Med-Surg Exam 1 - Practice: Cardio/PV NCLEX style questions
A client with suspected acute MI is admitted to the coronary care unit. To help confirm diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain? 30 minutes 4 to 6 hours 2 to 3 hours 12 to 18 hours
4 to 6 hours
Which intervention suggested to the client with Raynaud's disease is aimed at preventing complications? A. "Take oral vasoconstrictive agents when you have symptoms." B. "Wear warm clothing when exposed to cool temperatures." C. "Avoid placing lotion on affected extremities." D. "Check the pulses in your arms and legs daily."
B. "Wear warm clothing when exposed to cool temperatures."
In the immediate post operative period which measure would best prevent a DVT: A. Adding a multivitamin to the patient's medication B. Early ambulation C. Measuring I/O D. Lowering the legs below the level of the heart
B. Early ambulation
A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? A client 4 days post-operative after mitral valve replacement. A client with hypertrophic cardiomyopathy. A client with a history of repaired ventricular septal defect. A client 1 day post coronary stent placement.
A client 4 days post-operative after mitral valve replacement.
What health teaching should be included in the continuing plan of care for a client with chronic venous stasis ulcers? A. "Apply the elastic stockings before getting out of bed in the morning." B. "Clean the ulcer with Betadine before applying a dressing." C. "Take one low-dose aspirin daily to prevent inflammation." D. "Remove and reapply the DuoDerm dressing daily."
A. "Apply the elastic stockings before getting out of bed in the morning."
Circle all the interventions that the nurse will suggest for a client with peripheral arterial disease? A. Keep the legs in a dependent position B. Using a heating pad to warm the affected limb C. Encourage gradually increasing exercise, such as walking D. Abstaining from smoking
A. Keep the legs in a dependent position C. Encourage gradually increasing exercise, such as walking D. Abstaining from smoking
A 60 year old male client comes into the emergency department with a complaint of crushing substernal chest pain that radiates to his shoulder and left arm. His blood pressure is 136/92 and O2 saturation of 96%. The admitting diagnosis is acute MI. Orders include administer NC O2 at 4L/min, blood work, chest xray, 12 lead ekg, and 2mg of morphine sulfate. What should the nurse do first? Administer the morphine. Obtain the EKG Obtain the blood work Order the chest x-ray
Administer the morphine to reduce the crushing chest pain and reduce O2 demands.
The nurse notes a small, circular, deep reddened ulcer on the tip of the patient's great toe. The patient states it is extremely painful, even at rest. The nurse suspects this may be: A venous ulcer An arterial ulcer Gangrene of the toe venous stasis
An arterial ulcer
The nurse who notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40 is aware that this may indicate: Venous narrowing Arterial narrowing Adequate peripheral circulation Inadequate coronary output
Arterial narrowing
You are performing an assessment of the carotid arteries of a client with atherosclerosis. Upon auscultation of the right carotid artery, you hear a swishing sound. What would be your best action? A. Perform carotid massage. B. Notify the health care provider. C. No action is necessary because this is a normal finding. D. Simultaneously palpate the carotid arteries bilaterally.
B. Notify the health care provider.
A client with a diagnosed abdominal aortic aneurysm develops lower back pain radiating to the groin. What is your interpretation of this information? A. The aneurysm has become obstructed. B. The aneurysm may be undergoing expansion. C. The client is experiencing symptoms of a Urinary Tract Infection. D. The client is experiencing normal sensations associated with this condition.
B. The aneurysm may be undergoing expansion.
The health care provider has prescribed the client with a deep vein thrombosis to be started on oral warfarin after the second day of receiving intravenous heparin. What is your best action? A. Administer the medications as prescribed. B. Turn off the heparin drip for 1 hour before administration of the warfarin. C. Discontinue the heparin drip completely before warfarin administration. D. Hold the dose of warfarin, because two anticoagulants cannot be given concurrently.
B. Turn off the heparin drip for 1 hour before administration of the warfarin.
A nurse is planning care for a client scheduled for admission to the surgical nursing unit following femoral-popliteal bypass grafting. The nurse plans to use which of the following items for the protection of the client's surgical extremity? Knee gatch Overhead trapeze Heavyweight blankets Bed Cradle
Bed Cradle
A client who has undergone percutaneous insertion of an inferior vena cava (IVC) filter was on heparin infusion therapy prior to surgery. The nurse interprets that this client is most at risk for which of the following in the early postoperative period? Wound dehiscence and evisceration Thrombosis and abdominal wound infection Bleeding and wound dehiscence Bleeding and infection
Bleeding and infection
A client with chest pain is prescribed IV nitroglycerin. Which assessment is of greatest concern? Serum potassium of 3.5mEq/L Blood pressure 88/46 ST elevation on EKG HR of 61
Blood pressure 88/46
What instructions should you provide to a client at risk of deep vein thrombosis who is being discharged home with low-molecular-weight heparin? A. "You must have your aPTT checked every 2 weeks." B. "Massage the injection site after the heparin is expelled." C. "Notify your health care provider if your stools appear tarry." D. "You will have a heparin lock placed before discharge for injection of the medication."
C. "Notify your health care provider if your stools appear tarry."
A client recovering from aortofemoral bypass surgery has developed swelling, pain, and tenseness of the operative limb. What complication of this procedure is most likely the cause of this client's symptoms? A. Infection B. Graft occlusion C. Compartment syndrome D. Disseminated intravascular coagulation
C. Compartment syndrome
Following a left anterior MI, a client undergoes insertion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? Decreased central venous pressure Increase in the cardiac index Increased pulmonary artery diastolic pressure Decreased mean pulmonary artery pressure
Increased pulmonary artery diastolic pressure
The client is receiving heparin therapy for a deep vein thrombosis. Which of the following activated partial thromboplastin times (aPTT) indicates to you that anticoagulation is adequate? A. The client's aPPT is one half the control value. B. The client's aPPT is the same as the control value. C. The client's aPPT is twice the control value. D. The client's aPPT is 5 times the control value.
C. The client's aPPT is twice the control value.
A client presents to the out-patient clinic with a venous ulcer located on the left ankle. What additional assessment findings would you expect to be present in this client? A. Dependent rubor is present, accompanied by hair loss on the extremity. B. Weak pedal pulse, and toenails are thickened. C. There is a brownish discoloration of the leg and a moist, red ulcer bed. D. The extremity is cold and gray-blue in color
C. There is a brownish discoloration of the leg and a moist, red ulcer bed.
Which of the following sets of conditions is an indication that a client with a history of left sided heart failure is developing pulmonary edema? JVD and wheezing Dependent edema and anorexia Coarse crackles and HR 120 BP 90/50 and HR 130
Coarse crackles and HR 120
The nurse has completed an assessment on a client with a decreased cardiac output. Which finding is highest priority? BP 110/62, Afib with HR of 82, bibasilar crackles Confusion, urine output of 15ml over the last 2 hours, orthopnea Sp02 of 92 on 2L NC O2, RR20, 1+ edema of lower extremities. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise
Confusion, urine output of 15ml over the last 2 hours, orthopne
Which monitoring technique should be avoided by the nurse providing care to a client with an unrepaired abdominal aortic aneurysm? A. Measurement of abdominal girth B. Observation of abdominal wall movement C. Auscultation of any area of the abdomen D. Palpation of the abdominal midline area
D. Palpation of the abdominal midline area
A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical exam reveals an apical systolic thrill and heave, along with a fourth heart sound(S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate? Decreased cardiac output Risk for deficient fluid volume Ineffective thermoregulation Risk for peripheral neurovascular dysfunction
Decreased cardiac output
A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and JVD. What condition should the nurse suspect? Pulmonary embolism Heart failure Cardiac tamponade Tension pneumothorax
Heart failure
When teaching a patient with an MI, the nurse explains that the pain associated with MI is caused by: Left ventricular overload Impending circulatory collapse Extracellular electrolyte imbalances Insufficient O2 reaching the heart muscle
Insufficient O2 reaching the heart muscle
A nurse is assessing a client who visits the physician's office with complaints of color changes in the right leg and a cold feeling in the right foot. The client complains of leg pain and cramping after walking three blocks, which is relieved when the client stops and rests. The nurse documents that the client is experiencing which of the following symptoms? Intermittent claudication Venous insufficiency Thrombophlebitis Deep vein thrombosis
Intermittent claudication
A patient reports experiencing pain in the left lower leg and foot when walking. The nurse notes that the leg is slightly edematous and is hairless. This pain is relieved with rest. The nurse suspects that the patient may be experiencing: Coronary artery disease Intermittent claudication Arterial embolus Raynaud's disease
Intermittent claudication
A client was initially admitted for an MI, but then develops cardiogenic shock. Which characteristic sign would the nurse observe? Oliguria Bradycardia Elevated BP Fever
Oliguria
A client is admitted to the hospital directly from the physician's office with a leg ulcer. The nurse concludes that the client has impairment of arterial circulation based on which of the following characteristics of the leg ulcer? Pale with little granulation tissue brown pigmentation of surrounding skin deep reddish base superficial with uneven edges
Pale with little granulation tissue
A nurse is evaluating the effects of care for a client with deep vein thrombosis. Which of the following limb observations would the nurse identify as indicating the least success in meeting the outcome criteria for this problem? Pedal edema that is 3+ Slight residual calf tenderness Skin warm, equal temperature both legs Calf girth 1/8 inch larger than unaffected limb
Pedal edema that is 3+
A nurse enters the room of a client who has undergone embolectomy and finds that an intravenous heparin infusion has infused too rapidly because of malfunction of the infusion device. After assessing the client, the nurse checks to see whether which of the following medications is available on the nursing unit? Potassium chloride Protamine sulfate vitamin K (AquaMEPHYTON) Aminocaproic acid (Amicar)
Protamine sulfate
The nurse is administering warfarin (Coumadin) to a patient with deep vein thrombophlebitis. Which laboratory value indicates warfarin is at therapeutic levels? Partial thromboplastin time (PTT) 1.5 to 2 times the control Prothrombin time (PT) 1.5 to 2 times the control International normalized ratio (NR) of 3 to 4 Hematocrit of 32%
Prothrombin time (PT) 1.5 to 2 times the control
A client was admitted to the hospital with a diagnosis of thrombophlebitis 2 days ago. The client complains of severe shortness of breath, chest pain, and is anxious and agitated. The nurse interprets that this client could most likely be experiencing which of the following Pulmonary embolism Pulmonary edema Myocardial infarction Pneumonia
Pulmonary embolism
A physician has scheduled a client with mitral stenosis for mitral valve replacement. Which condition may arise as a complication of mitral stenosis? Left-sided heart failure Myocardial ischemia Left ventricular hypertrophy Pulmonary hypertension
Pulmonary hypertension Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include pulmonary hemorrhage and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.
A client has chest pain of 8/10. The EKG reveals ST elevation and troponin level of .8ng/ml. What is the highest priority for the patient at this time? Monitor daily weights and urine output Permit unrestricted visitation by family and friends. Provide client education on medications and diet. Reduce pain and myocardial oxygen demand
Reduce pain and myocardial oxygen demand
A client with a history of MI is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart beat of 120 BPM, audible third and fourth heart sounds, PCWP of 18, CO of 2.5L/min, blood pressure of 84/64 mmHg, bibasilar crackles on lung auscultation, and urine output of 5 mL over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because: The client is experiencing heart failure The client is going into cardiogenic shock The client shows signs of aneurysm rupture The client is in the early stage of right-sided heart failure
The client is going into cardiogenic shock
A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first? The client admitted with unstable angina pectoris who wants to be discharged. The client who suffered an acute MI who is complaining of constipation. The client who had a pacemaker inserted yesterday and who is complaining of incisional pain. The client is who has her call light on.
The client who suffered an acute MI who is complaining of constipation.
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which client statement most strongly suggests angina pectoris? The pain lasted about 45 minutes. The pain resolved after I ate a sandwich. The pain got worse when I took a deep breath. The pain occurred while I was mowing the lawn.
The pain occurred while I was mowing the lawn.
A client with severe angina pectoris and ST-segment elevation on an ECG is being seen in the ER. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a: Creatine Kinase Hemoglobin Level Troponin Level Liver Panel
Troponin Level
A client hospitalized 3 days ago after multiple trauma is at risk for deep vein thrombosis (DVT) due to immobility. The nurse routinely assesses this client for which of the following signs and symptoms compatible with DVT? Calf muscle atrophy Unilateral edema Coolness and pallor of the affected lib Diminished distal peripheral pulses
Unilateral edema
The most appropriate goal for a patient with peripheral arterial insufficiency is promotion of: Vasoconstriction Vasodilatation Vascular compression Atherosclerosis
Vasodilatation
To maintain adequate tissue integer to the lower legs of a patient with peripheral vascular disease, the nurse should encourage the patient to: Use strong soaps to clean the feet Avoid trimming toenails Eat a low-protein diet Wear sturdy, well-fitting shoes
Wear sturdy, well-fitting shoes
4. What condition includes the classic signs and symptoms of jugular vein distention, muffled heart sounds, and decreasing systolic pressure? a. HF b. Pericardial tamponade c. Pulmonary edema d. Cardiogenic shock
b. Pericardial tamponade Cardiac tamponade results in hypotension, (falling systolic blood pressure), narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds.
A nurse is caring for a client who underwent a femoral-popliteal bypass grafting on the right leg 12 hours ago. The client's IV rate is 125 mL/hour, unchanged for the past 8 hours. Urine output for the past 2 hours was 30 mL and 24 mL. The client's pulse rate has increased from 76 (baseline) to 94 beats per minute. Blood pressure (BP) has decreased from 134/78 (baseline) to 106/68 mm Hg. The right foot is becoming paler and the pulse is weakening. Which of the following actions should the nurse take next? Put the IV on a pump to ensure a stable infusion rate Wrap the client's surgical leg in a blanket Check the specific gravity of the last hour's urine Notify the surgeon immediately
Wrap the client's surgical leg in a blanket
5. Management of patients with cardiomyopathy is directed at preventing and treating heart failure. The treatment of heart failure includes (select all that apply): a. Reducing circulating blood volume b. Reducing myocardial oxygen needs c. Increasing CO by improving contractility or reducing peripheral resistance d. Increasing preload
a & b & c Heart failure occurs when the heart is unable to generate sufficient cardiac output to meet the needs of the body. Reduction of fluid volume, myocardial oxygen requirements, peripheral resistance, and improving cardiac output can reduce heart failure symptoms
2. What does the nurse recognize as an absolute contraindication for thrombolytic therapy? a. Active bleeding b. Current anticoagulant therapy c. Over age 75 d. Severe hepatic disease
a. Active bleeding Because bleeding is a major complication of thrombolytic therapy, any patient with active bleeding should not be administered this treatment
6. All of the following are indications for a VAD to be used as a bridge to recovery except: a. Acute myocarditis b. Cardiogenic shock following an acute myocardial infarction c. End-stage heart failure d. Failure to wean from cardiopulmonary bypass following cardiac surgery
a. Acute myocarditis
3. The following are symptoms associated with AS (aortic stenosis): a. Angina, syncope, dyspnea b. Diastolic murmur, syncope, dyspnea c. Syncope, diastolic murmur, angina d. Dyspnea, angina, diastolic murmur
a. Angina, syncope, dyspnea A triad of symptoms is associated with AS: (a) angina due to LV hypertrophy and diminished coronary blood flow, (b) dyspnea due to heart failure, and (c) syncope, in particular, with exertion, due to fixed cardiac output. A diastolic murmur is characteristic of aortic regurgitation while a systolic ejection murmur is commonly heard with aortic stenosis
5. The nurse notes that a patient has a new second-degree type I block (Wenckebach). The patient denies chest pain or other symptoms, and the patient's blood pressure is 90/60. After paging the provider stat, what intervention would the nurse perform first? a. Apply oxygen, assess IV access, bring the portable monitor/external pacemaker to the bedside b. Administer nitroglycerin as ordered p.r.n. for chest discomfort and obtain a 12-lead ECG c. Call for stat labs to be drawn and prepare the patient for surgical pacemaker implantation d. Ask the nurse's aide to stay with the patient and monitor the blood pressure every 5 minutes
a. Apply oxygen, assess IV access, bring the portable monitor/external pacemaker to the bedside The nurse should be prepared to intervene if the patient becomes symptomatic. The application of oxygen may avoid the development of patient symptoms such as shortness of breath and chest pain. Securing IV access will allow for prompt treatment with medications as necessary and having the monitor/pacemaker near the patient will facilitate early recognition of the arrhythmia and early rescue through pacing the patient's rhythm if needed
4. The nurse notes a new wide complex tachycardia on the telemetry monitor. Upon assessing the patient, the nurse finds the patient cannot be aroused and has gasping respirations. The nurse's next action is to: a. Call a code b. Notify the provider stat c. Document the findings in the telemetry record d. Defibrillate the patient at 100 J
a. Call a code Gasping respirations and not being arousable warrant calling for immediate resuscitation.
5. What medication is commonly used to treat cardiogenic shock related to hypervolemia? a. Diuretics b. Beta blockers c. Vasoconstrictors d. Inotropes
a. Diuretics Since the patient is in cardiogenic shock because of hypervolemia, diuretics are expected in order to decrease the fluid volume excess
A new postsurgical patient has been prescribed unfractionated heparin to prevent DVT. Which of the following is a true statement regarding the use of heparin? a. Heparin has a half-life of approximately 60 minutes. b. Therapeutic aPTT level is 3 times the baseline control. c. If renal insufficiency exists, high doses of heparin are needed. d. Heparin is administered by gravity drip.
a. Heparin has a half-life of approximately 60 minutes. Heparin has a half-life of about 60 minutes. Heparin is in the effective or therapeutic range when the activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the baseline control. If renal insufficiency exists, lower doses of heparin are required. Unfractionated heparin is administered via an infusion pump to carefully control the rate.
8. Which of the following describes the best place to auscultate for the presence of a pericardial friction rub? a. Left lower sternal border in the fourth intercostal space b. Right lower sternal border in the fourth intercostal space c. Left lower sternal border in the second intercostal space d. Right lower sternal border in the second intercostal space
a. Left lower sternal border in the fourth intercostal space
9. What condition requires IE (infective endocarditis) prophylaxis? a. MVP b. Rheumatic heart disease c. Bicuspid valve disease d. Prosthetic valve
a. MVP
3. A man was just admitted after experiencing chest pain and shortness of breath. Blood tests were sent while he was in the emergency department, and the nurse is evaluating the results. An elevation in which one of the following blood tests indicates that he is having an acute myocardial infarction? a. Troponin b. Cholesterol c. Brain natriuretic peptide (BNP) d. C-reactive protein (CRP)
a. Troponin Troponin is a protein that rises after myocardial injury. The remaining responses are not related to myocardial cell injury.
1. The nurse is reviewing the vital signs of a patient admitted with cellulitis whose BP is 136/86. Which of the following should the nurse teach the patient about this BP reading? a. "Your BP is in the normal range, you don't need to worry." b. "This BP shows prehypertension; try to cut down on sodium and see your health care provider." c. "I will notify the provider of your BP; a BP of 136/86 indicates you have hypertension." d. "You are at risk for organ damage; this BP indicates a hypertensive urgency."
b. "This BP shows prehypertension; try to cut down on sodium and see your health care A BP greater than 120/80 but below 139/90 indicates prehypertension, which places the patient at risk for complications of hypertension. Although not hypertensive, a BP of 136/86 is not considered normal on the continuum of normotension to hypertension. A hypertensive urgency exists when the BP is greater than 180/120 but there is no evidence of target organ damage
2. During routine screening, the nurse notes a BP of 172/96. The patient states, "I feel fine—what's the big deal?" Which of the following indicates the best response by the nurse? a. "As long as you are feeling well and you are under 60 years old, there is no need to worry." b. "Untreated high BP may result in kidney failure, heart attack, or stroke." c. "This BP elevation indicates you have not been compliant with your medication." d. "Have you had any unusual nosebleeds or headaches lately?"
b. "Untreated high BP may result in kidney failure, heart attack, or stroke." Hypertension is described as the "silent killer" and is frequently asymptomatic, while target organs such as heart, brain, and eyes are sustaining damage. There is no information given to indicate the patient is taking medication and has been noncompliant. Because hypertension is most frequently asymptomatic, nosebleeds or headaches are rarely presenting symptoms.
4. A 45-year-old woman who has a history of diabetes, hypertension, and cigarette smoking walks into the emergency room with shortness of breath, indigestion, and diaphoresis. She should be evaluated immediately for: a. Community-acquired pneumonia b. Acute coronary syndrome c. Pulmonary embolus d. Aortic dissection
b. Acute coronary syndrome Patients with diabetes develop neuropathies that diminish the perception of pain, which can mask the pain associated with acute myocardial infarction. Because this woman has diabetes, she is more likely to present with atypical acute myocardial infarction symptoms rather than experiencing chest pain or pressure. Despite her younger age, she has multiple cardiac risk factors that put her at high risk for having an acute myocardial infarction. An ECG should be done immediately to determine if she is having an acute myocardial infarction, before assessing her for other medical problems.
2. After which of the following diagnostic tests will the patient need to remain on bedrest for 2 to 6 hours? a. Exercise stress test b. Cardiac catheterization c. Myocardial perfusion imaging d. Traditional echocardiography
b. Cardiac catheterization Cardiac catheterization is an invasive procedure that involves insertion of catheters into a large vein and an artery. Bed rest for 2 to 6 hours is necessary to ensure that hemostasis is achieved. The other diagnostic tests are noninvasive and do not place the patient at risk for bleeding; therefore, they do not require postprocedure bed rest.
4. Two hours after cardiac catheterization that was accessed via the right femoral artery route, an adult client complains of numbness and pain in the right foot. What action should the nurse take first? a. Call the provider immediately. b. Check the client's peripheral pulses (pedal/posterior tibial). c. Take the client's blood pressure. d. Recognize that this is an expected response and reassess the patient in 1 hour.
b. Check the client's peripheral pulses (pedal/posterior tibial). Complications after accessing the femoral artery are bleeding or clotting of the vessel. Any complaint of the patient's must be assessed immediately. The nurse assesses limb perfusion as the priority intervention and then notifies the health care provider of the results of the findings
3. A patient presents to the emergency room in atrial fibrillation. The nurse understands that the treatment plan for this patient will be determined based on which factor? a. Whether or not the patient has a "do not resuscitate" prescription b. How long the patient has been in atrial fibrillation c. The number of episodes of atrial fibrillation the patient has experienced in the past year d. The rate of atrial contractions
b. How long the patient has been in atrial fibrillation Patients in atrial fibrillation are at risk for an embolic event if they have been in the rhythm for more than 48 hours and require anticoagulation before cardioversion.
7. A patient presents with chest pain. Acute myocardial infarction is excluded and the patient is diagnosed with pericarditis. Which of the following medications would the provider be most likely to prescribe initially? Select all that apply. a. Acetaminophen (Tylenol) b. Ibuprofen (Motrin) c. Colchicine d. Broad Spectrum Antibiotic e. Coumadin (Warfarin)
b. Ibuprofen (Motrin); c. Colchicine; d. Broad Spectrum Antibiotic
3. A patient is admitted with angina and hypertensive crisis. On admission, the BP is 240/120. The nurse recognizes which of the following is consistent with current BP management strategies? a. In 2 hours, the target BP is 140/90. b. In 1 hour, the patient's target BP should be 180/90. c. Lowering the BP too quickly may lead to rebound hypertension. d. The nurse should anticipate using oral medications for hypertensive crisis.
b. In 1 hour, the patient's target BP should be 180/90. The BP should be reduced gradually (10% decrease in the first hour and an additional 15% in the next 3 to 12 hours) to a BP no lower than 160/100 mm Hg. Lowering the BP too quickly can lead to decreased cerebral perfusion and even stroke. This patient is demonstrating hypertensive emergency, not urgency, as evidenced by chest pain (angina). The BP is gradually reduced over 48 hours until a normal BP is achieved.
2. Severe AS (aortic stenosis) is consistent with all of the following except: a. Pulmonary edema b. Increased CO c. Right-sided heart failure d. Left ventricular hypertrophy
b. Increased CO To overcome the obstruction of the narrowed, stenotic valve opening, the left ventricle contracts more slowly but with greater energy than normal, forcibly squeezing the blood through the smaller orifice. This increases pressure on the left ventricle. The ventricular wall hypertrophies and becomes dilated. LV failure ensues, and cardiac output is diminished rather than increased
2. The nurse is caring for a patient with right ventricular failure. What symptom will the patient most likely exhibit? a. Crackles on auscultation b. Jugular vein distention c. Pulmonary edema d. Normal CVP
b. Jugular vein distention Right ventricular failure leads to congestion of systemic circulation and is evidenced by edema, jugular vein distention, weight gain, ascites and hepatomegaly. All other distracters are associated with left ventricular failure
Using a hydrocolloid dressing, a patient is undergoing autolytic debridement of necrotic venous ulcer. The nurse understands that this type of debridement is which of the following? a. Accomplished by applying enzymatic ointment to the lesion b. Left in place for 3 to 7 days c. The fastest method of debridement d. Accomplished by applying saline impregnated gauze to the ulcer
b. Left in place for 3 to 7 days With autolytic debridement, an occlusive absorptive dressing, such as a hydrocolloid, is placed over the wound and left in place for 3 to 7 days to allow enzymes from the body to liquefy the necrotic tissues and separate it from the viable tissue. Enzymatic debridement involves the application of enzyme ointments prescribed to treat the ulcer. Surgical debridement is the fastest method of debridement. Wet to dry or nonselective debridement can be accomplished by applying saline-impregnated gauze to the ulcer.
1. In interpreting a patient's rhythm strip, the nurse is most concerned with which of the finding? a. A PR interval of 0.22 second b. Progressively lengthening PR interval c. A premature and short PR interval d. A PR interval of 0.10 second
b. Progressively lengthening PR interval A progressively lengthening PR interval is the most concerning finding as it represents second degree A-V block, type I and may need treatment with atropine or transcutaneous pacing. The other findings, although abnormal do not usually require emergency treatment.
3. The nurse is caring for a nonsmoking female patient with the diagnosis of coronary atherosclerosis who has been admitted to the hospital with angina. The patient states that she never experiences chest pain going down her arm or in the middle of her chest. The nurse is not surprised at this statement and explains to the patient that: a. Women who have ischemia are usually totally asymptomatic. b. Women have been found to have more atypical symptoms such as dyspnea, nausea, and weakness. c. Chest pain occurs only with strenuous exercise. d. Cigarette smoking is usually the contributing factor to chest pain.
b. Women have been found to have more atypical symptoms such as dyspnea, nausea, and weakness. Women with acute coronary syndromes report atypical symptoms such as indigestion, nausea, fatigue, and palpitations rather than chest pain.
5. A nurse is completing medication teaching for a patient diagnosed with hypertension. What directive is important to include in the plan to prevent rebound hypertension? a. Caution the client about the use of OTC vitamins. b. Inform the client that beta blockers can cause sexual dysfunction. c. Avoid abruptly stopping antihypertensive medication. d. Teach the patient/client to arise slowly.
c. Avoid abruptly stopping antihypertensive medication. The nurse provides written information about the expected effects and side effects of antihypertensive medications, warning the patient not to abruptly stop medications because rebound hypertension may occur. Both female and male patients should be informed that certain medications, such as beta-blockers, may cause sexual dysfunction or dissatisfaction and that other medications are available should the problem develop. Patients should be cautioned to avoid OTC medications especially nasal decongestants containing vasoconstrictors, which can further elevate the BP
5. A 54-year-old man comes to triage complaining of severe, left-sided, pressure-like chest pain and left arm numbness. The pain began 2 hours ago and is unrelieved by rest. The patient is anxious, diaphoretic, and complaining of nausea. Cardiac monitoring is begun, and oxygen is given at 2 L/min. An intermittent infusion device (IID) is in place, and vital signs are as follows: BP of 128/68 mm Hg; pulse, 76 beats/min; respirations easy and regular at 20 breaths/min. ECG reveals normal sinus rhythm with occasional unifocal premature ventricular contractions (PVCs). The nurse suspects an MI based on an elevation in the which lab study? a. CK-MB and LDH b. LDH and troponin I c. CK-MB and troponin I d. Troponin I and SGPT
c. CK-MB and troponin I CK-MB is an enzyme specific to myocardial muscle and is released when there has been damage to the muscle; therefore, it will be present when there has been an MI. Additionally, troponin I is a protein that is released exclusively from the myocardial muscle; therefore, a "positive" troponin I is indicative of an MI
4. Which diagnostic test is preferred for evaluation of heart function? a. Electrocardiogram b. Chest x-ray c. Echocardiogram d. Cardiac catheterization
c. Echocardiogram The echocardiogram is the preferred test to evaluate heart valves because it allows the visualization of the valves as they open and close. A chest x-ray will determine the size of the heart, cardiac catheterization evaluates the patency of the coronary arteries, and an electrocardiogram identifies electrical activity
The nurse is assessing the lower extremities of a patient with a possible DVT. Which of the following is not a reliable indicator of a possible DVT? a. Calf tenderness b. Edema of the extremity c. Homan's sign d. Increased circumference of affected extremity
c. Homan's sign Homan's sign (pain in the calf after the foot is sharply dorsiflexed) used to be considered a sign of a DVT is not reliable and is not used anymore. Calf tenderness is produced by inflammation of the vein wall and a cord may be detected in the involved veins by gently palpating the affected extremity. Warmth and erythema may also be noted. Deep vein thrombosis (DVT) is associated with edema of the eternity due to inhibition of venous outflow. Swelling can be measured obtaining the circumference of the affected extremity at specific levels and comparing one extremity with the other at the same level.
The nurse is caring for a patient diagnosed with peripheral arterial disease. Based on assessment, which of the following clinical manifestations would be inconsistent with acute arterial occlusion? a. Pallor b. Paresthesia c. Hyperthermia d. Poikilothermia
c. Hyperthermia When assessing acute arterial occlusion, the nurse must be aware of the "Six P's": Pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis.
5. Which of the following signs or symptoms are indications for performing an anklebrachial index (ABI)? a. Irregular, superficial ulcer along the medial malleolus b. 4+ pitting edema to lower extremities c. Intermittent claudication d. Pulse deficit greater than 20 mm Hg
c. Intermittent claudication Intermittent claudication is a symptom associated with peripheral arterial disease. The ABI is a test that evaluates arterial perfusion to the lower extremities and is used to quantify the severity of peripheral arterial disease. An irregular, superficial ulcer along the medial malleolus is due to chronic venous insufficiency, pitting edema is a nonspecific finding caused by certain medications and many other medical conditions, and a pulse deficit is the difference between the systolic and diastolic blood pressures.
1. Incomplete closure of the mitral valve results in backflow of blood from the: a. RV to the right atrium b. Right atrium to RV c. LV to LA d. LA to LV
c. LV to LA Incompetent closure of the mitral valve can result from disease processes that alter valve leaflets, mitral annulus, chordae tendineae, and the papillary muscle. When mitral valve leaflets thicken, fibrose, and contract, they cannot close completely during systole. This forces blood backward into the left atrium during systole.
3. A patient with CHF is being discharged home. What instruction will the nurse likely give this patient to assess fluid balance? a. Monitor blood pressure b. Assess radial pulses c. Monitor weight daily d. Monitor bowel movements
c. Monitor weight daily Obtaining daily weights and tracking trends in weight provide an easy and reliable assessment of fluid balance. Fluid balance is an important surveillance strategy in controlling heart failure symptoms
1. The nurse is performing a cardiac examination of a patient who has HF. When auscultating over the apical area, the nurse hears an extra sound between S1 and S2. This sound may be caused by: a. S3, indicating worsening HF b. S4, indicating the sound of blood moving into a noncompliant left ventricle c. A diastolic murmur, suggesting aortic regurgitation d. A systolic murmur, indicating a mitral valve regurgitation
d. A systolic murmur, indicating a mitral valve regurgitation. A leaky mitral valve causes regurgitation of blood back into the left atrial during systole that creates the murmur or vibration during systole. All of the other responses are abnormal sounds heard during diastole (between S2 and S1).
1. A patient arrives in the emergency room complaining of nausea, diaphoresis, SOB, and squeezing substernal chest pain that radiates to the left shoulder and jaw. The nurse should perform which interventions? a. Complete admission registration, alert the catheter laboratory team, establish an IV access, and record all vital signs b. Alert the catheter laboratory team, administer oxygen, obtain blood work, and notify the health care provider c. Establish an IV, give sublingual nitroglycerin as ordered, insert a Foley catheter, and alert the catheter laboratory team d. Administer oxygen, apply a cardiac monitor, record patient's vital signs, and give sublingual nitroglycerin as ordered
d. Administer oxygen, apply a cardiac monitor, record patient's vital signs, and give sublingual nitroglycerin as ordered The patient must be assessed before alerting the laboratory team; therefore, vital sign assessment is a priority, and the nurse recalls the mnemonic MONA and anticipates the administration of morphine, oxygen, nitroglycerine (Nitrates), and aspirin
1. Which outcome best demonstrates the effectiveness of treatment for a patient with right ventricular failure? a. Clear breath sounds b. Oxygen saturation greater than 96% c. Moist mucous membranes d. Central venous pressure of 4 mm Hg
d. Central venous pressure of 4 mm Hg In right ventricular failure, the systemic circulation is congested, leading to jugular vein distention, elevated central venous pressure (CVP) and edema. Evidence of improvement would be a decreasing CVP. Normal CVP is 2 to 8 mm Hg. A CVP greater than 8 mm Hg indicates hypervolemia (excessive fluid circulating in the body) or right-sided heart failure
4. The nurse is teaching a patient about BP self-monitoring. What direction should be included in the plan of care? a. You may sit or stand when taking your BP. b. Do not eat or drink for at least 2 hours before measuring your BP. c. Make sure the cuff is loose enough to avoid squeezing your arm too tightly. d. Keep your arm at heart level and avoid talking during BP measurement.
d. Keep your arm at heart level and avoid talking during BP measurement. BP should be measured in the seated position with the patient relaxed and the manometer at heart level. It is not necessary to refrain from food or drink. The cuff should fit snugly to avoid a false low reading
When assessing for an arterial and venous ulcer, which of the following characteristics are consistent with an arterial ulcer? a. Pink or beefy red with granulation tissue b. May have severe edema c. Darkened color tissue in gaiter area d. Pale and cool extremity
d. Pale and cool extremity Arterial ulcers have a regular border, are pale, and cooler than other skin areas. Venous ulcers may be pink or beefy red in color, tissues are darker in the gaiter area, and may have severe edema.
2. The nurse is observing the central monitoring station and notes the following rhythm alarms. Which alarm should the nurse respond to first? a. Atrial fibrillation rate of 90 b. First-degree heart block, rate of 80 c. Ventricular tachycardia (monomorphic) d. Torsade des pointes (polymorphic)
d. Torsade des pointes (polymorphic) Although all rhythms are abnormal, Torsades des points is a lethal rhythm which often leads to ventricular fibrillation and requires immediate intervention. Some patients may not experience a drop in cardiac output with monomorphic ventricular tachycardia.
The chest pain associated with a dissecting aortic aneurysm differs from the chest pain associated with an acute myocardial infaraction (AMI) in that the aneurysm pain usually is: a. a squeezing tight pressure. b. relieved by rest. c. an intermittent dull aching pain d. a sudden sharp stabbing tearing pain
d. a sudden sharp stabbing tearing pain (answer not confirmed)
