Cardiovascular-Nclex

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

1. 3 Rationale: Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. Test-Taking Strategy Use the process of elimination, focusing on the subject, pain resulting from a noncardiac problem. The three incorrect options, although appropriate to use in practice, are general assessment questions only. Option 3 will discriminate between a cardiac and noncardiac cause of pain. Review pain assessment measures for the client with a cardiovascular problem if you had difficulty with this question.

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

10. 4 Rationale: The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias. Test-Taking Strategy Use the process of elimination. Eliminate option 2 because the client will just be beginning digoxin therapy. No data indicate the presence of renal insufficiency; therefore, eliminate option 3. Furosemide therapy can cause hyponatremia and hypokalemia, but remember that the risk of hypokalemia has more severe consequences in this situation. Review the nursing considerations related to administering furosemide if you had difficulty with this question.

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

11. 2 Rationale: To help prevent tolerance, clients need a 12-hour "no-nitrate" time, sometimes referred to as a pharmacological vacation away from the medication. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination, focusing on the subject, preventing tolerance to nitrates. This subject and knowledge regarding administering this medication will direct you to option 2. Review the administration of nitrate patches if you had difficulty with this question.

12. A nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened, with no apparent drainage. Temperature is 99° F orally. The white blood cell count is 7500 cells/mm3. How should the nurse interpret these findings? 1. Incision is slightly edematous but shows no active signs of infection. 2. Incision shows early signs of infection, although the temperature is nearly normal. 3. Incision shows early signs of infection, supported by an elevated white blood cell count. 4. Incision shows no sign of infection, although the white blood cell count is elevated.

12. 1 Rationale: Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. Elevated temperature and white blood cell count after 3 to 4 days postoperatively usually indicate infection. Test-Taking Strategy Use the process of elimination. Eliminate options 3 and 4 because the white blood cell count is within normal range. From the remaining options, focus on the data in the question. A nonreddened incision with no apparent drainage indicates no signs of infection. Review the signs of infection if you had difficulty with this question.

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

12. 2 Rationale: This is a therapeutic, nonjudgmental response. The statement reflects the family's concern but remains nonjudgmental. Option 1 dismisses the family's concerns and disempowers the family. Option 3 creates doubt about the physician's practice without actually knowing the circumstances. Option 4 is argumentative and nontherapeutic. Test-Taking Strategy: Use therapeutic communication techniques. Reflection of the client's or family's concerns is the most therapeutic. Review these techniques if you had difficulty with this question.

13. A nurse is caring for a client receiving dopamine. Which of the following potential nursing diagnoses is appropriate for this client? 1. Fluid volume, excess 2. Cardiac output, increased 3. Tissue perfusion, ineffective 4. Sensory perception, disturbed

13. 3 Rationale: The client receiving dopamine therapy should be assessed for ineffective tissue perfusion related to peripheral vasoconstriction. Options 1, 2, and 4 are not related directly to this medication therapy. Test-Taking Strategy: Use the process of elimination. Recalling that dopamine causes peripheral vasoconstriction will direct you to option 3. Review the action of this medication if you had difficulty with this question.

14. A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? 1. Remove telemetry equipment. 2. Provide the client with a walker. 3. Premedicate the client with an analgesic. 4. Encourage the client to cough and deep breathe.

14. 3 Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 and 4 will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed. Test Taking Strategy Use the process of elimination. Focus on the subject, how best to tolerate the ambulation. Coughing and deep breathing will not actively help endurance, so eliminate option 4. Removal of telemetry equipment is contraindicated unless ordered. From the remaining options, focusing on the subject will direct you to option 3. Review comfort measures for the client following cardiac surgery if you had difficulty with this question.

17. A client has developed paroxysmal nocturnal dyspnea. Which of the following medications does a nurse anticipate will be prescribed by the physician? 1. Propranolol (Inderal) 2. Bumetanide (Bumex) 3. Lidocaine (Xylocaine) 4. Streptokinase (Streptase)

17. 2 Rationale: Bumetanide (Bumex) is a diuretic. The paroxysmal nocturnal dyspnea may be due to increased venous return when the client is lying in bed, and the client needs diuresis. Propranolol is a b-blocker, lidocaine is an antiarrhythmic, and streptokinase is a thrombolytic. Test-Taking Strategy: Use the process of elimination. Knowledge of each medication type and that a diuretic will increase urine output will direct you to option 2. Review the actions of the medications identified in the options, if you had difficulty with this question.

18. A nurse notices frequent artifact on the electrocardiographic monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? 1. Frequent movement of the client 2. Tightly secured cable connections 3. Leads applied over hairy areas 4. Leads applied to the limbs

18. 2 Rationale: Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and cable disconnection. Test-Taking Strategy Use the process of elimination, focusing on the subject, artifact and note the strategic word unlikely. Recalling the causes of artifact will direct you to option 2. Review these causes if you had difficulty with this question.

2. A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which of the following medications should the nurse first anticipate administering? 1. Atropine sulfate 2. Warfarin (Coumadin) 3. Lidocaine (Xylocaine) 4. Metoprolol (Lopressor)

2. 4 Rationale: b-Blockers such as metoprolol slow conduction of impulses through the AV node and decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the cardiac output and then attempt to restore normal sinus rhythm. Test-Taking Strategy: Use the process of elimination. Eliminate option 1 because atropine sulfate will further increase the heart rate and will further decrease the cardiac output. Eliminate option 3 because lidocaine is only useful in suppressing ventricular dysrhythmias. Although warfarin (Coumadin) is administered to clients with atrial fibrillation to prevent clots from forming in the atria it will have no effect in decreasing the ventricular rate or restoring normal sinus rhythm. Review these medications if you had difficulty with this question.

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

20. 1 Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Test-Taking Strategy Use the process of elimination and note the strategic words most concerned. Option 2 is incorrect and is eliminated first. From the remaining options, focusing on the strategic words will direct you to option 1 because this option identifies the life-threatening condition. Review the concerns associated with ventricular tachycardia if you had difficulty with this question.

21. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11 seconds. How would the nurse interpret these results? 1. Client needs to have test repeated. 2. Client results are within the therapeutic range. 3. Client results are higher than the therapeutic range. 4. Client results are lower than the needed therapeutic level.

21. 2 Rationale: The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. Test-Taking Strategy: Use the process of elimination. Look at the control value. Remembering that the purpose of anticoagulant therapy is to prolong clotting times will assist in eliminating options 3 and 4. Eliminate option 1, because there is no basis for repeating the test. Because the prothrombin value identified in the question is not even double the control, select option 2 from the remaining options. Review the therapeutic prothrombin level for a client at risk for pulmonary embolism if you had difficulty with this question.

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

21. 4 Rationale: Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. Options 1, 2, and 3 will not assist in terminating the dysrhythmia. Test-Taking Strategy To answer this question, you must be familiar with the treatment for unstable ventricular tachycardia. Remember that cough CPR sometimes is used in the client with unstable ventricular tachycardia. Review the concept of cough CPR if you are not familiar with it.

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

22. 4 Rationale: Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beat leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol. Test-Taking Strategy Note the strategic words priority on assessment. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review the effects of premature ventricular contractions if you had difficulty with this question.

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

23. 3 Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Test-Taking Strategy Use the process of elimination. Flat neck veins are normal or indicate hypovolemia, so eliminate option 1. Nausea and vomiting (option 2) are associated with vagus nerve activity and do not correlate with a tachycardic state. From the remaining options, think of the consequences of falling cardiac output to direct you to option 3. Review the effects of atrial fibrillation if you had difficulty with this question.

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

23. 4 Rationale: Enalapril (Vasotec) is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion. Nausea, insomnia, and a cough can occur as side (not adverse) effects of the medication. Test-Taking Strategy: Note the strategic word adverse. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review the adverse effects of this medication if you had difficulty with this question.

24. Which of the following would be an expected outcome of nesiritide (Natrecor) administration? 1. Client will have an increase in urine output. 2. Client will have an absence of dysrhythmias. 3. Client will have an increase in blood pressure. 4. Client will have an increase in pulmonary capillary wedge pressure.

24. 1 Rationale: Nesiritide is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and increases urine output. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Nesiritide does not have antidysrhythmic properties. Dysrhythmias may be a side effect of the medication, so option 2 should be eliminated. Eliminate option 3 because the medication is a vasodilator and causes a decrease in blood pressure. Eliminate option 4 because the medication decreases pulmonary capillary wedge pressure (PCWP). Review the effects of this medication if you had difficulty with this question.

25. A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid sinus massage. Which of the following would be reflective of a correct explanation provided by the nurse? 1. The vagus nerve slows the heart rate. 2. The diaphragmatic nerve slows the heart rate. 3. The diaphragmatic nerve overdrives the rhythm. 4. The vagus nerve increases the heart rate, overdriving the rhythm.

25. 1 Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm. Options 2, 3, and 4 are incorrect descriptions of this procedure. Test-Taking Strategy Knowledge of anatomy and physiology alone may be sufficient to answer this question. Eliminate options 3 and 4 because a rapid rate dysrhythmia would need to be slowed. Recalling the functions of the vagus nerve and the diaphragmatic nerve will direct you to option 1. The vagus nerve affects heart rate. The diaphragmatic nerve affects respiration. If you are unfamiliar with the functions of these nerves, review this content.

25. A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA, Activase) by infusion. Of the following parameters, which one would a nurse determine requires the least frequent assessment to detect complications of therapy with tissue plasminogen activator? 1. Neurological signs 2. Presence of bowel sounds 3. Blood pressure and pulse 4. Complaints of abdominal and back pain

25. 2 Rationale: Thrombolytic agents dissolve existing clots, and bleeding can occur anywhere in the body. The nurse monitors for any obvious signs of bleeding and also for occult signs of bleeding, which would include hemoglobin and hematocrit values, blood pressure and pulse, neurological signs, assessment of abdominal and back pain, and the presence of blood in the urine or stool. Test-Taking Strategy: Note the strategic words least frequent assessment. Remember that bleeding is the primary complication of thrombolytic therapy. Therefore, look for the option that is not related to bleeding. A change in neurological signs could indicate cerebral bleeding, abdominal and back pain could indicate abdominal bleeding, and change in blood pressure and pulse could be general indicators of hemorrhage. The presence of bowel sounds is unrelated to this medication. Review nursing considerations for the client receiving tissue plasminogen activator if you had difficulty with this question.

27. A nurse is preparing to defibrillate a client in ventricular fibrillation. After placing the paddles on the client's chest and before discharging them, which of the following should be done? 1. Ensure that the client has been intubated. 2. Set the defibrillator to the "synchronize" mode. 3. Administer lidocaine hydrochloride (Xylocaine). 4. Confirm that the rhythm is actually ventricular fibrillation.

27. 4 Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. Lidocaine may be given subsequently but is not required before defibrillation. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Test-Taking Strategy Use the process of elimination, focusing on the subject, ventricular fibrillation. Note that option 4 directly addresses this subject and also addresses assessment of the client. Review the procedure for defibrillation if you had difficulty with this question.

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

3. 2 Rationale: On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet). Test-Taking Strategy Use the process of elimination. Eliminate options 3 and 4 first because they are excessive, given that the client has just been transferred from the coronary care unit. Option 1 is not appropriate because the client would be doing less activity than in the coronary care unit before transfer. Review activity prescriptions for the client with a myocardial infarction if you had difficulty with this question.

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

3. 3 Rationale: Spironolactone is a potassium-sparing diuretic and competes with aldosterone at receptor sites in the distal tubule, resulting in excretion of sodium, chloride, and water and retention of potassium and phosphate. Use of the medications noted in options 1, 2, and 4 could result in hypokalemia. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are both loop diuretics, which lead to the side effect of hypokalemia. Next eliminate option 4 because it is a thiazide diuretic, which acts on the distal tubule and inhibits sodium, chloride, and potassium reabsorption. Review the effects of these medications if you had difficulty with this question.

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

30. 2 Rationale: Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Test Taking Strategy Use the process of elimination, noting the strategic words highest priority. Use the ABCs—airway, breathing, and circulation—to direct you to option 2. Review care of the client following cardioversion if you had difficulty with this question.

31. A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client's cardiac rhythm? 1. Hold the defibrillator paddles firmly against the chest. 2. Apply adhesive patch electrodes to the chest and move away from the client. 3. Apply standard electrocardiographic monitoring leads to the client and observe the rhythm. 4. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device.

31. 2 Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if defibrillation is necessary. Test-Taking Strategy Use the process of elimination. If you are not familiar with this piece of equipment, look first at the word automatic in the name. This implies that a person is not as involved in the process as with a conventional defibrillator and will help eliminate option 1. Because standard electrocardiogram monitoring leads do not play an active role once resuscitation is underway (options 3 and 4), you can eliminate these comparative or alike options. Review the procedure related to the use of an automatic external defibrillator if you had difficulty with this question.

32. A nurse employed in a cardiac unit determines that which of the following clients is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)? 1. A client with syncopal episodes related to ventricular tachycardia 2. A client with ventricular dysrhythmias despite medication therapy 3. A client with an episode of cardiac arrest related to myocardial infarction 4. A client with three episodes of cardiac arrest unrelated to myocardial infarction

32. 3 Rationale: An automatic internal cardioverter-defibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes related to ventricular tachycardia. Test-Taking Strategy Use the process of elimination and note the strategic words least likely. Ventricular dysrhythmias that induce syncope or occur while the client is on medication are likely to be true indications for the AICD, so eliminate options 1 and 2 first. From the remaining options, the main difference is whether or not the cardiac arrest was related to myocardial infarction. Of these two, the one most likely to be responsive to AICD would be the client without myocardial infarction because those dysrhythmias are spontaneous. Review the indications for the use of an AICD, if you had difficulty with this question.

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

33. 4 Rationale: The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. Options 1, 2, and 3 are also nursing interventions but are not the priority. Test-Taking Strategy Use Maslow's Hierarchy of Needs theory. Option 4 is the option that identifies the physiological need. Review care to the client following insertion of an automatic internal cardioverter-defibrillator if you had difficulty with this question.

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

34. 2 Rationale: In the first several hours after insertion of a permanent or a temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Test-Taking Strategy Use the process of elimination. Note that the pacemaker was inserted on the right side. Therefore, to prevent pacing electrode dislodgment, motion must be limited on that side. Options 3 and 4 involve movement of the right arm and are eliminated first. Limiting the movement of the left arm (option 1) is of no benefit to the client. Thus, option 2 is the correct option. Review care of the client following insertion of a pacemaker if you had difficulty with this question.

35. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of which of the following? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction

35. 3 Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. Test-Taking Strategy Focus on the client's diagnosis to answer the question. Recalling the complications related to thrombophlebitis will direct you to option 3. Review these complications and the associated signs and symptoms if you had difficulty with this question.

36. A client seeks treatment in a physician's office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how this sclerotherapy is done?" Which of the following statements would reflect accurate teaching by the nurse? 1. "The varicosity is surgically removed." 2. "The vein is tied off at the upper end to prevent stasis from occurring." 3. "The vein is tied off at the lower end to prevent stasis from occurring." 4. "An agent is injected into the vein to damage the vein wall and close the vein off."

36. 4 Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with hook and wires via multiple small incisions in the leg. Test-Taking Strategy Use the process of elimination and note the name of the procedure, sclerotherapy. A vessel that is sclerosed is blocked. This will direct you to option 4. Review this procedure if you had difficulty with this question.

37. A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which of the following would be an appropriate action by the nurse based on evaluation of the client's comment? 1. Instruct the client to apply warm packs. 2. Report the complaint to the physician. 3. Reassure the client that this is only temporary. 4. Advise the client to take acetaminophen (Tylenol) until it is gone.

37. 2 Rationale: Hypersensitivity or a sensation of "pins and needles" in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported. Test-Taking Strategy Use the process of elimination. Pins and needles sensations usually indicate nerve irritation or damage. If you know this, you can eliminate options 1 and 4. Reassuring the client about something being "only temporary" is often not an appropriate action, unless this is known to be absolutely true. Review the complications associated with vein ligation and stripping if you had difficulty with this question.

38. Postoperatively, a nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for evidence of which of the following? 1. Bleeding and infection 2. Thrombosis and infection 3. Bleeding and wound dehiscence 4. Wound dehiscence and evisceration

38. 1 Rationale: After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any other postoperative client. Test-Taking Strategy Use the process of elimination. Because inferior vena cava filters are inserted percutaneously through a deep vein, options 3 and 4 are eliminated because no abdominal incision is made. From the remaining options, noting that the client has been on anticoagulant therapy before surgery because of the high risk of pulmonary embolism will direct you to option 1. Review care of the client following insertion of an inferior vena cava filter if you had difficulty with this question.

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

4 Rationale: Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beat leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol. Test-Taking Strategy: Note the strategic words priority on assessment. Use the ABCs—airway, breathing, and circulation—to direct you to option 4. Review the effects of premature ventricular contractions if you had difficulty with this question.

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

40. 3 Rationale: A cardiac catheterization requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is a concern and the presence of allergies must be assessed before the procedure. Although options 1, 2, and 4 are accurate, they are not the most critical preprocedure assessments. Test-Taking Strategy Use the process of elimination and note the strategic words most critical. Recalling the concern related to allergy to the dye and the risk of anaphylaxis makes option 3 correct. Review preprocedure interventions for a cardiac catheterization if you had difficulty with this question.

41. A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How would the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

41. 1 Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Therefore, options 2, 3, and 4 are incorrect interpretations. Test-Taking Strategy Use the process of elimination. Option 2 can be eliminated because the pedal pulse is unchanged from admission. Venous complications from immobilization resulting from surgery would not be apparent within 4 hours, so eliminate option 4. From the remaining options, think about the effects of sudden reperfusion in an ischemic limb. There would be redness from new blood flow and edema from the sudden change in pressure in the blood vessels. Review the expected assessment findings following this surgical procedure if you had difficulty with this question.

42. A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful? 1. Rising blood pressure 2. Clearly audible heart sounds 3. Client expressions of relief 4. Rising central venous pressure

42. 4 Rationale: Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant. Test-Taking Strategy Use the process of elimination and note the strategic word unsuccessful. Successful therapy is measured by the disappearance of the original signs and symptoms of cardiac tamponade. Therefore, look for the option that identifies a sign consistent with continued tamponade. Review signs of cardiac tamponade and the expected effects of pericardiocentesis if you had difficulty with this question.

43. A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen

43. 2 Rationale: Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Test-Taking Strategy Use the process of elimination and note the strategic word unrelated. Note that options 1, 3, and 4 are comparative or alike in that they identify a circulatory component. Review the signs of abdominal aortic aneurysm if you had difficulty with this question.

45. Cardiac magnetic resonance imaging (MRI) is prescribed for a client. The nurse identifies that which of the following is a contraindication for performance of this diagnostic study? 1. Client has a pacemaker. 2. Client is allergic to iodine. 3. Client has diabetes mellitus. 4. Client has a biological porcine valve.

45. 1 Rationale: The magnetic fields used for magnetic resonance imaging (MRI) can deactivate the pacemaker. Options 2, 3, and 4 are not contraindications for an MRI. Test-Taking Strategy Focus on the name of the test and note the strategic word magnetic. Remember that the magnetic fields of the MRI can deactivate the pacemaker. Review the contraindications for an MRI if you had difficulty with this question.

5. A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A physician orders a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin? 1. 0.5 to 2 ng/mL 2. 1.2 to 2.8 ng/mL 3. 3 to 5 ng/mL 4. 3.5 to 5.5 ng/mL

5. 1 Rationale: Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Therefore, options 2, 3, and 4 are incorrect. Test-Taking Strategy: Knowledge of the therapeutic serum digoxin level will direct you to option 1. If you had difficulty with this question, learn the therapeutic level for digoxin.

6. A nurse notes bilateral 12 edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 1. Order daily weights starting on the following morning. 2. Review the intake and output records for the last 2 days. 3. Request a sodium restriction of 1 g/day from the physician. 4. Change the time of diuretic administration from morning to evening.

6. 2 Rationale: Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms. Test-Taking Strategy Use the process of elimination, noting the strategic word next. Use the steps of the nursing process to prioritize. Option 2 is the only option that addresses assessment of data. Review care of the client with a myocardial infarction if you had difficulty with this question.

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

6. 4 Rationale: Signs of toxicity from procainamide include confusion, dizziness, drowsiness, decreased urination, nausea, vomiting, and tachydysrhythmias. If the client complains of dizziness, the nurse should assess the vital signs first. Although options 2 and 3 may be interventions, these would be done after the vital signs are taken. Nitroglycerin is a vasodilator and will lower the blood pressure. Test-Taking Strategy: Use the steps of the nursing process to eliminate options 1 and 3. From the remaining options, remember always to assess the client first, not the monitoring devices. Therefore, option 4 is correct. Review the signs of toxicity and the nursing interventions if you had difficulty with this question.

692. A client is admitted to an emergency department with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows: at 11 AM, pulse (P), 92 beats/min, respiratory rate (RR), 24 breaths/min, blood pressure (BP), 140/88 mm Hg; 11:15 AM, P, 96 beats/min, RR, 26 breaths/min, BP, 128/82 mm Hg; 11:30 AM, P, 104 beats/min, RR, 28 breaths/min, BP, 104/68 mm Hg; 11:45 AM, P, 118 beats/min, RR, 32 breaths/min, BP, 88/58 mm Hg. The nurse should alert the physician because these changes are most consistent with which of the following complications? 1. Cardiogenic shock 2. Cardiac tamponade 3. Pulmonary embolism 4. Dissecting thoracic aortic aneurysm

692. 1 Rationale: Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain. Test-Taking Strategy: Use the process of elimination. Recalling that the early serious complications of myocardial infarction include dysrhythmias, cardiogenic shock, and sudden death will direct you to option 1. No information in the question is associated with options 2, 3, or 4. Review the complications of myocardial infarction if you had difficulty with this question.

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

693. 4 Rationale: Metformin (Glucophage) needs to be withheld 48 hours before and after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in options 1, 2, and 3 do not need to be withheld 48 hours before or after cardiac catheterization. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 3 first. Although these medications may be withheld on the morning of the procedure because of the client's NPO status, there is no indication for withholding the medication the day prior to and the day postprocedure. Regular insulin may be administered if elevated blood glucose levels from infused intravenous solutions occur on the day of the procedure. Review preprocedure and postprocedure interventions if you had difficulty with this question.

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

694. 4 Rationale: Hypotension and dizziness are signs of decreased cardiac output. Transcutaneous pacing provides a temporary measure to increase the heart rate and thus perfusion in the symptomatic client. Digoxin will further decrease the client's heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation. Continuing to monitor the client delays necessary intervention. Test-Taking Strategy: Use the process of elimination. Eliminate option 3 because the client is symptomatic and requires intervention. Option 2 is eliminated because digoxin will further decrease the client's heart rate. Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillation; therefore eliminate option 1. Review the indications for transcutaneous pacing if you had difficulty with this question.

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

696. 2 Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway. Test-Taking Strategy: Use the process of elimination. Recalling that fluid produces sounds that are called crackles will assist you in eliminating options 1, 3, and 4. If you had difficulty with this question, review the manifestations found in pulmonary edema.

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

697. 2 Rationale: Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Test-Taking Strategy: Use the process of elimination and focus on the strategic words myocardial ischemia. Recall that ischemia makes the myocardium irritable, producing dysrhythmias. Also, knowledge of the classic signs of shock helps eliminate the incorrect options. Review the clinical manifestations associated with cardiogenic shock if you had difficulty with this question.

698. A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. Based on these findings, the nurse would anticipate that the client is at risk for which of the following? 1. Hypovolemia 2. Acute renal failure 3. Glomerulonephritis 4. Urinary tract infection

698. 2 Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or glomerulonephritis. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because no data indicate infection or inflammation. Noting that the urine output is inadequate will assist you in eliminating option 1. Review the complications associated with cardiac surgery if you had difficulty with this question.

7. A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? 1. Atrial fibrillation 2. Nutritional anemia 3. Peptic ulcer disease 4. Recent upper respiratory infection

7. 3 Rationale: Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Test-Taking Strategy Use the process of elimination and note the strategic word unlikely. Remembering that heart failure is exacerbated by factors that increase the workload of the heart will assist you in eliminating options 1, 2, and 4. Review the precipitating factors associated with heart failure if you had difficulty with this question.

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

700. 3 Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. Options 1, 2, and 4 are unnecessary. Test-Taking Strategy: Use the steps of the nursing process. Always assess the client directly before taking any action. Option 3 is the only option that addresses assessment. Review care of the client on a cardiac monitor if you had difficulty with this question.

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

702. 1 Rationale: Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time. Test-Taking Strategy: Use the process of elimination and note the strategic words most concerned. Option 2 is incorrect and is eliminated first. From the remaining options, focusing on the strategic words will direct you to option 1 because this option identifies the life-threatening condition. Review the concerns associated with ventricular tachycardia if you had difficulty with this question.

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

704. 3 Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Test-Taking Strategy: Use the process of elimination. Flat neck veins are normal or indicate hypovolemia, so eliminate option 1. Nausea and vomiting (option 2) are associated with vagus nerve activity and do not correlate with a tachycardic state. From the remaining options, think of the consequences of falling cardiac output to direct you to option 3. Review the effects of atrial fibrillation if you had difficulty with this question.

712. A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How would the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

712. 1 Rationale: An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Therefore options 2, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Use the process of elimination. Option 2 can be eliminated because the pedal pulse is unchanged from admission. Venous complications from immobilization resulting from surgery would not be apparent within 4 hours, so eliminate option 4. From the remaining options, think about the effects of sudden reperfusion in an ischemic limb. There would be redness from new blood flow and edema from the sudden change in pressure in the blood vessels. Review the expected assessment findings following this surgical procedure if you had difficulty with this question.

714. A nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion with a rate of 150 mL/hr, unchanged for the last 10 hours. The client's urine output for the last 3 hours was 90, 50, and 28 mL (28 mL most recent). The client's blood urea nitrogen level is 35 mg/dL and serum creatinine level is 1.8 mg/dL, measured this morning. Which of the following actions should the nurse take next? 1. Call the physician. 2. Check the urine specific gravity. 3. Check to see if the client had a sample for serum albumin level drawn. 4. Put the intravenous line on a pump so that the infusion rate is sure to stay stable.

714. 1 Rationale: Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of renal failure. Renal failure can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. The nurse monitors hourly intake and output and notes the results of daily blood urea nitrogen and creatinine levels. Urine output lower than 30 to 50 mL/hr is reported to the physician. Test-Taking Strategy: Focus on the information in the question and the abnormal assessment data. This question indicates elevations in blood urea nitrogen and creatinine levels and a significant drop in hourly urine output. These assessment findings should direct you to option 1. Review the complications associated with this surgical procedure if you had difficulty with this question.

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

715. 2 Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. Test-Taking Strategy: Use the process of elimination, focusing on the data in the question. Noting the strategic words at rest will direct you to option 2. If you had difficulty with this question, review the characteristics of the various types of angina.

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

716. 1, 2, 3, 4 Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high Fowler's position to ease the work of breathing. Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is inserted to measure output accurately. Intravenously administered morphine sulfate reduces venous return (preload), decreases anxiety, and also reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client's response to treatment is successful. Test-Taking Strategy: Note the strategic words priority interventions and focus on the client's diagnosis. Recall the pathophysiology associated with pulmonary edema and use the ABCs—airway, breathing, and circulation—to help determine priority interventions. Review priority interventions for the client with pulmonary edema if you had difficulty with this question.

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

717. 2 Rationale: Common laboratory ranges for activated partial thromboplastin time are 20 to 36 seconds. Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the client's activated partial thromboplastin time would be considered therapeutic if it was 60 seconds. Test-Taking Strategy: Use the process of elimination. Option 1 is eliminated because the prothrombin time assesses response to warfarin (Coumadin) therapy. Eliminate option 3 because at 28 seconds the client is receiving no therapeutic effect from the continuous heparin infusion. Eliminate option 4 because this value is beyond the therapeutic range and the client is at risk for bleeding. Review laboratory tests to monitor the effectiveness of heparin therapy if you had difficulty with this question.

718. A nurse provides discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will avoid alcohol consumption." 3. "I have already called my family to pick up a Medic-Alert bracelet." 4. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

718. 4 Rationale: Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information. Test-Taking Strategy: Use the process of elimination and note the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that warfarin (Coumadin) is an anticoagulant and that Ecotrin is an aspirin-containing product will direct you to option 4. Review client teaching points related to warfarin if you had difficulty with this question.

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

721. 2 Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. β-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored. Test-Taking Strategy: Use the process of elimination, eliminating options 3 and 4 because these are expected effects from the medication. Note the strategic words potential serious complication. These strategic words will direct you to option 2. Review the adverse effects of this medication if you had difficulty with this question.

723. A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which of the following is a priority nursing intervention? 1. Monitor for renal failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.

723. 3 Rationale: Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications. Test-Taking Strategy: Use the process of elimination and note the strategic word priority. Remember, bleeding is a priority. Review care of the client on tissue plasminogen activator if you had difficulty with this question.

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

724. 3 Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. Test-Taking Strategy: Use the process of elimination. Recalling that thiazide diuretics carry a sulfa ring will direct you to option 3. Review the nursing considerations related to administering this medication if you had difficulty with this question.

725. A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education? 1. "Constipation and bloating might be a problem." 2. "I'll continue to watch my diet and reduce my fats." 3. "Walking a mile each day will help the whole process." 4. "I'll continue my nicotinic acid from the health food store."

725. 4 Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels. Test-Taking Strategy: Use the process of elimination and note the strategic words need for further education. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Remembering that over-the-counter medications should be avoided when a client is taking a prescription medication will direct you to option 4. Review client teaching points related to this medication if you had difficulty with this question.

726. A client is on nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client would indicate an understanding of the instructions? 1. "It is not necessary to avoid the use of alcohol." 2. "The medication should be taken with meals to decrease flushing." 3. "Clay-colored stools are a common side effect and should not be of concern." 4. "Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing."

726. 4 Rationale: Flushing is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals but this will decrease gastrointestinal upset; taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the physician. Test-Taking Strategy: Use the process of elimination. Option 1 can be eliminated because alcohol must be abstained from. Option 2 can be eliminated because taking the medication with meals helps decrease the gastrointestinal symptoms. The clay-colored stools in option 3 is a sign of hepatic dysfunction and should be immediately reported to the physician. Review the client teaching points related to this medication if you had difficulty with this question.

727. A 66-year-old client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include atenolol (Tenormin), digoxin (Lanoxin), and chlorothiazide (Diuril). A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis? 1. Dyspnea, edema, and palpitations 2. Chest pain, hypotension, and paresthesia 3. Double vision, loss of appetite, and nausea 4. Constipation, dry mouth, and sleep disorder

727. 3 Rationale: Double vision, loss of appetite, and nausea are early signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, other visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence. Test-Taking Strategy: Use the process of elimination. Recalling that gastrointestinal and visual disturbances occur with digoxin toxicity will direct you to option 3. If you had difficulty with this question, review the signs of digoxin toxicity.

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

729. 1 Rationale: The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Aminocaproic acid is the antidote for thrombolytic therapy. Potassium chloride is administered for a potassium deficit. Test-Taking Strategy: Knowledge regarding the various antidotes is needed to answer this question. Remember the antidote to heparin is protamine sulfate. Learn these antidotes if you had difficulty with this question.

730. A client is receiving thrombolytic therapy with a continuous infusion of streptokinase (Streptase). The client suddenly becomes extremely anxious and complains of itching. A nurse hears stridor and on examination of the client notes generalized urticaria and hypotension. Which of the following should be the priority action of the nurse? 1. Administer oxygen and protamine sulfate. 2. Stop the infusion and call the physician. 3. Cut the infusion rate in half and sit the client up in bed. 4. Administer diphenhydramine

730. 2 Rationale: The client is experiencing an anaphylactic reaction to streptokinase, which is allergenic. The infusion should be stopped, the physician notified, and the client treated with epinephrine, antihistamines, and corticosteroids. Test-Taking Strategy: Recall that an allergic reaction and possible anaphylaxis are risks associated with streptokinase therapy. Also, focusing on the signs and symptoms in the question will assist in answering the question. When a severe allergic reaction occurs, the offending substance should be stopped, and lifesaving treatment should begin. Review the adverse effects of this medication if you had difficulty with this question.

731. A client is admitted with pulmonary embolism and is to be treated with streptokinase (Streptase). A nurse would report which of the following assessments to the physician before initiating this therapy? 1. Adventitious breath sounds 2. Temperature of 99.4° F orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/min

731. 3 Rationale: Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore the nurse would report the results of the blood pressure to the physician before initiating therapy. Test-Taking Strategy: Use the process of elimination and focus on the client's diagnosis. Options 1, 2, and 4 may be present in the client with pulmonary embolism but are not necessarily signs that warrant reporting before this therapy is initiated. Review the contraindications associated with the administration of this medication if you had difficulty with this question.

732. The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity. Select all that apply. 1. Tremors 2. Diarrhea 3. Irritability 4. Blurred vision 5. Nausea and vomiting

732. 2, 4, 5 Rationale: Digoxin (Lanoxin) is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache, visual disturbances such as diplopia, blurred vision, yellow-green halos, photophobia, drowsiness, fatigue, and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Test-Taking Strategy: Specific knowledge regarding the characteristics of digoxin toxicity is needed to answer this question. Recall that the early signs are gastrointestinal manifestations. Next, recall that visual disturbances occur. If you had difficulty with this question review the manifestations associated with digoxin toxicity.

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

8. 3 Rationale: Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration. Taking the medication at the same time each day improves compliance. Because furosemide is a diuretic, the morning is the best time to take the medication so as not to interrupt sleep. Notification of the health care provider is appropriate if edema is noticed in the hands, feet, or face or if the client is short of breath. Sitting up slowly prevents postural hypotension. Test-Taking Strategy: Use the process of elimination, noting the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recalling that tea and coffee are stimulants and that diuretics potentially can worsen dehydration will direct you to option 3. In addition, coffee and tea are not healthy items to consume. Review client teaching points related to this medication if you had difficulty with this question.

9. A client who has developed severe pulmonary edema would most likely exhibit which of the following? 1. Mild anxiety 2. Slight anxiety 3. Extreme anxiety 4. Moderate anxiety

9. 3 Rationale: Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. Test-Taking Strategy Use the process of elimination. Noting the strategic word severe will direct you to option 3. Review the clinical manifestations associated with severe pulmonary edema if you had difficulty with this question.

9. A nurse is caring for a client receiving a heparin intravenous (IV) infusion. The nurse anticipates that which laboratory study will be prescribed to monitor the therapeutic effect of heparin? 1. Hematocrit 2. Hemoglobin 3. Prothrombin time 4. Activated partial thromboplastin time

9. 4 Rationale: The prothrombin time will assess for the therapeutic effect of warfarin sodium (Coumadin), and the activated partial thromboplastin time (aPTT) will assess the therapeutic effect of heparin. Hematocrit and hemoglobin values assess red blood cell concentrations. Baseline assessment, including an aPTT value, should be completed, as well as ongoing daily aPTT values while the client is taking heparin. Heparin doses are determined based on the result of the aPTT. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are comparative or alike and are unrelated to heparin therapy. From the remaining options, recall the relationship between the prothrombin time and warfarin and the aPTT and heparin. Review care of a client on heparin infusion if you had difficulty with this question.

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

Answer: 4, 5, 6 Rationale: The usual guidelines for administering nitroglycerin tablets for chest pain include administering one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. If the client does not obtain relief after taking a third dose of nitroglycerin, the physician is notified. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a Code Blue. Additionally, it is not necessary to contact the client's family unless the client has requested this. Test-Taking Strategy: Focus on the data in the question. Use the steps of the nursing process to determine that assessing the client's pain level and checking the client's blood pressure are appropriate actions. Next, recalling the usual guidelines for administering nitroglycerin tablets will assist in determining that an appropriate action is to administer a second nitroglycerin tablet, 0.4 mg, sublingually. Review care of the client with chest pain and the guidelines for the administration of nitroglycerin if you had difficulty with this question.