Med Surg 2 Exam 1 Review

The intensive care unit nurse is caring for a client with sepsis whose tissue perfusion is declining. What sign would indicate to the nurse that end-organ damage may be occurring?

Selected Answer: A. Heart and respiratory rates are elevated Answers: A. Heart and respiratory rates are elevated B. Urinary output increases C. Skin becomes warm and dry D. Adventitious lung sounds occur in the upper airway Response Feedback: Rationale: As sepsis progresses, tissues become less perfused and acidotic, compensation begins to fail, and the client begins to show signs of organ dysfunction. The cardiovascular system also begins to fail, the blood pressure does not respond to fluid resuscitation and vasoactive agents, and signs of end-organ damage are evident (e.g., acute kidney injury, pulmonary failure, hepatic failure). As sepsis progresses to septic shock, the blood pressure drops, and the skin becomes cool, pale, and mottled. Temperature may be normal or below normal. Heart and respiratory rates remain rapid. Urine production ceases, and multiple organ dysfunction progressing to death occurs. Adventitious lung sounds occur throughout the lung fields, not just in the upper fields of the lungs.

A client who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse's best response?

Selected Answer: A. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." Answers: A. "To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently." B. "To detect and treat bradycardia, which is an excessively slow heart rate." C. "To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia." D. "To shock your heart if you have a heart attack at home." Response Feedback: Rationale: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia.

A client presents to the ED reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?

Selected Answer: A. Begin ECG monitoring. Answers: A. Begin ECG monitoring. B. Obtain information about family history of heart disease. C. Auscultate lung fields. D. Determine if the client smokes. Response Feedback: Rationale: The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a client reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the client smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.

The nurse is caring for an adult client who has gone into ventricular fibrillation. When assisting with defibrillating the client, what must the nurse do?

Selected Answer: A. Call "all clear" once before discharging the defibrillator. Answers: A. Call "all clear" once before discharging the defibrillator. B. Maintain firm contact between paddles and the client's skin. C. Apply a layer of water as a conducting agent. D. Ensure the defibrillator is in the sync mode. Response Feedback: Rationale: When defibrillating an adult client, the nurse should maintain good contact between the paddles and the client's skin. To prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles, and ensure the defibrillator is in the nonsync mode. "Clear'' should be called three times before discharging the paddles.

The nurse has just admitted a client for cardiac surgery. The client tearfully describes feeling afraid of dying while undergoing the surgery. What is the nurse's best response?

Selected Answer: A. Explore the factors underlying the client's anxiety. Answers: A. Explore the factors underlying the client's anxiety. B. Obtain an order for a PRN benzodiazepine. C. Describe the procedure in greater detail. D. Teach the client guided imagery techniques. Response Feedback: Rationale: An assessment of anxiety levels is required in the client to assist the client in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the client's anxiety before providing interventions such as education or medications.

A client has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The health care provider's choice of antibiotics would be primarily based on what diagnostic test?

Selected Answer: A. Full blood count Answers: A. Full blood count B. Cardiac aspiration C. Echocardiography D. Blood cultures Response Feedback: Rationale: To help determine the causative organisms and the most effective antibiotic treatment for the client, blood cultures are taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism. Echocardiography cannot indicate the microorganisms causing the infection. "Cardiac aspiration" is not a diagnostic test.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances?

Selected Answer: A. Maintain a low-sodium diet. Answers: A. Maintain a low-sodium diet. B. Ensure the client has sufficient potassium intake. C. Encourage fluid intake. D. Encourage the use of over-the-counter calcium supplements. Response Feedback: Rationale: Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

Family members bring a client to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?

Selected Answer: A. The symptoms indicate an acute coronary episode and should be treated as such. Answers: A. The symptoms indicate an acute coronary episode and should be treated as such. B. Treatment should be determined pending the results of an exercise stress test. C. The symptoms indicate a pulmonary etiology rather than a cardiac etiology. D. The symptoms indicate angina and should be treated as such. Response Feedback: Rationale: Angina and MI have similar symptoms and are considered the same process but are on different points along a continuum. That the client's symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale, cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

The nurse is caring for a client admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this client. The nurse should recognize what implication of this assessment finding?

Selected Answer: A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. Answers: A. This is only an accurate indicator of myocardial damage when it reaches its peak in 24 hours. B. Because the client has a history of unstable angina, this is a poor indicator of myocardial injury. C. This result indicates muscle injury, but does not specify the source. D. This is an accurate indicator of myocardial injury. Response Feedback: Rationale: Troponin I, which is specific to cardiac muscle, is elevated within hours after myocardial injury. Even with a diagnosis of unstable angina, this is an accurate indicator of myocardial injury.

The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm?

Selected Answer: A. Ventricular fibrillation Answers: A. Ventricular fibrillation B. Ventricular tachycardia C. Pulseless electrical activity (PEA) D. Asystole Response Feedback: Rationale: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute absence of a heart rhythm.

During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What would be the instructor's best response?

Selected Answer: B. "Cardioversion is done on a beating heart; defibrillation is not." Answers: A. "The difference is the timing of the delivery of the electric current." B. "Cardioversion is done on a beating heart; defibrillation is not." C. "Defibrillation is synchronized with the electrical activity of the heart, but cardioversion is not." D. "Cardioversion is always attempted before defibrillation because it has fewer risks." Response Feedback: Rationale: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical current. In cardioversion, the delivery of the electrical current is synchronized with the client's electrical events; in defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a dysrhythmia). Cardioversion is not necessarily attempted first.

A client is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect the client's busy work schedule. Which guidance would the nurse provide to the client?

Selected Answer: B. "Clients are kept in the hospital until they are independent with all aspects of their care." Answers: A. "Clients need to stay in the hospital until they regain normal heart function for their age." B. "Clients are kept in the hospital until they are independent with all aspects of their care." C. "Clients usually remain at the hospital for 24 to 48 hours." D. "Clients generally stay in the hospital for 6 to 8 days." Response Feedback: Rationale: After undergoing percutaneous balloon valvuloplasty, the client usually remains in the hospital for 24 to 48 hours. Prediagnosis levels of heart function are not always attainable and the client does not need to be wholly independent prior to discharge.

A nurse has taken on the care of a client who had a coronary artery stent placed yesterday. When reviewing the client's daily medication administration record, the nurse should anticipate administering what drug?

Selected Answer: B. Acetaminophen Answers: A. Ibuprofen B. Acetaminophen C. Dipyridamole D. Clopidogrel Response Feedback: Rationale: Because of the risk of thrombus formation within the stent, the client receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.

The ICU nurse is caring for a client in neurogenic shock following an overdose of antianxiety medication. When assessing this client, the nurse should recognize what characteristic of neurogenic shock?

Selected Answer: B. Bradycardia Answers: A. Cool, moist skin B. Bradycardia C. Hypertension D. Signs of sympathetic stimulation Response Feedback: Rationale: In neurogenic shock, the sympathetic system is not able to respond to body stressors. Therefore, the clinical characteristics of neurogenic shock are signs of parasympathetic stimulation. It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is hypotension with bradycardia, rather than the tachycardia that characterizes other forms of shock.

The nurse is caring for a client who is in the recovery room following the implantation of an ICD. The client has developed ventricular tachycardia (VT). What should the nurse assess and document?

Selected Answer: B. Client's activity at time of dysrhythmia Answers: A. ECG to compare time of onset of VT and onset of device's shock B. Client's activity at time of dysrhythmia C. Client's level of consciousness (LOC) at the time of the dysrhythmia D. ECG so health care provider can see what type of dysrhythmia the client has Response Feedback: Rationale: If the client has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be recorded to note the time between the onset of the dysrhythmia and the onset of the device's shock or antitachycardia pacing. This is a priority over LOC or activity at the time of onset.

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?

Selected Answer: B. Cool, clammy skin Answers: A. Decreased heart rate B. Cool, clammy skin C. Increased urine output D. Hyperactive bowel sounds Response Feedback: Rationale: In the compensatory stage of shock, the body shunts blood from the organs, such as the skin and kidneys, to the brain and heart to ensure adequate blood supply. As a result, the client's skin is cool and clammy. Also in this compensatory stage, blood vessels vasoconstrict, the heart rate increases, bowel sounds are hypoactive, and the urine output decreases.

The nurse is reviewing the echocardiography results of a client who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure is this client experiencing?

Selected Answer: B. Dilation and hypertrophy of all four heart chambers Answers: A. Dilation of the atria and hypertrophy of the ventricles B. Dilation and hypertrophy of all four heart chambers C. Dilated ventricles without hypertrophy of the ventricles D. Dilated ventricles with atrophy of the ventricles Response Feedback: Rationale: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in clients with DCM.

A client has been scheduled for cardiovascular computed tomography (CT) with contrast. To prepare the client for this test, what action should the nurse perform?

Selected Answer: B. Keep the client NPO for at least 6 hours prior to the test. Answers: A. Limit the client's activity for 2 hours before the test. B. Keep the client NPO for at least 6 hours prior to the test. C. Establish peripheral IV access. D. Teach the client to perform incentive spirometry. Response Feedback: Rationale: An IV is necessary if contrast is to be used to enhance the images of the CT. The client does not need to fast or limit activity. Incentive spirometry is not relevant to this diagnostic test.

A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, "Wouldn't sterile water be a more appropriate choice than saltwater?" Under what circumstances would the nurse administer electrolyte-free water intravenously?

Selected Answer: B. Never, because it rapidly enters red blood cells, causing them to rupture. Answers: A. When the client is in excess of calcium and/or magnesium ions B. Never, because it rapidly enters red blood cells, causing them to rupture. C. When a client's fluid volume deficit is due to acute or chronic kidney disease D. When the client is severely dehydrated, resulting in neurologic signs and symptoms Response Feedback: Rationale: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.

The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation?

Selected Answer: B. Overdose of amphetamines Answers: A. Endocarditis B. Overdose of amphetamines C. Guillain-Barré syndrome D. Multiple myeloma Response Feedback: Rationale: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a client with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.

The hospital nurse is caring for a client who reports that an angina attack is beginning. Which action is the nurse's most appropriate initial action?

Selected Answer: B. Place the client on bed rest in a semi-Fowler position. Answers: A. Have the client sit down and put the head between the knees. B. Place the client on bed rest in a semi-Fowler position. C. Have the client stand still and bend over at the waist. D. Have the client perform pursed-lip breathing. Response Feedback: Rationale: When a client experiences angina, the client is directed to stop all activities and sit or rest in bed in a semi-Fowler position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. There is no need to have the client put the head between the legs because cerebral perfusion is not lacking

The nurse is caring for a client with mitral stenosis who is scheduled for a balloon valvuloplasty. The client reports being unsure of why the surgeon did not opt to replace the damaged valve rather than repair it. Which statement indicates an advantage of valvuloplasty that the nurse should cite?

Selected Answer: B. Repaired valves tend to function longer than replaced valves. Answers: A. Lower doses of antirejection drugs are required than with valve replacement. B. Repaired valves tend to function longer than replaced valves. C. The procedure is not associated with a risk of infection. D. The procedure can be performed on an outpatient basis in a health care provider's office. Response Feedback: Rationale: In general, valves that undergo valvuloplasty function longer than prosthetic valve replacements and clients do not require continuous anticoagulation. Valvuloplasty carries a risk of infection, like all surgical procedures, and it is not performed in a health care provider's office. Antirejection drugs are unnecessary because foreign tissue is not introduced.

A client with a complex cardiac history is scheduled for transthoracic echocardiography. What should the nurse teach the client in anticipation of this diagnostic procedure?

Selected Answer: B. The client will remain on bed rest for 1 to 2 hours after the test. Answers: A. The client's pain will be managed aggressively during the procedure. B. The client will remain on bed rest for 1 to 2 hours after the test. C. The test is noninvasive, and nothing will be inserted into the client's body. D. The test will provide a detailed profile of the heart's electrical activity. Response Feedback: Rationale: Before transthoracic echocardiography, the nurse informs the client about the test, explaining that it is painless. The test does not evaluate electrophysiology, and bed rest is unnecessary after the procedure.

When assessing a client diagnosed with angina pectoris, it is most important for the nurse to gather what information?

Selected Answer: B. The client's symptoms and the activities that precipitate attacks Answers: A. The client's coping strategies surrounding the attacks B. The client's symptoms and the activities that precipitate attacks C. The client's activities, limitations, and level of consciousness after the attacks D. The client's understanding of the pathology of angina Response Feedback: Rationale: The nurse must gather information about the client's symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The client's coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

When caring for a client in shock, one of the major nursing goals is to reduce the risk that the client will develop complications of shock. How can the nurse best achieve this goal?

Selected Answer: B. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Answers: A. Provide a detailed diagnosis and plan of care in order to promote the client's and family's coping. B. Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. C. Keep the health care provider updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. D. Monitor for significant changes and evaluate client outcomes on a scheduled basis focusing on blood pressure and skin temperature. Response Feedback: Rationale: Shock is a life-threatening condition with a variety of underlying causes. It is critical that the nurse apply the nursing process as the guide for care. Shock is unpredictable and rapidly changing so the nurse must understand the underlying mechanisms of shock. The nurse must also be able to recognize the subtle as well as more obvious signs and then provide rapid assessment and response to provide the client with the best chance for recovery. Coping skills are important, but not the ultimate priority. Keeping the health care provider updated with the most accurate information is important, but the nurse is in the best position to provide rapid assessment and response, which gives the client the best chance for survival. Monitoring for significant changes is critical, and evaluating client outcomes is always a part of the nursing process, but the subtle signs and symptoms of shock are as important as the more obvious signs, such as blood pressure and skin temperature. Assessment must lead to diagnosis and interventions.

A nurse is assigned four clients with diagnoses that rule out myocardial infarction (MI) due to chest pain. Which client's test results best demonstrate the specific diagnosis of unstable angina (USA)?

Selected Answer: C. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q waves. Answers: A. A 72-year-old client with an increase in myoglobin, no elevation in the ST segment, and no elevation in troponins. B. A 54-year-old client with elevated creatine kinase myocardial band (CK-MB) and ST segment elevations in two contiguous leads on the electrocardiogram (ECG). C. A 48-year-old client with T wave inversions, ST elevation, and abnormal Q waves. D. A 63-year-old client with elevated troponins and no elevation in the ST segment. Response Feedback: Rationale: The 72-year-old client with chest pain had clinical manifestations of coronary ischemia, but the ECG showed no evidence of an acute MI. The 72-year-old client had an elevated myoglobin, which is a biomarker but is not a very specific indicator of a cardiac event because an elevation may also occur due to seizures, muscle diseases, trauma, and surgery. The 63-year-old client had test results consistent with a non-ST-elevated myocardial infarction: elevated cardiac biomarkers but no ECG evidence of an acute MI. The 48- and 54-year-old clients had test results consistent with an ST-elevated myocardial infarction: elevated cardiac biomarkers, ECG changes in two contiguous leads, ST elevation, and Q wave abnormalities.

When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?

Selected Answer: C. A systolic blood pressure that is higher during exhalation Answers: A. A diastolic blood pressure that is higher during inhalation B. A diastolic blood pressure that is lower during exhalation C. A systolic blood pressure that is higher during exhalation D. A systolic blood pressure that is lower during inhalation Response Feedback: Rationale: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.

A client has returned to the cardiac care unit after having a permanent pacemaker implantation. For which potential complication should the nurse most closely assess this client?

Selected Answer: C. Chest pain Answers: A. Bleeding at the implantation site B. Bradycardia C. Chest pain D. Malignant hyperthermia Response Feedback: Rationale: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.

A client who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse's most appropriate action?

Selected Answer: C. Document the client's low urine output and monitor closely for the next several hours. Answers: A. Increase the infusion rate of the client's IV fluid to prompt an increase in renal function. B. Contact the client's health care provider and continue to assess fluid balance and renal function. C. Document the client's low urine output and monitor closely for the next several hours. D. Contact the dietitian and suggest the need for increased oral fluid intake. Response Feedback: Rationale: Nursing management includes accurate measurement of urine output. An output of less than 0.5 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

An adult client with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac monitoring. What rhythm characteristic will the ECG most likely show?

Selected Answer: C. Fewer QRS complexes than P waves Answers: A. PP interval and RR interval are irregular. B. PR interval is constant. C. Fewer QRS complexes than P waves D. PP interval is equal to RR interval. Response Feedback: Rationale: In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes are not consistent with this diagnosis.

A brain (B-type) natriuretic peptide (BNP) sample has been drawn from an older adult client who has been experiencing vital fatigue and shortness of breath. This test will allow the care team to investigate the possibility of what diagnosis?

Selected Answer: C. Heart failure Answers: A. Valve dysfunction B. Cardiomyopathy C. Heart failure D. Pleurisy Response Feedback: Rationale: The level of BNP in the blood increases as the ventricular walls expand from increased pressure, making it a helpful diagnostic, monitoring, and prognostic tool in the setting of HF. It is not specific to cardiomyopathy, pleurisy, or valve dysfunction.

When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize?

Selected Answer: C. Heart rate and rhythm Answers: A. Core body temperature B. Blood pressure C. Heart rate and rhythm D. Oxygen saturation level Response Feedback: Rationale: For clients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though each of the other listed vital signs must be assessed.

The nurse is caring for a client with a history of endocarditis. Which topic would the nurse prioritize during health promotion education?

Selected Answer: C. Oral hygiene Answers: A. Physical activity B. Fluid intake C. Oral hygiene D. Dietary guidelines Response Feedback: Rationale: For clients with endocarditis, regular professional oral care combined with personal oral care may reduce the risk of bacteremia. In most cases, diet and fluid intake do not need to be altered. Physical activity has broad benefits, but it does not directly prevent complications of endocarditis.

The nurse has entered a client's room and found the client unresponsive and not breathing. What is the nurse's next appropriate action?

Selected Answer: C. Palpate the client's carotid pulse. Answers: A. Begin performing chest compressions. B. Illuminate the client's call light. C. Palpate the client's carotid pulse. D. Activate the Emergency Response System (ERS). Response Feedback: Rationale: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.

A client who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurse's assessment findings is most consistent with myocarditis?

Selected Answer: C. Pleuritic chest pain Answers: A. Sudden changes in level of consciousness (LOC) B. Peripheral edema and pulmonary edema C. Pleuritic chest pain D. Flulike symptoms Response Feedback: Rationale: The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not characteristic of myocarditis.

The nurse is doing discharge teaching with a client who has coronary artery disease. The client asks why they have to take an aspirin every day if they don't have any pain. Which rationale for this intervention would be the best?

Selected Answer: C. To help prevent blockages that can cause chest pain or heart attacks Answers: A. To help the blood penetrate the heart more freely B. To help restore the normal function of the heart C. To help prevent blockages that can cause chest pain or heart attacks D. To help the blood carry more oxygen than it would otherwise Response Feedback: Rationale: An aspirin a day is a common nonprescription medication that improves outcomes in clients with coronary artery disease due to its antiplatelet action, which helps to prevent clots that can lead to chest pain or heart attacks. It does not affect oxygen-carrying capacity or perfusion. Aspirin does not restore cardiac function.

The nurse is auscultating the breath sounds of a client with pericarditis. Which finding is most consistent with this diagnosis?

Selected Answer: C. Wheezes Answers: A. Friction rub B. Coarse crackles C. Wheezes D. Fine crackles Response Feedback: Rationale: A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with pericarditis.

The nurse is preparing a client for cardiac surgery. During the procedure, the client's heart will be removed and a donor heart implanted at the vena cava and pulmonary veins. What procedure will this client undergo?

Selected Answer: C. Xenograft Answers: A. Homograft B. Heterotopic transplant C. Xenograft D. Orthotopic transplant Response Feedback: Rationale: Orthotopic transplantation is the most common surgical procedure for cardiac transplantation. The recipient's heart is removed, and the donor heart is implanted at the vena cava and pulmonary veins. Some surgeons still prefer to remove the recipient's heart, leaving a portion of the recipient's atria (with the vena cava and pulmonary veins) in place. Homografts, or allografts (i.e., human valves), are obtained from cadaver tissue donations and are used for aortic and pulmonic valve replacement. Xenografts and heterotopic transplantation are not terms used to describe heart transplantation.

The public health nurse is participating in a health fair and interviews a client with a history of hypertension, who is currently smoking one pack of cigarettes per day. The client denies any of the most common manifestations of CAD. The nurse should expect the focuses of CAD treatment to be:

Selected Answer: C. drug therapy and smoking cessation. Answers: A. diet therapy and smoking cessation. B. diet and drug therapy. C. drug therapy and smoking cessation. D. diet therapy only. Response Feedback: Rationale: Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostic findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

In preparation for cardiac surgery, a client was taught about measures to prevent venous thromboembolism. What statement indicates that the client clearly understood this education?

Selected Answer: D. "I'll keep pillows under my knees to help my blood circulate better." Answers: A. "I'll try to stay in bed for the first few days to allow myself to heal." B. "I'll make sure that I don't cross my legs when I'm resting in bed." C. "I'll put on those compression stockings if I get pain in my calves." D. "I'll keep pillows under my knees to help my blood circulate better." Response Feedback: Rationale: To prevent venous thromboembolism, clients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

The nurse is providing care to a client who has just undergone an electrophysiologic (EP) study. The client reports being nervous about "things going wrong" during the procedure. What is the nurse's best response?

Selected Answer: D. "The whole team will be monitoring you very closely for the entire procedure." Answers: A. "Remember that this is a step that will bring you closer to enjoying good health." B. "Thousands of clients undergo EP every year." C. "This is basically a risk-free procedure." D. "The whole team will be monitoring you very closely for the entire procedure." Response Feedback: Rationale: Clients who are to undergo an EP study may be anxious about the procedure and its outcome. A detailed discussion involving the client, the family, and the electrophysiologist usually occurs to ensure that the client can give informed consent and to reduce the client's anxiety about the procedure. It is inaccurate to state that EP is "risk-free" and stating that it is common does not necessarily relieve the client's anxiety. Characterizing EP as a step toward good health does not directly address the client's anxiety.

The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client?

Selected Answer: D. A calcium channel blocker Answers: A. A nonsteroidal anti-inflammatory drug (NSAID) B. A beta-adrenergic blocker C. An antiplatelet aggregator D. A calcium channel blocker Response Feedback: Rationale: Several medications are routinely prescribed for systolic heart failure, including ACE inhibitors, beta-blockers, diuretics, and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.

The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the sinoatrial (SA) node and then proceeds in which sequence?

Selected Answer: D. AV node to bundle of His to Purkinje fibers Answers: A. Bundle of His to Purkinje fibers to AV node B. Bundle of His to atrioventricular (AV) node to Purkinje fibers C. AV node to Purkinje fibers to bundle of His D. AV node to bundle of His to Purkinje fibers Response Feedback: Rationale: The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinje fibers.

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure?

Selected Answer: D. An S3 heart sound Answers: A. Faint breath sounds B. Pleural friction rub C. A heart murmur D. An S3 heart sound Response Feedback: Rationale: An S3 heart sound is a sign that the heart is beginning to fail and that increased blood volume fills the ventricle with each beat. Heart failure does not normally cause a pleural friction rub or murmurs. Changes in breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of heart failure.

An older adult client has been diagnosed with aortic regurgitation. Which change in blood flow should the nurse expect to see on this client's echocardiogram?

Selected Answer: D. Blood to flow back from the aorta to the left ventricle Answers: A. Obstruction of blood from the left atrium to left ventricle B. Blood to flow back from the left atrium to the left ventricle C. Obstruction of blood flow from the left ventricle D. Blood to flow back from the aorta to the left ventricle Response Feedback: Rationale: Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle.

An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that what vessel is most commonly used as source for a CABG?

Selected Answer: D. Brachial artery Answers: A. Femoral artery B. Brachial vein C. Greater saphenous vein D. Brachial artery Response Feedback:Rationale: The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.

A client in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in the femoral region. What is the nurse's most appropriate action?

Selected Answer: D. Call for assistance and initiate cardiopulmonary resuscitation. Answers: A. Reposition the client's leg in a nondependent position. B. Promptly remove the femoral sheath. C. Call for help and apply pressure to the access site. D. Call for assistance and initiate cardiopulmonary resuscitation. Response Feedback: Rationale: The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.

A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention?

Selected Answer: D. Defibrillation Answers: A. ECG monitoring B. Implantation of a cardioverter defibrillator C. Angioplasty D. Defibrillation Response Feedback: Rationale: Any type of VT in a client who is unconscious and without a pulse is treated in the same manner as ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the dysrhythmia.

During a shift assessment, the nurse is identifying the client's point of maximum impulse (PMI). Where should the nurse best palpate the PMI?

Selected Answer: D. Left midclavicular line of the chest at the fifth intercostal space Answers: A. Midline between the xiphoid process and the left nipple B. Left midclavicular line of the chest at the level of the nipple C. Two to three centimeters to the left of the sternum D. Left midclavicular line of the chest at the fifth intercostal space Response Feedback: Rationale: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.

A nurse in the intensive care unit (ICU) receives a report from the nurse in the emergency department (ED) about a new client being admitted with a neck injury received while diving into a lake. The ED nurse reports that the client's blood pressure is 85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU nurse recognize that the client is probably experiencing?

Selected Answer: D. Neurogenic shock Answers: A. Hypovolemic shock B. Septic shock C. Anaphylactic shock D. Neurogenic shock Response Feedback: Rationale: Neurogenic shock can be caused by spinal cord injury. The client will present with a low blood pressure; bradycardia; and warm, dry skin due to the loss of sympathetic muscle tone and increased parasympathetic stimulation. Anaphylactic shock is caused by an identifiable offending agent, such as a bee sting. Septic shock is caused by bacteremia in the blood and presents with a tachycardia. Hypovolemic shock presents with tachycardia and a probable source of blood loss.

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include what intervention?

Selected Answer: D. Promoting communication with the client and family along with addressing end-of-life issues Answers: A. Discussing organ donation on a number of different occasions to allow the family time to adjust to the idea B. Encouraging the family to leave the hospital and to take time for themselves as acute care of MODS clients may last for several months C. Encouraging the family to stay hopeful and educating them to the fact that, in nearly all cases, the prognosis is good D. Promoting communication with the client and family along with addressing end-of-life issues Response Feedback: Rationale: Promoting communication with the client and family is a critical role of the nurse with a client in progressive shock. It is also important that the health care team address end-of-life decisions to ensure that supportive therapies are congruent with the client's wishes. Many cases of MODS result in death, and the life expectancy of clients with MODS is usually measured in hours and possibly days, but not in months. Organ donation should be offered as an option on one occasion, and then allow the family time to discuss and return to the health care providers with an answer following the death of the client.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect?

Selected Answer: D. Respiratory acidosis Answers: A. Respiratory alkalosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory acidosis Response Feedback: Rationale: The pH is below 7.35, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range, so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis, but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

The nurse is caring for a client who is undergoing an exercise stress test. Prior to reaching the target heart rate, the client develops chest pain. What is the nurse's most appropriate response?

Selected Answer: D. Stop the test and monitor the client closely. Answers: A. Administer analgesia and slow the test. B. Administer sublingual nitroglycerin to allow the client to finish the test. C. Initiate cardiopulmonary resuscitation. D. Stop the test and monitor the client closely. Response Feedback: Rationale: The client may be experiencing signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident. The client should not be permitted to continue the test due to risk of MI, therefore the first option, administer nitroglycerin is incorrect. The nurse would not administer pain medication and slow the test as this could mask the symptoms of MI and the client should not be permitted to continue with the test. Further assessment by the nurses must be completed and protocol for MI initiated.

The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics?

Selected Answer: D. Take the diuretic in the morning to avoid interfering with sleep. Answers: A. Avoid drinking fluids for 2 hours after taking the diuretic. B. Take the diuretic only on days when experiencing shortness of breath. C. Avoid taking the medication within 2 hours consuming dairy products. D. Take the diuretic in the morning to avoid interfering with sleep. Response Feedback: Rationale: Oral diuretics should be given early in the morning so that diuresis does not interfere with the client's nighttime rest. Discussing the timing of medication administration is especially important for older adult clients who may have urinary urgency or incontinence. The nurse would not teach the client about the timing of fluid intake. Fluid intake does not need to be adjusted and dairy products are not contraindicated.

A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

Selected Answer: D. The kidneys react rapidly to compensate for imbalances in the body. Answers: A. The kidneys regulate the bicarbonate level in the intracellular fluid. B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. C. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. D. The kidneys react rapidly to compensate for imbalances in the body. Response Feedback: Rationale: The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by kidney disease. Renal compensation for imbalances is relatively slow (a matter of hours or days).