color and temperature of toes and fingers Capillary refill Ventricular arrhythmias

Color and temperature of toes and fingers

15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?

Connect the client to a cardiac monitor.

When a patient's renin-angiotensin-aldosterone system is activated, which responses would the nurse expect? Select all that apply. Dilation of veins Diuresis by the kidneys Constriction of arterioles Retention of water by the kidneys Constriction of renal blood vessels

Constriction of arterioles Retention of water by the kidneys Constriction of renal blood vessels

A provider orders digoxin to be given intramuscularly to a patient with heart failure. Which action should the nurse take? Dilute the drug in normal saline before injecting Administer the medication using the Z-track method Inject the medication quickly to ensure rapid digitalization Contact the provider and question the route of administration

Contact the provider and question the route of administration

A nurse is teaching the staff about Starling's law. Which image should the nurse use to depict this concept in the teaching session? Contractile force v fiber length Deep veins v superficial vein communication Blood flow to heart between open and closed valves Pressure gradient (high--> low)

Contractile force v fiber length

With which client does the nurse remain alert for and assess most frequently for signs and symptoms of hypokalemia? A. 72-year-old taking the diuretic spironolactone for control of hypertension B. 62-year-old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hour C. 42-year-old trauma victim receiving a third infusion of packed red blood cells in 12 hours D. 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

D 22-year-old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate? a. Administer the medications as ordered. b. Ask the patient about the use of salt substitutes. c. Contact the provider to request an order for serum electrolytes. d. Request an order for furosemide [Lasix].

D Administer the medications as ordered. Spironolactone takes up to 48 hours for its effects to develop, so it should not be used when the patient needs immediate diuresis. This patient has shortness of breath, crackles, and edema and needs a short-acting diuretic, such as furosemide. Asking the patient about the use of salt substitutes is not indicated. The patient does not need assessment of serum electrolytes.

Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why? a) Cations, because they carry a positive charge b) Cations, because they carry a negative charge c) Anions, because they carry a positive charge d) Anions, because they carry a negative charge

D Anions, because they carry a negative charge

A patient's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patient's dietary intake of potassium. Which of the following would be a good source of potassium? A) Apples B) Asparagus C) Carrots D) Bananas

D Bananas

The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A) Decrease in the release of aldosterone B) Increase of filtration in the Loop of Henle C) Decrease in the reabsorption of sodium D) Decrease in glomerular filtration

D Decrease in glomerular filtration

The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following? a) Osmosis b) Filtration c) Hydrostatic pressure d) Diffusion

D Diffusion

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload? a. Checking for presence of dependent edema b. Assessing blood pressure c. Measuring intake and output d. Elevating the head of the bed

D Elevating the head of the bed

A patient has been admitted to the hospital with medical diagnoses of hypervolemia, acute renal failure, and cardiac dysrhythmias. The patient's vital signs are: T = 98.4°F (36.9°C); P = 110; R = 32; BP = 162/102. On physical examination, the nurse notes distended neck veins and 3+ pitting edema in both lower extremities. The patient reports he has been drinking and eating as usual but has been unable to urinate. Which is the most appropriate nursing diagnosis for this patient? a) Excess Fluid Volume related to excessive food and fluid intake b) Deficient Fluid Volume related to increased metabolic demands c) Imbalanced Electrolytes secondary to fluid shifts d) Excess Fluid Volume secondary to acute renal failure

D Excess Fluid Volume secondary to acute renal failure

Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high aniongap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis? A) Metastases B) Excessive potassium intake C) Water intoxication D) Excessive administration of chloride

D Excessive administration of chloride

Which laboratory value indicates to the nurse that a client's hyponatremia may be related to a fluid volume excess? a. Serum chloride level is 100 mEq/L (mmol/L) b. Blood urea nitrogen (BUN) is elevated c. Arterial blood pH is 7.37 d. Hematocrit is 29% (0.29 volume fraction)

D Hematocrit is 29% (0.29 volume fraction)

A nurse caring for a hospitalized patient is told in the shift change report that the patient's laboratory results are sodium = 140 mEq/L; potassium = 4.1 mEq/L; calcium = 9.5 mg/dL; and magnesium = 3.4 mEq/L. Which abnormal level will the nurse report to the primary care provider? a. High sodium level b. Low potassium c. Low calcium level d. High magnesium level

D High magnesium level

Which assessment finding indicates to the nurse that the older client's therapy for dehydration is successful? a. Pulse pressure has decreased. b. Client reports feeling hungry. c. Hematocrit is 58% (0.58 volume fraction). d. Hourly urine output is greater than 15 mL.

D Hourly urine output is greater than 15 mL.

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A) Active transport of hydrogen ions across the capillary walls B) Pressure of the blood in the renal capillaries C) Action of the dissolved particles contained in a unit of blood D) Hydrostatic pressure resulting from the pumping action of the heart

D Hydrostatic pressure resulting from the pumping action of the heart

You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance? A) Hypernatremia B) Hypomagnesemia C) Hypophosphatemia D) Hypercalcemia

D Hypercalcemia

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia

D Hypovolemia

Which action will the nurse perform first for the client who has a serum potassium level of 6.9 mEq/L (mmol/L)? a. Teaching the client which foods to avoid b. Administering sodium polystyrene sulfonate orally c. Collaborating with the registered dietitian nutritionist to provide a potssium-restricted diet d. Initiating continuous cardiac monitoring

D Initiating continuous cardiac monitoring

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis

D Metabolic acidosis with a compensatory respiratory alkalosis

A nurse is caring for an adult patient who has gastric suction following abdominal surgery. The patient tells the nurse that he has tingling in his fingers and toes and is feeling dizzy. Which acid-base imbalance is the patient most likely experiencing? a. Respiratory alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Metabolic alkalosis

D Metabolic alkalosis

The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acid base disorder? A) Respiratory acidosis B) Metabolic alkalosis C) Respiratory alkalosis D) Mixed acid-base disorder

D Mixed acid-base disorder

The nurse is discontinuing a central venous access device. When she removes the catheter, she notes that a portion of the tip is missing. What action must she take? a) Apply a tourniquet above the site. b) Start a new peripheral IV. c) Apply warm compresses to the site. d) Notify the physician and radiologist.

D Notify the physician and radiologist.

A patient is to receive two units of packed red blood cells. Her blood group is O+. The nurse knows that the patient may receive blood from which of the following donors? a) AB+, A-, B+, and O- b) A+ and O+ c) AB- and O+ d) O+ and O-

D O+ and O-

A 65-year-old female patient is a two-pack-a-day cigarette smoker with a history of chronic obstructive pulmonary disease (COPD). What is the interpretation of her arterial blood gas values (pH 7.34, PCO2 55, PO2 82, HCO3 32)? a. Partially compensated respiratory alkalosis b. Uncompensated metabolic acidosis c. Uncompensated respiratory alkalosis d. Partially compensated respiratory acidosis

D Partially compensated respiratory acidosis

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A) Hypertension B) Kussmaul respirations C) Increased DTRs D) Shallow respirations

D Shallow respirations

A patient with hypertension is taking furosemide [Lasix] for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient? a. Bumetanide [Bumex] b. Chlorothiazide [Diuril] c. Hydrochlorothiazide [HydroDIURIL] d. Spironolactone [Aldactone]

D Spironolactone [Aldactone] Spironolactone is used in conjunction with furosemide because of its potassium-sparing effects. Furosemide can contribute to hypokalemia, which can increase the risk of fatal dysrhythmias, especially with digoxin administration. The other diuretics listed are all potassium-wasting diuretics.

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine specific gravity is high. D. The hematocrit is 52%.

D The hematocrit is 52%.

A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse's most likely explanation for the low urine output? A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place. B) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin. C) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output. D) The man is having a sympathetic reaction, which has stimulated the reninñangiotensinñaldosterone system that result

D The man is having a sympathetic reaction, which has stimulated the reninñangiotensinñaldosterone system that result

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nursespreceptor is going over the patients past lab reports with the new nurse. The nurse takes note that thepatients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the newnurse why they will be cautious administering oxygen. What is the new nurses best response? A) The patients calcium will rise dramatically due to pituitary stimulation. B) Oxygen will increase the patients intracranial pressure and create confusion. C) Oxygen may cause the patient to hyperventilate and become acidotic. D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

D Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

How many cigarette pack-years has this client smoked: Smoked half a pack a day for 6 years? A. 1⁄2 pack-year B. 1 pack-year C. 2 pack-years D. 3 pack-years

D 3 pack-years Pack-years are the number of packs of cigarettes per day multiplied by the number of years the client has smoked. 1⁄2 x 6 = 3 pack-years.

What is the lowest mean arterial pressure (MAP) necessary to perfuse the major organs of the body? A. 90 to 100 mm Hg B. 80 to 90 mm Hg C. 70 to 80 mm Hg D. 60 to 70 mm Hg

D 60 to 70 mm Hg A MAP between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs, such as the kidneys and brain. While all of these MAPs will maintain perfusion to the major organs, this question asks for the lowest MAP necessary to maintain major organ perfusion and therefore option D is the best response.

What is the priority problem when a nurse assesses a client with CVD and notes skin that is pale, cool, and moist? A. Skin integrity B. Abnormal body temperature C. Peripheral neurovascular dysfunction D. Decreased perfusion

D Decreased perfusion Decreased perfusion is manifested as cool, pale, and moist skin. If there is normal blood flow or adequate perfusion to a given area in light-colored skin, it appears pink, perhaps rosy, and is warm.

Which parameter indicates to the nurse that a client's exercise electrocardiogram (ECG) should be stopped? A. Increase in heart rate B. Increase in blood pressure C. ECG shows P waves before every QRS complex D. ECG shows ST-segment depression

D ECG shows ST-segment depression Increases in heart rate and blood pressure are expected. P waves before each QRS complex is a normal finding. The client exercises until one of these findings occurs: a predetermined HR is reached and maintained; signs and symptoms such as chest pain, fatigue, extreme dyspnea, vertigo, hypotension, and ventricular dysrhythmias appear; or significant ST-segment depression or T-wave inversion occurs.

What is the priority medical-surgical concept when the nurse is assessing a client with cardiovascular disease (CVD)? A. Acid-base balance B. Fluid and electrolyte balance C. Gas exchange D. Perfusion

D Perfusion The priority concept when assessing for cardiovascular disease is perfusion. The interrelated concept for this chapter is fluid and electrolyte balance. Gas exchange and acid-base balance are more pertinent to respiratory and renal illnesses.

Which information from a client's medical history causes the nurse to check for abnormalities of the heart valves? A. Staphylococcal infections of the skin B. Yeast infections of the vagina C. Fungal infections on the toenails D. Streptococcal infections of the throat

D Streptococcal infections of the throat Ask clients about recurrent tonsillitis, streptococcal infections, and rheumatic fever because these conditions may lead to valvular abnormalities of the heart.

What does the nurse suspect when a client who had a bruit on assessment during the previous 2 days does not have a bruit on assessment to-day? A. The prescribed antiplatelet therapy is working. B. The problem has resolved spontaneously. C. The previous findings may have been an anomaly. D. The occlusion of the blood vessel is now 90%.

D The occlusion of the blood vessel is now 90% Bruits are swishing sounds that may occur from turbulent blood flow in narrowed or atherosclerotic arteries. Assess for the absence or presence of bruits by placing the bell of the stethoscope on the neck over the carotid artery while the client holds his or her breath. Normally there are no sounds if the artery has un-interrupted blood flow. A bruit may develop when the internal diameter of the vessel is narrowed by 50% or more, but this does not indicate the severity of disease in the arteries. Once the vessel is blocked 90% or greater, the bruit often cannot be heard.

In assessing the circulatory status of a patient, the nurse understands that what percentage of circulating blood is in the systemic veins? A) 16% B) 32% C) 48% D) 64%

D) 64% The largest percentage of blood volume is contained in the venous system and represents approximately 64% of circulating blood volume.

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

D- Pulse decreased from 100 beats/min to 80 beats/min Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

D- A 58-year-old male who describes his pain as intense stabbing that spreads across his chest All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

D- Allergies to iodine-based agents Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.

The nurse is reviewing the chart of a patient with heart failure. Which information would lead the nurse to notify the provider? digoxin 0.25mg PO daily = hypokalemia = abdomen soft, nontender Furodemide 40mg PO daily = hyponatremia = pulse rate 62 Carvedilol 12.5 mg bid = low urine specific gravity = large amount of clear yellow urine Hypokalemia Pulse rate 62 Large amount clear yellow urine Carvedilol 12.5mg bid

Hypokalemia

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping

D- Use pillows to elevate your head and chest while you are sleeping The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.

Complete the equation: Cardiac output = Volume of blood ejected at each heartbeat × ____. A. Stroke volume B. Preload C. Afterload D. Heart rate

D. Heart rate The amount of blood ejected with each heartbeat is known as the stroke volume. To determine the cardiac output, multiply the stroke volume by the number of beats per minute.

A patent with early heart failure (HF) has an average heart rate of 90 beats/min and a stroke volume of 55 mL. What is true about this patient's per-minute cardiac output? A. It is extremely low. B. It is low. C. It is high. D. It is within normal limits.

D. It is within normal limits.

Which acid-base imbalance is characterized by increases in both the pH and bicarbonate content of plasma? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

D. Metabolic alkalosis Metabolic alkalosis is characterized by increases in both the pH and bicarbonate content of plasma. Causes include excessive loss of gastric acid (through vomiting or suctioning) and administration of alkalinizing salts (eg, sodium bicarbonate).

Which hemodynamic system serves as a reservoir for circulating blood? A. Heart B. Lungs C. Arteries D. Veins

D. Veins Most of the circulating blood is in the veins, venules, and venous sinuses. The venous system serves as a reservoir for circulating blood.

16. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?

Dangle the client on the bedside before ambulating.

The nurse plans to closely monitor for which clinical manifestation after administering furosemide [Lasix]? Decreased pulse Decreased temperature Decreased blood pressure Decreased respiratory rate

Decreased blood pressure

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?

Decreased orthostatic changes when standing

Which of the following effects of calcium channel blockers causes a reduction in blood pressure? Increased cardiac output Decreased peripheral vascular resistance Decreased renal blood flow Calcium influx into cardiac muscles

Decreased peripheral vascular resistance

9. A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?

Depth of respirations

Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L?

Determining what drugs are taken daily

The nurse who is caring for a patient with heart failure informs the patient that, "This drug will increase the contractions of your heart." Which drug is the nurse administering? Digoxin Carvedilol Bisoprolol Verapamil

Digoxin

Blurred vision or halos are signs of Digoxin toxicity Nothing related to digoxin Corneal side effects of digoxin

Digoxin toxicity

The nurse should monitor for which adverse effect after administering hydrochlorothiazide [HydroDIURIL] and digoxin [Lanoxin] to a patient? Digoxin toxicity Decreased diuretic effect Dehydration Heart failure

Digoxin toxicity

The nurse is caring for a patient with heart failure. Which drugs would the nurse typically administer for routine first-line therapy? Select all that apply. Diuretics Beta blockers Cardiac glycosides Sympathomimetics Angiotensin-converting enzyme (ACE) inhibitors

Diuretics Beta blockers Angiotensin-converting enzyme (ACE) inhibitors

Which of the following blood tests will tell the nurse that an adequate amount of drug is present in the blood to prevent arrhythmias? Serum chemistries Complete blood counts Drug levels None of the above

Drug levels

Match the terms and descriptors: The amount of stretch in the ventricle before it contracts.

E. Preload.

When administering an antiarrhythmic agent, which of the following assessment parameters is the most important for the nurse to evaluate? ECG Pulse rate Respiratory rate Blood pressure

ECG

Match the terms and descriptors: Pressure in the aorta that the heart must overcome to eject blood out of the heart.

F. Afterload.

T or F: Arteries readily stretch in response to pressure changes.

False.

T or F: Normal adult blood volume is 8 L.

False.

T or F: Stimulation of the vagal nerve, such as bearing down to defecate, speeds the heart rate.

False.

T or F: The majority of the blood in the body is in the arteries of the heart.

False.

T or F: Vasodilation increases resistance to blood flow.

False.

Which of the following ECG findings alerts the nurse that the client needs an antiarrhythmic? Normal sinus rhythm Sinus bradycardia Sinus arrhythmia Frequent ventricular ectopy

Frequent ventricular ectopy

After reviewing the chart of a patient with heart failure, the nurse should be prepared to administer which diuretic? venous distention present = low glomerular filtration rate = heart disease ankle edema = reduced cardiac output = stage C crackles in lungs = sodium normal = functional classification: Class II Eplerenone Furosemide Spironolactone Hydrochlorothiazide

Furosemide

Match the terms and descriptors: Pressure sensors in the aortic arch and carotid sinus.

G. Baroreceptors.

The nurse is preparing to administer an oral dose of digoxin [Lanoxin]. The apical pulse rate is 64. Which nursing action is most appropriate? Give the medication Obtain a serum digoxin level Notify the healthcare provider Assess for signs of digoxin toxicity

Give the medication

Routine laboratory monitoring in clients taking beta blockers should include Sodium Glucose Thyrotropin Creatine phosphokinase

Glucose

6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching?

Grilled chicken breast with glazed carrots

Match the terms and descriptors: Primarily promotes vasodilation.

H. C-natriuretic peptide.

A nurse discovers that a patient has a cardiac output of 5 L/min. What else should the nurse assess to determine cardiac output besides stroke volume? Heart rate Blood pressure Cardiac preload Cardiac afterload

Heart rate

Complete the equation: Cardiac output = Volume of blood ejected at each heartbeat × ____. Preload Afterload Heart rate Stroke volume

Heart rate

Which of the following is a contraindication for digoxin administration? Blood pressure of 140/90 Heart rate above 80 Heart rate below 60 Respiratory rate above 20

Heart rate below 60

The nurse caring for a patient taking furosemide [Lasix] is reviewing the patient's most recent laboratory results, which are: sodium, 136 mEq/L; potassium, 3.2 mEq/L; chloride, 100 mEq/L; blood urea nitrogen, 15 mg/dL. What is the nurse's best action? Administer Lasix as ordered. Place the patient on a cardiac monitor. Begin a 24-hour urine collection. Hold the Lasix and notify the physician

Hold the Lasix and notify the physician

The nurse should recognize that which drug only dilates arterioles? Hydralazine Nitroglycerin Isosorbide dinitrate Sodium nitroprusside

Hydralazine

The nurse is reviewing the home medication list with the patient. The nurse recognizes that hydrochlorothiazide is used primarily for which condition? Hypertension Edema Diabetes insipidus Protection against postmenopausal osteoporosis

Hypertension

Which laboratory value places the patient at greatest risk of digoxin toxicity? Hypokalemia Hyponatremia Hypocalcemia Hypomagnesemia

Hypokalemia Hypokalemia increases the risk of digoxin toxicity. Potassium has a major role in nerve impulse conduction and maintaining the electrical excitability of muscles.

Which of the following adverse reactions is found more often in volume-depleted elderly clients? Bradycardia Conduction defects Ankle edema Hypotension

Hypotension

Norepinephrine (Levophed) is contraindicated in which of the following conditions? Hypovolemic shock Neurogenic shock Blood pressures above 80-100 mmHg (systolic) Decreased renal perfusion

Hypovolemic shock

Match the terms and descriptors: Shift fluid from vascular to extravascular compartment, increases diuresis, dilate arterioles and veins.

I. Natriuretic Peptides ANP and BNP.

The action of a medication is inotropic when it Decreases afterload Increases heart rate Increases the force of contraction Is used to treat CHF

Increases the force of contraction

Amrinone (Inocor) is used for short term therapy of CHF and acts by which of the following mechanisms? Increasing stroke volume and heart rate Slowing ventricular rate and increasing cardiac output Vasodilating and increasing peripheral vascular resistance Increasing cardiac output and enhancing renal perfusion

Increasing stroke volume and heart rate

A patient of African American heritage with heart failure is unable to tolerate angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). Which medication is an appropriate alternative for this patient? Eplerenone [Inspra] Triamterene [Dyrenium] Hydrochlorothiazide [Microzide] Isosorbide dinitrate and hydralazine [BiDil]

Isosorbide dinitrate and hydralazine [BiDil]

The nurse who administers spironolactone to a patient with heart failure should recognize that it promotes improvement by what mechanism? It is a strong diuretic It promotes fluid retention It blocks the action of aldosterone It promotes elimination of excess potassium

It blocks the action of aldosterone

The nurse understands that the serum level of potassium is regulated by which organ? Liver Lungs Kidneys Small intestine

Kidneys The kidneys, largely under the control of aldosterone from the adrenal cortex, retain potassium while losing sodium and water.

Match the terms and descriptors: Stimulation of these receptors increases heart rate.

L. Beta2-adrenergic receptors.

Johanna has ventricular ectopy, which of the following drugs is the first line used to treat her condition? quinidine (Cardioquin) digoxin (Lanoxin) procainamide ( Pronestyl) lidocaine (Xylocaine)

Lidocaine (Xylocaine)

Which of the following statements about mannitol [Osmitrol] are correct? (Select all that apply.) Mannitol cannot be given orally. Mannitol can cause edema. Mannitol can cause renal failure. Diuresis begins in 30 to 60 minutes after administration. Mannitol is a loop diuretic.

Mannitol cannot be given orally. Mannitol can cause edema. Diuresis begins in 30 to 60 minutes after administration.

Which is the MOST appropriate action for the nurse to take before administering digoxin? Monitor potassium level Assess blood pressure Evaluate urinary output Avoid giving with thiazide diuretic

Monitor potassium level

The nurse monitors the patient with hypermagnesemia for what clinical manifestation? Seizures Disorientation Muscle weakness Hyperactive reflexes

Muscle weakness Clinical manifestations of hypermagnesemia include increasing muscle weakness related to neuromuscular blockade. Depression of respiration can occur. Additionally, hypotension, sedation, and ECG changes are associated with elevated magnesium levels.

4. A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate? a. Administer the medications as ordered. b. Ask the patient about the use of salt substitutes. c. Contact the provider to request an order for serum electrolytes. d. Request an order for furosemide [Lasix].

NS: D Request an order for furosemide [Lasix]. Spironolactone takes up to 48 hours for its effects to develop, so it should not be used when the patient needs immediate diuresis. This patient has shortness of breath, crackles, and edema and needs a short-acting diuretic, such as furosemide. Asking the patient about the use of salt substitutes is not indicated. The patient does not need assessment of serum electrolytes. PTS: 1 DIF: Cognitive Level: Application REF: p. 454

Which of the following calcium channel blockers is used to counteract or prevent cerebral vasospasm> verapamil nimodipine nifedipine felodipine

Nimodipine

The nurse is evaluating the effectiveness of treatment for heart failure in a patient. Which finding indicates a therapeutic effect? Presence of ankle edema Paroxysmal nocturnal dyspnea Absence of nausea and vomiting No neck vein distention with head of bed elevation

No neck vein distention with head of bed elevation

Which situation will cause the natriuretic peptides to protect the cardiovascular system? Patient has blood loss Patient has dehydration Patient has decreased preload Patient has sodium and water retention

Patient has sodium and water retention

The nurse is using the New York Heart Association's (NYHA's) functional classification of heart failure. Which patients would receive a class III ranking? Patients with symptoms at rest Patients with slight limitation of physical activity Patients with marked limitation of physical activity Patients with no limitation of ordinary physical activity

Patients with marked limitation of physical activity

Which area should the nurse assess to best determine systemic circulation function? Heart Lungs Periphery Lymph nodes

Periphery

The nurse is caring for a patient who takes spironolactone [Aldactone] and quinapril [Accupril] for treatment of heart failure. Which finding indicates a potential additive effect between these two drugs? Heart rate of 58 beats/min Glucose level of 180 mg/dL Potassium level of 5.7 mEq/L Elevated serum quinapril level

Potassium level of 5.7 mEq/L

10. A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?

Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

Which of the following drugs can cause severe hematologic disorders? Digoxin (Lanoxin) Quinidine (Cardioquin) Disopyramide (Norpace) Procainamide (Pronestyl)

Procainamide (Pronestyl)

Which ECG changes would the nurse expect to observe in a patient with hyperkalemia? Widened QRS Inverted P wave Inverted T waves Prolonged PR interval

Prolonged PR interval An increased serum potassium level is associated with cardiac changes, including a prolonged PR interval. These changes are attributed to disruption of the electrical activity in the heart.

Jason James is taking Beta blockers. All of the following should be included in his assessment except Pulmonary function tests Baseline ECG Glucose level Blood pressure

Pulmonary function tests

Which assessment is most important for the nurse to obtain prior to administering digoxin to a patient with heart failure? Pulse Blood pressure Respiratory rate Weight in kilograms

Pulse

Which are the primary regulatory systems of arterial pressure? Select all that apply. Renal system Pulmonary system P450 enzyme system Autonomic nervous system Renin-angiotensin-aldosterone system

Renal system Autonomic nervous system Renin-angiotensin-aldosterone system

A patient is given medication to make the blood vessels constrict. The nurse understands that what occurs with this medication? Blood flow increases Resistance increases Vessel diameter enlarges Blood pressure decreases

Resistance increases

The nurse notes that a patient is hyperventilating and assesses him for which acid-base imbalance? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory alkalosis Hyperventilation leads to the blowing off of carbon dioxide, resulting in respiratory alkalosis.

Before giving milrinone (Primacor) by an IV infusion to a client with symptoms of CHF, which of the following nursing actions is necessary? Record sodium level Administer loading dose over 15 minutes Assess CV status Review medication regimen to idenify if client is on IV furosemide (Lasix)

Review medication regimen to identify if client is on IV furosemide (Lasix)

Class IA antiarrhythmic agents have little effect on AV Node SA Node Purkinje fibers Bundle of His

SA Node

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?

Sacrum

A patient is prescribed digoxin to treat heart failure. Which biochemical parameter should be assessed by the nurse to ensure safe drug administration? Liver enzyme concentration Blood glucose concentration Serum calcium concentration Serum potassium concentration

Serum potassium concentration

13. A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?

Sets the IV pump to deliver 30 mEq of potassium an hour.

The nurse notes that a patient's serum potassium level is 2.8 mEq/L. The nurse monitors her for which clinical manifestation as consistent with this laboratory value? Seizures Paresthesias Loss of consciousness Skeletal muscle weakness

Skeletal muscle weakness Hypokalemia is manifested by muscle weakness that may lead to paralysis with continued decreases in potassium. This electrolyte disorder can also lead to fatal dysthythmias.

In analyzing a patient's serum osmolality, the nurse recognizes which electrolyte as the principal extracellular ion? Chloride Glucose Potassium Sodium

Sodium Sodium is the primary serum electrolyte and contributes approximately 50% of the electrolytes used in the determination of serum osmolality.

The nurse is caring for a patient with heart failure who needs a diuretic. Which agent is likely to be chosen, because it has been shown to greatly reduce mortality in patients with heart failure? Furosemide [Lasix] Hydrochlorothiazide [HydroDIURIL] Spironolactone [Aldactone] Mannitol [Osmitrol]

Spironolactone [Aldactone]

When administering dopamine (Intropin) it is most important for the nurse to know that The drug's action varies according to the dose The drug may be used instead of fluid replacement The drug cannot be directly mixed in solutions containing bicarbonate or aminophylline The lowest dose to produce the desired effect should be used

The drug cannot be directly mixed in solutions containing bicarbonate or aminophylline

A patient's preload is decreased. How should the nurse interpret this information? The stroke volume has increased. The more the ventricles will stretch. The muscarinic receptors are activated. The end-diastolic volume has decreased

The end-diastolic volume has decreased

A patient's arterial pressure drops upon standing. How should the nurse report this finding to the oncoming shift? The patient has water retention The patient has reflex tachycardia The patient has steady-state control The patient has orthostatic hypotension

The patient has orthostatic hypotension

A nurse takes a rectal temperature, which stimulates the vagus nerve. When the nurse checks the pulse, what would the nurse expect to find? The pulse is lowered The pulse is elevated The pulse is the same The pulse will wildly fluctuate

The pulse is lowered

T or F: Arterioles determine blood flow to tissue.

True.

T or F: Cardiac output is determined by the rate of the heart contraction times the amount of blood ejected from the heart with each beat.

True.

T or F: Conditions that cause an inability of skeletal muscle to contract (or severe weakness) can cause peripheral edema.

True.

T or F: Conditions that decrease chest expansion with breathing decrease blood return to the heart.

True.

T or F: The average amount of blood ejected from the heart at each beat is slightly over 2 ounces.

True.

T or F: The heart of a normal adult pumps the entire blood volume in approximately 1 minute.

True.

A patient is admitted to the hospital after several days of vomiting and diarrhea. After an initial bolus of isotonic (0.9%) sodium chloride solution, the prescriber orders dextrose 5% in normal saline (D5NS) with 20 mEq potassium chloride to infuse at a maintenance rate. What should the nurse review before implementing this order? (Select all that apply.) a. Electrocardiogram b. Arterial blood gas levels c. Serum electrolyte levels d. Serum glucose level e. Urine output

a. Electrocardiogram c. Serum electrolyte levels e. Urine output

Which hemodynamic system serves as a reservoir for circulating blood? Heart Veins Lungs Arteries

Veins

The heart undergoes cardiac remodeling during the initial phase of heart failure. Which structural change occurs with heart failure? Ventricular atrophy Ventricular constriction Ventricular wall thickening Ventricles become more cylindric

Ventricular wall thickening

Conduction defects will most likely be an adverse associated with the use of Verapamil Nifedipine Diltiazem Felodipine

Verapamil

The natriuretic peptides serve to protect the cardiovascular system from which condition? Hypotension Hypovolemia Volume overload Myocardial infarction

Volume overload

The nurse correlates isotonic contraction with which condition? (Select all that apply.) Vomiting Excessive sweating Diarrhea Hyperaldosteronism Kidney disease Extensive burns

Vomiting Diarrhea Kidney disease Isotonic contraction is related to loss of water and sodium in equal proportions. Causes of isotonic contraction include vomiting, diarrhea, kidney disease, and misuse of diuretics. Hypertonic contraction is related to loss of water in greater proportion than sodium; causes include excessive sweating, osmotic diuresis, and extensive burns. Hypotonic contraction is defined as volume contraction in which sodium loss exceeds water loss; causes include diuretic therapy, chronic renal insufficiency, and lack of aldosterone.

The nurse assesses a patient's pulse before administering digoxin and notes a rate of 55 beats/min. What is the priority intervention by the nurse? Withhold the dose Administer the drug Check potassium level before giving Reduce the dose to half the prescribed dose

Withhold the dose

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

a b c e f a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.

An older adult patient with congestive heart failure develops crackles in both lungs and pitting edema of all extremities. The physician orders hydrochlorothiazide [HydroDIURIL]. Before administering this medication, the nurse reviews the patient's chart. Which laboratory value causes the nurse the most concern? a. Elevated creatinine clearance b. Elevated serum potassium level c. Normal blood glucose level d. Low levels of low-density lipoprotein (LDL) cholesterol

a. Elevated creatinine clearance

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

a c d e f a. Calculate pulse pressure with each blood pressure reading. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium. Appropriate interventions for the client who has overhydration include calculating the pulse pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client's dependent body areas, monitoring trends in the client's daily weight as fluid retention is not always visible, protecting the client's skin by helping him or her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

a e f a. Reports of palpitations e. Skeletal muscle weakness f. Tall, peaked T waves on ECG Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or "skipped beats," diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin.

a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

A patient arrives in the emergency department complaining of muscle weakness and drowsiness. The nurse notes a heart rate of 80 beats per minute, a respiratory rate of 18 breaths per minute, and a blood pressure of 90/50 mm Hg. The electrocardiogram reveals an abnormal rhythm. The nurse will question the patient about which over-the-counter medication? a. Antacids b. Aspirin c. Laxatives d. Potassium supplements

a. Antacids

A nurse is assessing a client with hypokalemia, and notes that the client's hand grip strength has diminished since the previous assessment 1 hour ago. What action does the nurse takefirst? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

a. Assess the client's respiratory rate, rhythm, and depth.

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

a. Assess the client's respiratory rate, rhythm, and depth. In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client's pulse and blood pressure would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.

4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min

a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood pressure.

The nurse knows that diuretics mostly affect which function of the kidneys? a. Cleansing and maintenance of extracellular fluid volume b. Maintenance of acid-base balance c. Excretion of metabolic waste d. Elimination of foreign substances

a. Cleansing and maintenance of extracellular fluid volume

12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a. Client with pancreatitis who has continuous nasogastric suctioning b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells d. Client with uncontrolled diabetes and a serum pH level of 7.33

a. Client with pancreatitis who has continuous nasogastric suctioning A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.

While performing an admission assessment on a patient, the nurse learns that the patient is taking furosemide [Lasix], digoxin, and spironolactone [Aldactone]. A diet history reveals the use of salt substitutes. The patient is confused and dyspneic and complains of hand and foot tingling. Which is an appropriate nursing action for this patient? a. Contact the provider to request orders for an electrocardiogram and serum electrolyte levels. b. Evaluate the patient's urine output and request an order for intravenous potassium. c. Hold the next dose of furosemide and request an order for intravenous magnesium sulfate. d. Request an order for intravenous insulin to help this patient regulate extracellular potassium.

a. Contact the provider to request orders for an electrocardiogram and serum electrolyte levels.

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L(2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

a. Depth of respirations

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

a. Depth of respirations A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client's respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client's respiratory status.

Besides having diuretic effects for patients with congestive heart failure, thiazides are also used to treat what? (Select all that apply.) a. Diabetes insipidus b. Hepatic failure c. Increased intracranial pressure d. Intraocular pressure e. Postmenopausal osteoporosis

a. Diabetes insipidus b. Hepatic failure e. Postmenopausal osteoporosis

The nurse should monitor for which adverse effect after administering hydrochlorothiazide [HydroDIURIL] and digoxin [Lanoxin] to a patient? a. Digoxin toxicity b. Decreased diuretic effect c. Dehydration d. Heart failure

a. Digoxin toxicity

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? a. Furosemide (Lasix) b. Hydrochlorothiazide (HydroDIURIL) c. Mannitol (Osmitrol) d. Spironolactone (Aldactone)

a. Furosemide (Lasix)

A patient is brought to the emergency department with shortness of breath, a respiratory rate of 30 breaths per minute, intercostal retractions, and frothy, pink sputum. The nurse caring for this patient will expect to administer which drug? a. Furosemide [Lasix] b. Hydrochlorothiazide [HydroDIURIL] c. Mannitol [Osmitrol] d. Spironolactone [Aldactone]

a. Furosemide [Lasix]

The nurse is reviewing the home medication list with the patient. The nurse recognizes that hydrochlorothiazide is used primarily for which condition? a. Hypertension b. Edema c. Diabetes insipidus d. Protection against postmenopausal osteoporosis

a. Hypertension

Which of the following statements about mannitol [Osmitrol] are correct? (Select all that apply.) a. Mannitol cannot be given orally. b. Mannitol can cause edema. c. Mannitol can cause renal failure. d. Diuresis begins in 30 to 60 minutes after administration. e. Mannitol is a loop diuretic.

a. Mannitol cannot be given orally. b. Mannitol can cause edema. d. Diuresis begins in 30 to 60 minutes after administration.

A patient who was injured at home is brought to the emergency department. The nurse caring for this patient notes a respiratory rate of 32 breaths per minute and a heart rate of 90 beats per minute. The injuries are minor, but the patient is inconsolable and hysterical. The nurse expects that initial management will include: a. administering a gas mixture of 5% carbon dioxide (CO2). b. providing 100% oxygen via nasal cannula. c. giving sodium bicarbonate IV. d. providing sedatives to calm the patient.

a. administering a gas mixture of 5% carbon dioxide (CO2).

A child who ingested a handful of aspirin tablets from a medicine cabinet at home is brought to the emergency department. The nurse caring for the child notes a respiratory rate of 48 breaths per minute. The nurse understands that this child's respiratory rate is the result of the body's attempt to compensate for: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

a. metabolic acidosis.

A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol (Osmitrol). The nurse knows that this is given to: a. reduce intracranial pressure. b. reduce renal perfusion. c. reduce peripheral edema. d. restore extracellular fluid.

a. reduce intracranial pressure.

A patient who was in a motor vehicle accident sustained a severe head injury and is brought into the emergency department. The provider orders intravenous mannitol [Osmitrol]. The nurse knows that this is given to: a. reduce intracranial pressure. b. reduce renal perfusion. c. reduce peripheral edema. d. restore extracellular fluid.

a. reduce intracranial pressure.

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

b c d e f b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

b c d f b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration f. Magnesium: 0.8 mg/dL: Dehydration In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration, the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from diarrhea-causing diseases.

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

b e b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg) Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.

A patient collapses after running a marathon on a hot day and is brought to the emergency department to be treated for dehydration. The nurse will expect to provide which therapy? a. Intravenous hypertonic fluids given slowly over several hours b. Intravenous hypotonic fluids administered in stages c. Intravenous isotonic fluids given as a rapid bolus d. Oral electrolyte replacement fluids with potassium

b. Intravenous hypotonic fluids administered in stages

A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide [HydroDIURIL] and digoxin. The prescriber has ordered spironolactone [Aldactone] to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching? a. "I can expect improvement within a few hours after taking this drug." b. "I need to stop taking potassium supplements." c. "I should use salt substitutes to prevent toxic side effects." d. "I should watch closely for dehydration."

b. "I need to stop taking potassium supplements."

A patient with chronic congestive heart failure has repeated hospitalizations in spite of ongoing treatment with hydrochlorothiazide and digoxin. The prescriber has ordered spironolactone (Aldactone) to be added to this patient's drug regimen, and the nurse provides education about this medication. Which statement by the patient indicates understanding of the teaching? a. "I can expect improvement within a few hours after taking this drug." b. "I need to stop taking potassium supplements." c. "I should use salt substitutes to prevent toxic side effects." d. "I should watch closely for dehydration."

b. "I need to stop taking potassium supplements."

After teaching a client who is being treated for dehydration, a nurse assesses the client'sunderstanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

b. "I will weigh myself each morning before I eat or drink."

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

b. "I will weigh myself each morning before I eat or drink." One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day

A patient arrives in the emergency department after becoming dehydrated. Based on the patient's history, the provider determines that isotonic dehydration has occurred. Which solution will the nurse expect to infuse to treat this patient? a. 0.45% sodium chloride in sterile water b. 0.9% sodium chloride in sterile water c. 3% sodium chloride in sterile water d. 5% dextrose solution

b. 0.9% sodium chloride in sterile water

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain

b. Anxious client who has tachypnea.

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain

b. Anxious client who has tachypnea. Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for insensible fluid loss.

2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position.

b. Apply oxygen by mask or nasal cannula. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

b. Assess client further for fall risk.

Which order for potassium (KCl) would the nurse question? (Select all that apply.) a. NS with 20 mEq KCl to start after patient voids b. NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L c. K-Dur, 1 tablet daily for a patient in diabetic ketoacidosis d. K-Dur, 1 tablet with a full glass of water e. Potassium chloride, 10 mEq rapid IV push

b. NS with 60 mEq KCl for a patient with a serum potassium of 3.2 mEq/L c. K-Dur, 1 tablet daily for a patient in diabetic ketoacidosis e. Potassium chloride, 10 mEq rapid IV push

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

b. Assess client further for fall risk. Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

b. Assess the client's lung sounds every 2 hours.

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

b. Assess the client's lung sounds every 2 hours. All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client's respiratory status.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L).Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.

b. Connect the client to a cardiac monitor.

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin.

b. Connect the client to a cardiac monitor. This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.

A patient with congestive heart failure is admitted to the hospital. During the admission assessment, the nurse learns that the patient is taking a thiazide diuretic. The nurse notes that the admission electrolyte levels include a sodium level of 142 mEq/L, a chloride level of 95 mEq/L, and a potassium level of 3 mEq/L. The prescriber has ordered digoxin to be given immediately. What will the nurse do initially? a. Give the digoxin and maintain close cardiac monitoring. b. Hold the digoxin and report the laboratory values to the provider. c. Hold the thiazide diuretic and give the digoxin. d. Request an order for an electrocardiogram (ECG).

b. Hold the digoxin and report the laboratory values to the provider.

A nurse is caring for a postoperative patient who has a nasogastric tube with continuous suction. The nurse notes that the patient has shallow respirations and suspects that this patient has developed: a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.

b. metabolic alkalosis.

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG)

c d c. Strong productive cough d. Active bowel sounds A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

c. "Call your primary health care provider for diarrhea."

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

c. "Call your primary health care provider for diarrhea." One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.

The nurse is teaching a patient who has a new prescription for spironolactone [Aldactone]. Which statement by the patient indicates that the teaching was effective? a. "I will use salt substitutes to lower my sodium intake." b. "I will increase my intake of foods that are high in potassium." c. "I will call my doctor if I begin having menstrual irregularities." d. "I will take this medication at bedtime each evening."

c. "I will call my doctor if I begin having menstrual irregularities."

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure

c. A 76 year old who is cognitively impaired.

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure

c. A 76 year old who is cognitively impaired. Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.

15. A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I cant because of my high potassium level. How should the nurse respond? a. Potatoes and avocados can be substituted for fruit. b. If you cook the fruit, the amount of potassium will be lower. c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in potassium.

c. Berries, cherries, apples, and peaches are low in potassium. Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.

The nurse plans to closely monitor for which clinical manifestation after administering furosemide [Lasix]? a. Decreased pulse b. Decreased temperature c. Decreased blood pressure d. Decreased respiratory rate

c. Decreased blood pressure

A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide (Lasix). The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.5 mEq/L d. Sodium level of 140 mEq/L

c. Potassium level of 3.5 mEq/L

A patient who is taking digoxin is admitted to the hospital for treatment of congestive heart failure. The prescriber has ordered furosemide [Lasix]. The nurse notes an irregular heart rate of 86 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 130/82 mm Hg. The nurse auscultates crackles in both lungs. Which laboratory value causes the nurse the most concern? a. Blood glucose level of 120 mg/dL b. Oxygen saturation of 90% c. Potassium level of 3.5 mEq/L d. Sodium level of 140 mEq/L

c. Potassium level of 3.5 mEq/L

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment.

c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this clients teaching? a. Weigh yourself every morning and every night. b. Check your radial pulse twice a day. c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.

c. Read food labels to determine sodium content. Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.

A nurse is caring for a child whose respirations are shallow and marked by a prolonged expiratory phase. The nurse auscultates wheezes and poor air movement bilaterally. The child's respiratory rate is 26 breaths per minute, and the oxygen saturation is 89%. What does the nurse suspect? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis

A patient is taking gentamicin (Garamycin) and furosemide (Lasix). The nurse should counsel this patient to report which symptom? a. Frequent nocturia b. Headaches c. Ringing in the ears d. Urinary retention

c. Ringing in the ears

A patient is taking gentamicin [Garamycin] and furosemide [Lasix]. The nurse should counsel this patient to report which symptom? a. Frequent nocturia b. Headaches c. Ringing in the ears d. Urinary retention

c. Ringing in the ears

14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients understanding. Which dietary meal selection indicates the client correctly understands the teaching? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

c. Sets the IV pump to deliver 30 mEq of potassium an hour.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

c. Sets the IV pump to deliver 30 mEq of potassium an hour. IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.

A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? a. Bumetanide (Bumex) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Hydrochlorothiazide (HydroDIURIL)

c. Spironolactone (Aldactone)

A patient has 2+ pitting edema of the lower extremities bilaterally. Auscultation of the lungs reveals crackles bilaterally, and the serum potassium level is 6 mEq/L. Which diuretic agent ordered by the prescriber should the nurse question? a. Bumetanide [Bumex] b. Furosemide [Lasix] c. Spironolactone [Aldactone] d. Hydrochlorothiazide [HydroDIURIL]

c. Spironolactone [Aldactone]

The nurse is caring for a patient with heart failure who needs a diuretic. Which agent is likely to be chosen, because it has been shown to greatly reduce mortality in patients with heart failure? a. Furosemide [Lasix] b. Hydrochlorothiazide [HydroDIURIL] c. Spironolactone [Aldactone] d. Mannitol [Osmitrol]

c. Spironolactone [Aldactone]

A patient is taking a beta1-adrenergic drug to improve the stroke volume of the heart. The nurse caring for this patient knows that this drug acts by increasing: a.cardiac afterload. b.cardiac preload. c.myocardial contractility. d.venous return.

c. myocardial contractility. Beta1-adrenergic agents help increase the heart's stroke volume by increasing myocardial contractility. Cardiac afterload is determined primarily by the degree of peripheral resistance caused by constriction of arterioles; increasing afterload would decrease stroke volume. Beta1-adrenergic agents do not affect afterload. Cardiac preload is the amount of stretch applied to the cardiac muscle before contraction and is determined by the amount of venous return. Beta1-adrenergic agents do not affect cardiac preload. Venous return is determined by the systemic filling pressure and auxiliary muscle pumps and is not affected by beta1-adrenergic agents.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

d. Administers bisphosphonates as prescribed.

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

d. Administers bisphosphonates as prescribed. Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

d. Dangle the client on the bedside before ambulating.

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating.

d. Dangle the client on the bedside before ambulating. An older adult with moderate dehydration may experience orthostatic hypotension. The client needs to dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

d. Decreased orthostatic changes when standing

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

d. Decreased orthostatic changes when standing The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

d. Grilled chicken breast with glazed carrots

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

d. Grilled chicken breast with glazed carrots Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

The nurse caring for a patient taking furosemide [Lasix] is reviewing the patient's most recent laboratory results, which are: sodium, 136 mEq/L; potassium, 3.2 mEq/L; chloride, 100 mEq/L; blood urea nitrogen, 15 mg/dL. What is the nurse's best action? a. Administer Lasix as ordered. b. Place the patient on a cardiac monitor. c. Begin a 24-hour urine collection. d. Hold the Lasix and notify the physician.

d. Hold the Lasix and notify the physician. b/c potassium is low and Lasix can cause significant potassium loss

A nurse preparing to administer morning medications notes that a patient with a history of hypertension has been prescribed spironolactone [Aldactone]. The nurse assesses the patient and notes dyspnea, bilateral crackles, and pitting edema in both feet. Which intervention is appropriate? a. Administer the medications as ordered. b. Ask the patient about the use of salt substitutes. c. Contact the provider to request an order for serum electrolytes. d. Request an order for furosemide [Lasix].

d. Request an order for furosemide [Lasix].

A patient with hypertension is taking furosemide (Lasix) for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient? a. Bumetanide (Bumex) b. Chlorothiazide (Diuril) c. Hydrochlorothiazide (HydroDIURIL) d. Spironolactone (Aldactone)

d. Spironolactone (Aldactone)

A patient with hypertension is taking furosemide [Lasix] for congestive heart failure. The prescriber orders digoxin to help increase cardiac output. What other medication will the nurse expect to be ordered for this patient? a. Bumetanide [Bumex] b. Chlorothiazide [Diuril] c. Hydrochlorothiazide [HydroDIURIL] d. Spironolactone [Aldactone]

d. Spironolactone [Aldactone]

Which of the following calcium channel blockers has the most potent peripheral smooth muscle dilator effect? diltiazem nifedipine nimodipine verapamil

nifedipine

A patient's cardiac output is 8 L/min. Which hemodynamic effect would the nurse expect? A.Decreased contractility B.Increased stroke volume C.Decreased preload D.Increased arterial pressure

•Answer: B B.Increased stroke volume •Rationale: The average value for cardiac output is 4.9 L/min. An increase in stroke volume will increase cardiac output. Stroke volume is determined by contractility, preload, and afterload. A decrease in contractility or preload will decrease stroke volume and cardiac output. An increase in afterload (or arterial blood pressure) will decrease stroke volume and cardiac output.

A patient is prescribed a medication that causes venous dilation. It is most important for the nurse to teach the patient about what? A.B-natriuretic peptide B.Postural hypotension C.Increased urination D.Intermittent claudication

•Answer: B B.Postural hypotension •Rationale: Postural hypotension may occur with drugs that promote the dilation of veins or that prevent the veins from constricting.

A patient is prescribed a medication that lowers the arterial blood pressure. The nurse should assess for which response by the body to restore the blood pressure? A.Orthostatic hypotension B.Fluid retention C.Reflex tachycardia Increased natriuresis

•Answer: C C.Reflex tachycardia •Rationale: Drugs that lower the arterial pressure will trigger the baroreceptor reflex with the response of reflex tachycardia.