NCLEX RN flashcards cardiovascular

37. The client is in complete heart block. Which intervention should the nurse implement first? l 1. Prepare to insert a pacemaker. l 2. Administer atropine, an antidysrhythmic. l 3. Obtain a stat ECG. l 4. Assess the client's peripheral pulses.

Correct answer 2: Atropine decreases vagal stimula- tion and increases the heart rate; therefore, it is the first intervention. Remember, the client is in distress; therefore, do not assess the peripheral pulses first.

113. The nurse is preparing to administer digoxin to a client diagnosed with heart failure. Which nursing intervention should the nurse implement? l 1. Check the client's potassium level. l 2. Assess the client's radial pulse. l 3. Monitor the client's respirations. l 4. Ask if the client has eaten today.

113. 114. Correct answer 1: Digoxin can potentiate dys- rhythmias if the potassium level is low. The nurse should check the apical pulse and the digoxin level. The medication does not have to be given with food.

111. The nurse is discharging a client diagnosed with coronary artery disease. Which discharge instructions should the nurse teach the client? l 1. Instruct the client to decrease the amount of cigarettes smoked. l 2. Encourage to perform weight-lifting exercises 3 days a week . l 3. Teach the client how to take coronary vasodilators. l 4. Explain the need to prepare an advance directive and living will.

111. 112. Correct answer 3: The client diagnosed with coronary artery disease will have angina at times. The nurse should discuss how to use the medica- tion, storage, and when to know the medication is still potent. The nurse should also discuss when to call the emergency medical response system.

103. The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with folic acid deficiency anemia. Which interventions should be included in the plan of care? Select all that apply. l 1. Administer iron supplements. l 2. Move to room near the nurse's desk. l 3. Encourage the client to eat green vegetables. l 4. Assess for history of alcohol consumption. l 5. Allow for rest periods during the day.

103. 104. Correct answer 2, 3, 4, 5: A room near the nurse's desk is important because decreased oxygenation levels to the brain, resulting from the anemia, can cause the client to become confused, and a history of alcohol consumption can require observation for delirium tremens. The client should include leafy green vegetables in the diet. These are high in folate. Folic acid deficiency is common among heavy drinkers. Fatigue is the primary presenting symptom of anemia.

107. The charge nurse is making assignments on a medical floor. Which client should be assigned to the new graduate nurse ? l 1. The client diagnosed with iron-deficiency anemia who is prescribed iron tablets. l 2. The client diagnosed with pernicious anemia who is receiving intravenous iron l 3. The client diagnosed with aplastic anemia who has developed pancytopenia. l 4. The client diagnosed with renal disease on an experimental medication protocol.

107. 108. Correct answer 1: The new graduate can adminis- ter and teach about oral medications. Clients receiving parenteral iron are at risk for anaphylactic reactions. Pancytopenia requires an experienced nurse as does administering an experimental medication protocol.

115. The nurse is told in report that the client has mitral valve regurgitation. Which anatomical position should the nurse auscultate to assess the murmur? l 1. Second intercostal space, right sternal notch. l 2. Erb point. l 3. Fourth intercostal space, left axillary line. l 4. Fifth intercostal space, midclavicular line.

115. 116. 117. Correct answer 4: The fifth intercostal space, mid- clavicular line is directly over the mitral valve and is the best place to hear a mitral murmur. Option 1 is the aortic area; option 2 is the pulmonic area; and option 3 is in between areas.

119. The nurse is preparing to administer daily medications. Which medication would the nurse question?l 1. The ACE inhibitor to the client who tells the nurse his cough has gone away. l 2. The calcium channel blocker to the client who states an allergy to calcium. l 3. The beta blocker to the client who has a BP of 156/94 and a pulse of 58.

119. Correct answer 3: Beta blockers decrease the blood pressure and the pulse. The nurse should question administering this medication because of the pulse. Calcium channel blockers do not contain calcium. The body must have calcium in order to live.

12. The client asks the nurse, "My doctor just told me that atherosclerosis is why my chest hurts when I walk real fast. What does that mean?" Which statement is the nurse's best response? l 1. "The muscle fibers and endothelial lining of your arteries have become thickened." l 2. "You sound concerned because your chest hurts when you walk real fast." l 3. "The valves in your heart are incompetent, which is why your chest hurts with activity." l 4. "You have a hardening of your arteries with fatty buildup that decreases the oxygen to your heart."

12. 13. Correct answer 4: This response explains in plain terms why the client has chest pain with increased activity. The client needs information, not a thera peutic response (option 2). The nurse should assume the client is a layperson and should not explain disease processes using medical terminology such as in option 1.

120. The client admitted with deep vein thrombosis is prescribed heparin by constant infusion after an initial dose of 5000 units intravenous push. The heparin comes prepared 20,000 units in 500 mL of D5W. The bolus heparin was administered at 0800 and the infusion initiated per protocol at 25 mL/hr. At the 1900 shift change, how much heparin had been administered? Answer: ____________

120. Correct answer 5440: The nurse must determine the number of units in each mL; 20,000 divided by 500 = 40 units per mL; 40 units times 11 hours = 440 units administered via constant infusion + 5000 = 5440 units administered this shift.

3. Which statement indicates the client diagnosed with angina needs more discharge teaching? l 1. "I will keep my nitroglycerin in a dark bottle at all times." 2. "I should stay on a low-fat, low-cholesterol diet." 3. "I will not walk outside if it is colder than 40ºF." 4. "I should perform isometric exercises three times l l l a week."

3. Correct answer 4: Isometric exercises are muscle- building exercises such as weightlifting. The client should perform isotonic exercises such as walking and swimming. This indicates the client needs more discharge teaching. All other statements indicate the client understands the teaching.ContentArea-Medical;

4. The client comes to the emergency department complaining of chest pain. Which comment by the client would indicate to the nurse the client is experiencing angina instead of a myocardial infarction? l 1. "I was resting in my recliner when my chest started hurting." l 2. "I was mowing my lawn when I started having chest pain." l 3. "I started having chest pain when I took a deep breath." l 4. "My heart started pounding in my chest and then I felt pain."

4. Correct answer 2: Angina is usually brought on by activity such as exercising, cold weather (constriction), stress, or sexual intercourse.

86. The nurse is assessing the client who had an AAA repair 2 days ago. Which intervention should the nurse implement first? l 1. Assess the client's bowel sounds. l 2. Administer an IV prophylactic antibiotic. l 3. Encourage the client to splint the incision. l 4. Ambulate the client in the room with assistance.

86. Correct answer 1: Assessment is the first part of the nursing process and is the first intervention the nurse should implement. Antibiotic therapy, splinting the incision when coughing, and ambulating are appro- priate interventions but not prior to assessment.

106. The client is diagnosed with anemia. The HCP ordered a transfusion of 2 units of packed red blood cells. The unit has 250 mL of red blood cells plus 45 mL of additive. The blood transfusion set delivers 10 gtt/mL. At what rate should the nurse set the IV tubing to infuse each unit of packed red blood cells in 4 hours? Answer: ____________________

Correct answer 12 gtt/min: 250 + 45 = 295 mL to infuse in 4 hours. 295 divided by 4 = 73.75 mL to infuse in 1 hour, divided by 60 minutes = 12.2 mL per minute to infuse. Multiplied by 10 gtt per mL = 12 gtt per minute.

117. The nurse is reviewing HCP orders on a client diagnosed with an AAA who is scheduled for surgery in the morning. Which orders should the nurse question? l 1. Administer biscodyl (Dulcolax), a cathartic laxative, on admission to the unit. l 2. Send an intravenous piggyback (IVPB) antibiotic to surgery with the client. l 3. Have the client bathe using an iodine preparation at night and in the morning. l 4. Elevate the head of the bed at 45º.

Correct answer 1: Administering a stimulant laxative will increase intra-abdominal pressure and could cause the aneurysm to rupture. Sending an IVPB antibiotic to surgery for administration is 118. appropriate. Research indicates that administering antibiotics within an hour of the first incision is the best practice for prophylaxis of infection.

105. The nurse and UAP are caring for clients on a medical unit. Which task is inappropriate for the nurse to delegate to the UAP? l 1. Checking on the bowel movements of a client diagnosed with melena. l 2. Taking the vital signs of a client who received blood the day before. l 3. Documenting the amount of food a client consumed from the lunch tray. l 4. Setting up the food tray for a client with an intravenous line in the hand.

Correct answer 1: The nurse must assess the stools for blood (melena); the nurse should not delegate this task. The UAP can take vital signs on a stable client, document the amount of food consumed from a tray, and set up the tray for a client.

118. The nurse is admitting a client with a suspected myocardial infarction who was brought in by ambulance. Which nursing intervention has priority? l 1. Ask if the client is allergic to aspirin . l 2. Place the client on the telemetry monitor. l 3. Notify the cardiac catheterization lab. l 4. Have the client sign for permission to treat.

Correct answer 1: The nurse must immediately begin morphine, oxygen, nitroglycerin, and aspirin (MONA is an acronym to help the students remember the initial treatment ). Aspirin decreases platelet aggregation and may prevent worsening of the damage to the cardiac muscle.

104. The client diagnosed with iron deficiency anemia is prescribed iron dextran intravenously. Which intervention should the nurse implement when administering this medication? l 1. Administer epinephrine intravenously prior to beginning the infusion. l 2. Start the infusion with a test dose, and monitor the client for 15 minutes. l 3. Place the client on bedrest with bathroom privileges. l 4. Teach the client the stools may be very dark, and this can mask blood.

Correct answer 2: Because iron dextran can cause anaphylactic reactions in the client to the dextran, the nurse should start with a test dose and monitor the client for 15 minutes before initiating the full dose. Epinephrine is administered if the client has an allergic reaction to the medication, but not before. Activity is not restricted, and the stools become dark with oral iron.

114. Which client should the nurse on a cardiac unit assess first after receiving the shift report? l 1. The client diagnosed with a myocardial infarction with four unifocal PVCs in a minute . l 2. The client diagnosed with mitral valve prolapse (MVP) who has an audible S3 and dyspnea. l 3. The client diagnosed with coronary artery disease who wants to ambulate in the hallway. l 4. The client diagnosed with pericarditis whose third dose of intravenous antibiotic is late.

Correct answer 2: The development of an S3 heart sound indicates heart failure, a complication of MVP. The nurse should assess this client first. The client may have up to 6 unifocal PVCs in a minute and be considered within normal limits.

108. The client diagnosed with folic acid anemia is admitted to the medical unit. Which HCP order would the nurse question? l 1. Chlordiazepoxide (Librium), a benzodiazepine, every 8 hours. Serum vitamin B12 laboratory studies. Administer 3 units of packed red blood cells over 2 hours each. l 4. Assist the client with activities of daily living (ADLs).

Correct answer 3: Blood transfusions are given cautiously for clients diagnosed with anemia be cause the client's body has compensated for the anemia. If given, the blood is administered slowly to prevent pulmonary edema. Vitamin B12 studies are done to help differentiate between B12 anemia and folic acid deficiency. Antianxiety medications would not be questioned because folic acid anemia is usually secondary to alcoholism.

102. The client who has menorrhagia complains to the nurse of feeling listless and tired all the time. Which laboratory data should the nurse monitor? l 1. Blood urea nitrogen (BUN). l 2. White blood cell (WBC) count. l 3. Hemoglobin and hematocrit (H&H) . l 4. Urinalysis (UA).

Correct answer 3: Menorrhagia means excessive blood loss during menses. The nurse should monitor the client's H & H. The symptoms are the direct result of the excessive blood loss.

116. The nurse is assisting with a synchronized cardioversion on a client in atrial fibrillation. Which statement by the client indicates the client understands the pre-procedure teaching? l 1. "This procedure will cure my atrial fibrillation problems for good." l 2. "I should be able to eat breakfast before the procedure." l 3. "I will be given some medication to relax me before the procedure." l 4. "I won't need to be hooked up to telemetry after the procedure."

Correct answer 3: The client is given sedating medications prior to the procedure. The other options are false statements.

110. The nurse is admitting a client diagnosed with anemia. Which nursing intervention should the nurse implement first? l 1. Teach the client to pace activities. l 2. Refer the client to the dietitian. l 3. Assess the client's activity tolerance. l 4. Obtain an order for daily hemoglobin.

Correct answer 3: The nurse should assess for the symptoms associated with anemia first and then plan other interventions based on the assessment data.

109. The nurse is discharging a client prescribed oral iron supplements. Which instructions should the nurse teach? l 1. Sit upright after taking the medication for 30-60 minutes. l 2. Perform a daily stool test for occult blood. l 3. Eat a full meal and then take the iron supplement. l 4. Take the iron about 2 hours after you eat breakfast each day.

Correct answer 4: Approximately 2 hours after breakfast is the correct dosing time for iron to achieve the best effects. Iron preparations should be administered 1 hour before a meal or 2 hours after the meal. Iron can cause gastrointestinal upset if administered with a meal, and absorption can be diminished by as much as 50%.

112. The nurse is caring for a client diagnosed with congestive heart failure. Which diagnostic test indicates the client's condition is getting better? l 1. The client's chest x-ray (CXR) shows a large cardiac silhouette. The client's LDH and SGOT levels have decreased. The client's blood urea nitrogen (BUN) is 10 points higher. The client's B-type natriuretic peptide (BNP) has decreased.

Correct answer 4: BNP is secreted from the ventricles and directly relates to the amount of fluid volume overload. A decreased BNP indicates the therapy is effective. LDH and SGOT measure liver function; BUN measures kidney function; and a large cardiac silhouette indicates heart failure and does not indicate the client is getting better.

101. The nurse is admitting a client with a diagnosis of rule out (R/O) anemia. The client has a history of gastric bypass surgery for obesity 3 years ago. Current assessment findings include height 5'9", weight 75 kg, P 120, R 27, BP 100/70, pale mucous membranes, and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed? l 1. Sickle cell anemia. l 2. Folic acid deficiency. l 3. Iron deficiency. l 4. Vitamin B12 deficiency.

Correct answer 4: Gastric bypass surgery drasti- cally reduces the amount of rugae in the stomach. Rugae produce intrinsic factor, which allows the 102. body to utilize vitamin B12 from the foods eaten. With a reduced number of rugae, clients who have had gastric bypass surgery often develop pernicious anemia (vitamin B12 deficiency). Other symptoms of anemia include dizziness, tachycardia, and dyspnea.

47. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client understands the discharge teaching? l 1. "I must take the prescribed antibiotics for 7 days only." "I will have no problems as long as I take my medication." "My throat culture was positive for a staph infection."

. Correct answer 2: Female clients may experience vaginal yeast infections when taking antibiotics because the antibiotics kill the good bacteria and well as the bad. The client should take all the antibi- otics, not for just 7 days. Rheumatic fever is caused by a group A beta-hemolytic streptococcus infection.

31. Which medication should the nurse prepare to administer for the client exhibiting the following telemetry strip? l 1. The miscellaneous antidysrhythmic adenosine (Adenocard). l 2. The antidysrhythmic lidocaine (Xylocaine). l 3. The cardiac glycoside digoxin (Lanoxin). l 4. The inotropic medication dopamine (Intropin).

. Correct answer 2: Lidocaine is an antidysrhythmic medication that suppresses ventricular ectopy and is the drug of choice for multifocal premature ventricu- lar contractions, which is a potentially life-threatening dysrhythmia.

24. The nurse is preparing the 52-year-old male client di agnosed with mitral valve regurgitation for surgery. Which statement by the client warrants immediate intervention? l 1. "I have been told that I will be on medication for the rest of my life." l 2. "I get short of breath walking to the bathroom to bathe myself." l 3. "I made out an advance directive to make sure my wishes are known." l 4. "I will be in the intensive care unit for a day or two after surgery."

. Correct answer 2: This statement indicates heart failure, and the nurse should investigate this further and notify the HCP. The other statements convey correct information or indicate appropriate prepara- tion.

66. The nurse is preparing to administer digoxin (Lanoxin), a cardiac glycoside intravenous push (IVP). The digoxin vial has 5 mg/2 mL. The HCP has ordered 0.25 mg. How much medication would the nurse administer? Answer: ______________________

...66. Correct answer 4: The UAP could assist the client to take a bath. The UAP cannot assess, teach, evalu- ate, administer medications, or care for a client who is unstable. The client in an acute exacerbation of congestive heart failure is unstable. Content Area- Medical; Category of Health Alteration-Cardiovascular; Integrated Process-Implementation; Client Needs-Safe Effective Care Environment, Management ofCare; Cognitive Level-Application. Correct answer 0.1 mL: 5 is to 2 = 0.25 mg is to x. Cross-multiply to get 5x = 0.50. Divide both sides of the equation by 5 to solve for x and get the answer = 0.1 mL.

67. The nurse is caring for a client diagnosed with CHF who is receiving 40 mg furosemide (Lasix) intravenous push (IVP) daily. Which data indicate the medication is effective? l 1. The client's urine output for the last 8 hours is 300 mL. l 2. The client's lungs are clear bilaterally anterior and posterior. l 3. The client has lost 1 kg of weight in 2 days. l 4. The client's arterial blood pressure is 138/90 mm Hg.

...67. 68. Correct answer 2: Clear lung sounds indicate that the client's CHF is responding to diuretic therapy. The output should be much greater than 30 mL/hr for a diuretic to be effective, and a 2.2-lb weight loss does not indicate effective therapy. The blood pressure does indicate the effectiveness of a diuretic for the client with CHF.

68. The nurse is preparing to administer an ACE-inhibitor to a client diagnosed with congestive heart failure. Which statement best describes the scientific rationale for administering this medication? l 1. The medication will help increase the urine output, thereby decreasing the volume of blood in the intravascular system l 2. The medication will decrease the sympathetic stimulation to the beta cells in the heart muscle. l 3. The medication will help prevent vasoconstriction of the periphery and prevents the release of aldosterone. l 4. The medication blocks calcium from entering the cell membrane, resulting in vasodilation of the vessels.

...Correct answer 3: ACE inhibitors prevent angiotensin-1 from converting to angiotensin-2, which is a potent vasoconstrictor and prevents the release of aldosterone, which, in turn, prevents the reabsorption of sodium. The medication that increases urine output (option 1) is a diuretic. The medication that decreases sympathetic stimulation to the beta cells in the heart muscle (option 2) is a beta blocker. The medication that blocks calcium from entering the cell membrane (option 4) is a calcium-channel blocker.

1. The nurse is caring for a client who was diagnosed with a myocardial infarction 24 hours ago. The client has developed an audible S3 heart sound. Which action should the nurse implement first? l 1. Notify the health-care provider (HCP) immediately. l 2. Document the finding in the client's chart. l 3. Assess the client's blood pressure. l 4. Check the client's telemetry reading.

1. Correct answer 1: An audible S3 heart sound indicates heart failure, which is a complication of a myocardial infarction. Therefore, the nurse should notify the HCP first. Assessing the blood pressure, checking the telemetry, and documenting findings in the patient's chart are interventions that should be imple- mented, but the nurse should notify the HCP first.

10. The charge nurse is observing a licensed practical nurse (LPN) applying a nitroglycerin patch to the client diagnosed with angina. Which action warrants immediate intervention from the charge nurse? l 1. The LPN places the nitroglycerin patch on a non-hairy area. 2. The LPN dates and times the nitroglycerin patch. 3. The LPN wears gloves when applying the nitroglycerin patch. 4. The LPN applies the new patch while leaving the old patch in place.

10. 11. Correct answer 4: The LPN should remove the old patch prior to administering the new patch.

11. Which statement indicates to the nurse the client understands a modifiable risk factor for atherosclerosis? l 1. "As I get older my chance of having a heart attack increases." l 2. "My father and grandfather both died of heart disease." l 3. "I listen to relaxation tapes to help decrease my high stress level." l 4. "I will take saw palmetto every day to help decrease my blood pressure."

11. Correct answer 4: The LPN should remove the old patch prior to administering the new patch. ContentArea-Medical; Category of Health Alteration-Cardiovascular; Integrated Process- Implementation; Client Needs-Safe Effective Care Environment, Management ofCare; Cognitive Level-Application. Correct answer 3: A modifiable risk factor is a risk factor that can possibly be altered by modifying or changing behavior, such as developing new ways to deal with stress. Age and family history are nonmod- ifiable risk factors. Saw palmetto helps treat benign prostatic hypertrophy, not high blood pressure.

14. The female client tells the nurse that her cholesterol level was 189 mg/dL. Which action should the nurse implement? l 1. Praise the client for having an acceptable cholesterol level. l 2. Explain that the client needs to lower the cholesterol level. l 3. Discuss dietary changes that could help increase the level. l 4. Allow the client to ventilate feelings about the blood result.

14. Correct answer 1: The American Heart Association recommends the cholesterol level should be less than 200 mg/dL; therefore the nurse should praise the client.

15. The nurse is discussing the pathophysiology of atherosclerosis with a client who has a high low-density lipoprotein (LDL) level. Which information should the nurse discuss with the clients concerning the pathophysiology of LDL? l 1. A high LDL is good because it has a protective action in the body. l 2. This test result measures the free fatty acids and glycerol in the blood. l 3. LDLs are the primary transporters of cholesterol into the cell. l 4. The client needs to decrease the amount of cholesterol and fat in the diet.

15. 16. Correct answer 3: LDLs have the harmful effect of depositing cholesterol into the walls of the arterial vessels, which is the pathophysiology of LDL. High- density lipoprotein transports cholesterol away from the tissue and cells of the arterial wall to the liver for excretion, which helps decrease the development of atherosclerosis.

16. Which assessment data would cause the nurse to suspect the client has atherosclerosis? l 1. The client complains of her legs swelling when she stands for long periods. l 2. The client has episodes of jitteriness and headache when feeling hungry. l 3. The client has bilateral calf pain when walking for short periods. l 4. The client complains of mid-epigastric pain after eating spicy foods.

16. Correct answer 3: LDLs have the harmful effect of depositing cholesterol into the walls of the arterial vessels, which is the pathophysiology of LDL. High- density lipoprotein transports cholesterol away from the tissue and cells of the arterial wall to the liver for excretion, which helps decrease the development of atherosclerosis. ContentArea-Medical; Category of Health Alteration-Cardiovascular; Integrated Process-Implementation; Client Needs-Physiological Integrity, PhysiologicalAdaptation; Cognitive Level- Application. Correct answer 3: The client is describing intermit- tent claudication, which should make the nurse suspect the client has generalized atherosclerosis, a marker of coronary artery disease. Option 1 could be heart failure, option 2 hypoglycemia, and option 4 peptic ulcer disease.

17. The HCP prescribed atorvastatin, (Lipitor), an HMG-CoA reductase inhibitor. Which teaching intervention should the nurse include when discussing this medication? l 1. Tell the client to take the medication with food only. l 2. Instruct the client to take the medication in the evening. l 3. Explain that muscle pain is a common side effect of this medication. l 4. Demonstrate how to use the machine to check the cholesterol level daily.

17. Correct answer 2: These medications should be taken in the evening for best results, because the enzyme that destroys cholesterol works best in the evening, and the medication enhances this process. Muscle pain is an adverse effect and should be reported to the HCP immediately. Cholesterol levels cannot be checked daily.

7. The HCP has prescribed thrombolytic therapy for the client diagnosed with a myocardial infarction. Which data indicate the medication is effective? l 1. The client's cardiac enzymes decrease. l 2. The client's chest pain is relieved. l 3. The client exhibits reperfusion dysrhythmias. l 4. The client's blood pressure is within normal limits.

7. Correct answer 3: Reperfusion dysrhythmias (premature ventricular contractions) indicate the tissue is viable, which indicates the medication is effective.

18. Which menu selection indicates to the nurse the client diagnosed with atherosclerosis understands the teaching concerning a low-fat, low-cholesterol diet? l 1. Fried chicken, garlic mashed potatoes, and skim milk. l 2. Ham and cheese on white bread and whole milk. l 3. Baked fish, brown rice, lettuce salad, and iced tea. l 4. A hamburger, potato chips, and carbonated beverage.

18. 19. Correct answer 3: Baked, broiled, or grilled meats or fish, high-fiber brown rice, and ice tea would be an appropriate meal. Fried foods are high in fat and cholesterol; white bread is low in fiber; and whole milk is high in fat. Hamburger meat is high in fat, and carbonated beverages are high in calories.

19. Which interventions should the nurse implement when teaching the 54-year-old client diagnosed with atherosclerosis? Select all that apply. l 1. Include significant other when teaching the client. l 2. Provide the client with written handouts and pamphlets. l 3. Refer the client to the American Heart Association (AHA) . l 4. Help the client to identify ways to deal with stressful situations . l 5. Discuss the importance of isometric exercises daily.

19. Correct answer 3: Baked, broiled, or grilled meats or fish, high-fiber brown rice, and ice tea would be an appropriate meal. Fried foods are high in fat and cholesterol; white bread is low in fiber; and whole milk is high in fat. Hamburger meat is high in fat, and carbonated beverages are high in calories. ContentArea-Medical; Category of Health Alteration- Cardiovascular; Integrated Process-Evaluation; Client Needs-Health Promotion and Maintenance; Cognitive Level-Evaluation. Correct answer 1, 2, 3, 4: Including the significant other increases adherence to lifestyle modifications; written information helps the client review informa- tion after the teaching session; the AHA is an appro- priate referral; and decreasing stress is appropriate for teaching about atherosclerosis. Isotonic exercises, not isometric exercises, should be recommended.

2. While the nurse is ambulating the client diagnosed with angina to the bathroom, the client begins to complain of chest pain radiating to the left arm. Which intervention should the nurse implement first? l 1. Administer a nitroglycerin tablet sublingually . l 2. Return the client to bed and tell client to lie in the bed. l 3. Place oxygen on the client via nasal cannula. l 4. Request a stat electrocardiogram (ECG).

2. Correct answer 2: The nurse should first have the client lie down to help decrease the need for oxygen to the myocardium. Then the nurse should administer sublingual nitroglycerin and place oxygen on the client. After these interventions, the nurse should request a stat ECG.

20. The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to unlicensed assistive personnel (UAP)? l 1. Teach the client how to take their radial pulse for 1 minute. l 2. Escort the discharged client in a wheelchair to the client's car. l 3. Check the triglyceride level for the client diagnosed with atherosclerosis. l 4. Assist the client who just returned from a cardiac catheterization to ambulate.

20. Correct answer 2: The UAP can escort a stable client to the car. The nurse cannot delegate assess- ment (option 3), teaching (option 1), evaluation, administering medications, or care of an unstable client. A client returning from cardiac catheterization cannot ambulate for 6 hours.

21. The nurse is discharging a 65-year-old client diagnosed with aortic stenosis who had undergone mechanical valve replacement surgery. Which information should the nurse teach the client? l 1. Splint the incision when turning, coughing, and deep breathing. l 2. Sleep in a recliner or with the head on two pillows at night. l 3. Avoid being around children or people who have had an immunization. l 4. Take antibiotics prior to any dental or other invasive procedures.

21. 22. Correct answer 4: Clients with a mechanical valve are at risk for developing bacterial endocarditis after dental cleaning or other invasive procedures, such as genitourinary or gastrointestinal procedures. Prophy- lactic antibiotics prevent this.

22. The nurse caring for clients on a medical unit thinks she hears a murmur while assessing the client. After determining that no other HCP have documented a murmur, which action should the nurse implement next? l 1. Do nothing because the nurse was probably mistaken. l 2. Document the finding in the client's chart. l 3. Notify the HCP. l 4. Ask the client if there is a history ofa murmur.

22. Correct answer 4: Clients with a mechanical valve are at risk for developing bacterial endocarditis after dental cleaning or other invasive procedures, such as genitourinary or gastrointestinal procedures. Prophy- lactic antibiotics prevent this. ContentArea-Surgical; Category of Health Alteration-Cardiovascular; Integrated Process-Intervention; Client Needs-Health Promotion and Maintenance; Cognitive Level-Application. Correct answer 4: Part of assessing the client is to conduct a client interview about abnormal data. The nurse can reassess the client to gather more data before notifying the HCP and documenting the finding in the chart. The nurse should never ignore abnormal data.

23. The nurse is admitting a client diagnosed with a mitral valve murmur. Which information supports this finding? l 1. The client has a history of rheumatic fever as a child. l 2. The client takes an oral anticoagulant daily. l 3. The client has elevated troponin levels. l 4. The client recently took a vacation to Central America.

23. 24. Correct answer 1: Rheumatic fever is caused by a streptococcal infection that can result in vegetative growth on the cardiac valves, resulting in valvular disease later in life. Oral anticoagulants are pre- scribed after mechanical valve surgery, and troponin levels are elevated after a myocardial infarction.

25. The 24-year-old female client has had surgery to replace a diseased mitral graft. Which information should the nurse teach the client prior to discharge? l 1. Take your temperature four times a day and notify the HCP of the results. l 2. Have routine International Normalized Ratio (INR) lab tests performed. l 3. Limit lifting to less than 5 pounds until you are seen by the surgeon . l 4. Your menses will be heavier because of the anticoagulant medications.

25. 26. Correct answer 3: Postoperative instructions for any surgery that involves the abdomen or trunk area require a lifting restriction to prevent pulling on the surgical site. Female clients of childbearing age are given living-tissue valves so that anticoagulant ther- apy is not needed during a pregnancy, if one should occur, and therefore routine INR lab tests are not necessary.

27. The client diagnosed with aortic stenosis scheduled for an echocardiogram tells the nurse, "I am scared. What will they do during the test?" Which statement is the nurse's best response? l 1. "You're scared? We should discuss how you are feeling." l 2. "The doctor will insert a catheter into the artery in your groin." l 3. "I think you should talk with the doctor about you fears." l 4. "Sound waves will be used to determine how your heart is working."

27. Correct answer 4: An echocardiogram uses sound waves to determine the functioning of the heart. It is not invasive. The nurse should provide factual answers, not refer the client to a health-care provider. Nor should the nurse in a situation in which the client is asking for information provide a therapeutic response (option 1).

28. The client diagnosed with mitral valve stenosis complains of shortness of breath and chest pain while ambulating in the hall with a UAP. Which action should the nurse implement first? l 1. Tell the UAP to take the client's vital signs. l 2. Determine if this has happened to the client before . l 3. Get a wheelchair for the client to sit down. l 4. Have a stat electrocardiogram (ECG) done.

28. Correct answer 3: The nurse should first stop the activity that is causing the client's distress by provid- ing a place for the client to sit. Assessment can be made after interventions for the client's comfort or safety.

29. The client is admitted to the intensive care unit post aortic valve replacement. Which interventions should the nurse implement? Select all that apply. l 1. Monitor the client's telemetry readings. l 2. Monitor vital signs every 4 hours. l 3. Assess for S3 or S4 heart sounds. l 4. Auscultate for a heart click. l 5. Maintain intravenous lines.

29. Correct answer 1, 3, 5: The nurse should monitor the client's telemetry for dysrhythmias, assess for symptoms of heart failure such as S3 or S4 heart sounds, and maintain IV lines. Vital signs should be monitored every 5-15 minutes initially and then every 1-2 hours when the patient is stable. A heart click is a symptom of a mitral valve problem.

30. The client diagnosed with a grade II aortic murmur is admitted to the telemetry unit. Which symptoms should the nurse expect to assess? l 1. Peripheral edema, jugular vein distention, and a productive cough. l 2. A murmur heard with a stethoscope at the right sternal notch. l 3. Shortness of breath on exertion and weakness. l 4. Palpitations, fatigue, and pink frothy sputum.

30. 31. Correct answer 2: A stage 2 murmur can be heard over the area of the chest closest to the diseased valve. Many valve disorders are present long before any other symptoms occur. Answers 1, 3, and 4 are symptoms of heart failure and would not be present with a stage 2 aortic murmur. ContentArea-Medical; Category of Health Alteration-Cardiovascular;

32. The client is exhibiting the following telemetry strip. Which interventions should the nurse implement? Rank in order of performance. Administer the antidysrhythmic atropine. Determine if the telemetry strip is artifact Administer epinephrine, a sympathomimetic. l 4. Perform 30 hard and fast cardiac compressions. l 5. Administer two breaths with the nose pinched.

32. Correct answer in order 2, 5, 4, 3, 1: The nurse 33. should first determine if the client is in asystole (it could be an artifact). Then the nurse should start cardiopulmonary resuscitation by giving two breaths and cardiac compressions. This is followed by administering intravenous epinephrine to vaso- constrict the peripheral circulation and shunt the blood to the central circulation (brain, heart, lungs) in clients who do not have a heartbeat. Atropine is then administered; it decreases vagal stimulation and increases the heart rate and is the drug of choice for a client exhibiting asystole.

36. The client who has been exhibiting the following telemetry reading for the last 6 months is being discharged from the hospital. Which statement indicates the discharge teaching by the nurse has been effective? l 1. "I will take my blood pressure prior to taking my medication." l 2. "I need to eat a low-fat, low-cholesterol, and low-salt diet." l 3. "I must have an INR frequently while I am taking warfarin (Coumadin)." l 4. "I should use a straight razor instead of an electric razor."

36. 37. Correct answer 3: Atrial fibrillation could cause a blood clot; therefore, the client is placed on the anti coagulant warfarin (Coumadin), which is monitored for effectiveness by the INR (2-3). Atrial fibrillation does not cause hypertension; therefore, the client does not need to monitor the blood pressure or be on a low-salt diet. An electric razor is appropriate to prevent cuts, which lead to bleeding.

38. The client is 1 day postoperative open heart surgery and has a temperature (T) of 99ºF, a pulse (P) of 96, a respiration rate (R) of 22, and B/P 128/92 and is complaining of incisional pain of 8 on a 1-10 pain scale. Which intervention should the nurse implement? Continue to monitor the client and take no action. .Assess Administer a narcotic analgesic to the client. monitor the client's pulse oximeter reading.

38. Correct answer 3: Pain, elevated temperature, exer- cise, anxiety, hypoxemia, hypovolemia, and cardiac failure may all cause sinus tachycardia. The nurse should administer pain medication to the client. The pulse oximeter reading will not help the client's pain.

39. The client is exhibiting the following telemetry reading. Which intervention should the nurse implement? l 1. Document this as normal sinus rhythm. l 2. Request a 12-lead electrocardiogram. l 3. Prepare to administer the cardiotonic digoxin by mouth (PO). l 4. Assess the client's cardiac enzymes.

39. 40. Correct answer 1: The P-wave represents atrial contraction, and the QRS complex represents ventricular contraction. This electrocardiogram strip indicates a normal telemetry reading. In addition, a rate 60-100 indicates normal sinus rhythm. The nurse should document these findings and not take any action.

41. The client is diagnosed with pericarditis. Which signs/symptoms should the nurse expect in this client? l 1. The client has pulsus paradoxus and night sweats. l 2. Complaints of fatigue and arthralgias. l 3. Constant chest pain and friction rub. l 4. Increased chest pain when ambulating but not at rest.

41. 42. Correct answer 3: In pericarditis, chest pain is usually constant but can be aggravated by respiratory movements (deep inspiration, coughing), changes in body position, or swallowing. The most characteris- tic symptom is a friction rub. Pulsus paradoxus is associated with cardiac tamponade, not pericarditis.

65. The nurse, along with a UAP, is caring for a client diagnosed with an acute exacerbation of congestive heart failure. Which task could the nurse delegate to the UAP? l 1. Request the UAP to evaluate client's intake and output. l 2. Ask the UAP to assist the client to ambulate in the hall. l 3. Tell the UAP to increase the oxygen rate from 4 to 6 L. l 4. Instruct the UAP to assist the client with taking a bed bath.

65. 66. Correct answer 4: The UAP could assist the client to take a bath. The UAP cannot assess, teach, evalu- ate, administer medications, or care for a client who is unstable. The client in an acute exacerbation of congestive heart failure is unstable.

43. The nurse is assessing the client diagnosed with subacute bacterial endocarditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? l 1. "Have you had a sore throat in the last month?" l 2. "Did you have frequent strep throats as a child or young adult?" l 3. "Do you have a family history of heart disease?" l 4. "What prescription medications do you take?"

43. 44. Correct answer 2: Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta- hemolytic streptococci, causes carditis in about 50% of the people. Frequent strep throats can lead to rheu- matic fever; therefore, this would be the most appro- priate question.

45. The client diagnosed with endocarditis is complaining of increased dyspnea and nausea. Which intervention should the nurse implement first? l 1. Ask Respiratory Therapy to evaluate the client's dyspnea. l 2. Obtain an order for an indwelling urinary catheter. l 3. Auscultate the client's lung sounds and assess the periphery. l 4. Give the client a specimen cup to collect sputum.

45. 46. Correct answer 3: The nurse should assess the client for heart failure and then plan interventions based on the data collected. Some clients develop intractable heart failure as a result of endocarditis.

49. The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. l 1. Monitor vital signs every 2 hours for 24 hours. l 2. Assess the client for a fluid wave. l 3. Record the amount of fluid removed as output. l 4. Evaluate the client's cardiac rhythm. l 5. Keep the client in a semi-Fowler position.

49. 50. Correct answer 3, 4, 5: This fluid is output and should be documented on the client's daily intake and output record. The nurse must assess for cardiac failure. The client should be in the semi-Fowler position, not flat, which increases the workload of the heart. Vital signs should be assessed more frequently initially, and a fluid wave is for assessing the abdomen.

5. The nurse is discussing modifiable risk factors with the client diagnosed with angina. Which instructions should be included in the instructions? Select all that apply. l 1. Discuss the importance of eating a diet low in fiber. l 2. Explain the need to keep the cholesterol level under 200 mg/dL. l 3. Instruct the client to walk for 30 minutes three times a week. l 4. Tell the client to decrease the amount of cigarettes smoked daily . l 5. Inform the client the blood glucose level should be 70-120 mg/dL.

5. Correct answer 2, 3, 5: Risk factors include a high cholesterol level, sedentary lifestyle, cigarette smoking, and diabetes. The client must quit smoking, not just decrease smoking. The client should eat a low-fat, low- cholesterol, and high-fiber diet.

51. The male client diagnosed with hypertension has epistaxis and a flushed face. Which action should the nurse implement first? l 1. Notify the client's HCP. l 2. Assess the client's blood pressure lying, standing, and sitting. l 3. Elevate the client's head of the bed. l 4. Prepare to administer an intravenous antihypertensive medication.

51. 52. Correct answer 2: The client is exhibiting signs of a hypertensive crisis; therefore; the nurse should check the client's blood pressure. Epistaxis is a nosebleed. Elevating the head of the bed (option 3), administering antihypertensive medication (option 4), and notifying the HCP (option 1) should be done in this order.

55. The client newly diagnosed with essential hypertension tells the nurse, "I don't feel bad, so why do I have to take medication every day?" Which statement is the nurse's best response? l 1. "Even if you feel all right, your blood pressure could still be high." l 2. "Your doctor would not have prescribed them if you didn't need them." l 3. "People have strokes and heart attacks with high blood pressure." l 4. "If you don't feel bad, then you don't have to take your medication."

55. 56. Correct answer 1: Essential hypertension is the "silent killer," and the blood pressure could be ele- vated when the client is asymptomatic. Clients with hypertension may have stokes and heart attacks, but the nurse should address the client's comment.

57. The nurse is preparing to administer a calcium channel blocker to a client diagnosed with arterial hypertension. Which data would cause the nurse to question administering this medication? l 1. The client's blood pressure is 110/70. l 2. The client has a calcium level of 10.5 mg/dL. l 3. The client reports having a dry mouth. l 4. The client complains of being dizzy.

57. 58. Correct answer 4: Dizziness may indicate the client is experiencing hypotension; therefore, the nurse should question administering an antihypertensive medica- tion. The blood pressure is within normal limits, but if the client had elevated blood pressure, then the client could be experiencing hypotension; the calcium level is not monitored when administering this med- ication, and dry mouth will not affect the medication administration.

6. The nurse is caring for a client diagnosed with a myocardial infarction. Which assessment data would warrant immediate attention by the nurse? l 1. The client has a urinary output of 120 mL in 2 hours . l 2. The client's telemetry shows multifocal premature ventricular contractions (PVCs) . l 3. The client's bilateral anterior and posterior breath sounds are clear. l 4. The client's cardiac enzymes and white blood cells are elevated.

6. Correct answer 2: Cardiac dysrhythmias occur in about 90% of clients experiencing a myocardial infarction. Multifocal PVCs are life-threatening and require immediate intervention by the nurse.

61. The nurse is caring for a client diagnosed with congestive heart failure (CHF) who is complaining of shortness of breath and dyspnea. Which intervention should the nurse implement first? 1. Assess the client's lung sounds. l 2. Elevate the client's head of the bed. l 3. Administer oxygen via nasal cannula. l 4. Check the client's pulse oximeter reading.

61. 62. Correct answer 2: The nurse should first elevate the head of the bed to help the client breathe more easily, then apply oxygen, and then the nurse can assess the client.

63. The home health-care nurse is visiting a client diagnosed with CHF. Which comment by the client would warrant intervention by the nurse? l 1. "I take my water pill every morning." l 2. "I have to sleep on two pillows at night" l 3. "I have some leg cramps every now and then." l 4. "I must rest after I walk around the block."

63. 64. Correct answer 3: Leg cramps could indicate hypokalemia, which would warrant intervention by the nurse. Taking the diuretic every morning, sleep- ing with two pillows, and resting after extended walks would not warrant intervention by the nurse.

71. The client is diagnosed with arterial occlusive disease. Which data would the nurse expect the client to exhibit? l 1. Intermittent claudication and cool extremities. l 2. Capillary refill <3 seconds and 4+ pedal pulses. l 3. Dry scaly skin and 3+ pitting edema. l 4. Piloerection and "alligator" skin.

71. 72. Correct answer 1: Intermittent claudication, calf pain with walking, and cool extremities would be expected because the client has decreased arterial blood flow to the lower extremities.

73. The clinic nurse is caring for the female client diagnosed with venous insufficiency. Which intervention should the nurse implement? l 1. Instruct the client to elevate her feet frequently. l 2. Encourage the client to eat a low-sodium diet. l 3. Tell the client to wear open-toed shoes. l 4. Recommend going to the podiatrist for nail cutting.

73. 74. Correct answer 1: The client should elevate her feet to help decrease edema. A low-sodium diet will not help decrease the lower extremity edema; wearing open-toed shoes will not help; and as the client does not have decreased vision, the client can cut her own toenails.

75. The UAP and a nurse are caring for clients in a long-term facility. Which action by the UAP would require intervention by the nurse? l 1. The UAP elevated the legs of a client diagnosed with arterial occlusive disease. l 2. The UAP is ambulating the client using a gait belt around the waist. l 3. The UAP placed the client in the chair while assisting the client to eat. l 4. The UAP assisted the client with venous insufficiency to put on antiembolic hose.

75. 76. Correct answer 1: The client with arterial occlusive disease should have the legs in the dependent, not elevated, position, because elevating the feet further impedes the arterial blood supply to the legs. The nurse would need to intervene. Using a gait belt, sit- ting the client up to eat, and putting on antiembolic hose are all appropriate interventions.

77. The client is diagnosed with arterial occlusive disease. Which information should the nurse discuss with the client? l 1. Encourage the client to walk three times a day. l 2. Discuss the need to increase fluid intake. l 3. Explain how to prevent orthostatic hypotension. l 4. Tell the client to take acetaminophen four times a day.

77. 78. Correct answer 1: Walking will help increase collat- eral circulation, which will, in turn, increase the blood supply to the lower extremities. Increasing fluid intake will not help; the client does not experience orthostat- ic hypotension or take medications that would cause it; and acetaminophen is not prescribed to treat arte- rial occlusive disease.

79. The nurse is unable to palpate the dorsalis pedis pulse for the client diagnosed with arterial occlusive disease. Which action should the nurse implement first? l 1. Notify the client's HCP. l 2. Place the feet in the dependent position. l 3. Use a Doppler to assess for pedal pulse. l 4. Assess for proximal pulses bilaterally.

79. 80. Correct answer 3: The nurse should first attempt to assess the pedal pulse with a Doppler and place an X when the pulse is heard. Placing the feet in depen- dent position will increase blood supply, which is not desirable. The nurse can assess proximal pulses and notify the HCP if total occlusion is determined.

8. The charge nurse is making assignments for clients on a medical unit. Which client should the charge nurse assign to the recent graduate nurse? l 1. The client diagnosed with angina whose pain is unrelieved with nitroglycerin. l 2. The client who is scheduled for a left-sided cardiac catheterization. l 3. The client with a myocardial infarction whose pulse oximeter reading is 90%. l 4. The client diagnosed with heart disease who needs discharge teaching.

8. Correct answer 2: A newly graduated nurse would be able to care for a stable client scheduled for a cardiac catheterization. The client with angina not relieved by nitroglycerin is not stable, and a client with hypoxemia (a pulse oximeter reading less than 93%) should be assigned to a more experienced nurse, as should discharge teaching.

81. The nurse is assessing the client's abdomen. Which assessment data would support the diagnosis of abdominal aortic aneurysm (AAA)? l 1. Visible peristalsis and hyper bowel sounds. l 2. A palpable mass and an abdominal bruit. l 3. Rebound tenderness and protruding umbilicus. l 4. Hard rigid abdomen and low-grade fever.

81. Correct answer 2: A systolic bruit over the abdomen and a palpable mass are indicative of an AAA. The nurse should palpate the area very lightly to prevent rupture of the AAA.

82. The client diagnosed with a 3-cm AAA asks the nurse, "What will the doctors do for my abdominal aortic aneurysm?" Which statement is the nurse's best response? l 1. "You will probably have an ultrasound every 6 months to check on the size." l 2. "Usually an endoscopy is done once a year to make sure it doesn't get too big." l 3. "You will have to check your abdominal girth once a week and keep a record." l 4. "You will need to have an abdominal aortic aneurysm repair within 2 weeks."

82. Correct answer 1: When the aneurysm is small (<5-6 cm), an abdominal sonogram will be done every 6 months until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than possible complications of the surgery.

83. Which client would be most likely to develop an AAA? l 1. A 45-year-old African-American female with type 1 diabetes mellitus. l 2. A 75-year-old Oriental female with COPD. l 3. A 54-year-old Caucasian male diagnosed with essential hypertension. l 4. A 30-year-old Hispanic male with a genetic predisposition to AAA.

83. 84. 85. Correct answer 3: The most common cause of AAA is atherosclerosis (which is the cause of essential hyper- tension and peripheral vascular disease). AAA occurs in men four times more often than in women, and primarily in Caucasians.

87. The client is being admitted for repair of an AAA. Which HCP's order should the nurse question? l 1. Complete blood cell count. l 2. Tap water enema until clear fecal return. l 3. Bedrest with bathroom privileges. l 4. Start intravenous line with normal saline.

87. 88. Correct answer 2: Increasing pressure in the abdomen secondary to a tap water enema could cause the AAA to rupture. Blood work, bathroom privileges, and intravenous line would be expected HCP orders.

89. Which assessment data would require immediate intervention by the nurse for the client who is 6 hours postoperative AAA repair? l 1. A blood pressure of 92/68 and apical pulse 114. l 2. Complaints of incisional pain of 7 on a scale of 1-10. l 3. A soft nondistended, tender abdominal area. l 4. Green bile draining from the nasogastric tube.

89. 90. Correct answer 1: These vital signs indicate hypo- volemia, which is a medical emergency and requires immediate intervention. Incisional pain, a soft non- distended abdomen, and green bile would be expected assessment data.

9. The intensive care nurse is caring for a client diagnosed with a myocardial infarction. Which intervention should the nurse implement? l 1. Monitor the client's urine output every shift. l 2. Keep the head of the client's bed flat . l 3. Assess the client's breath sounds every 2 hours. l 4. Discourage the client from deep breathing.

9. Correct answer 3: The client is at risk for cardiac failure; therefore, the nurse should assess the breath sounds for crackles. The urine output should be checked more frequently than every shift, the head of the bed should be in semi-Fowler position, and deep breathing should be encouraged to decrease the chance of pneumonia.

91. The nurse is discharging a client diagnosed with deep vein thrombosis (DVT). Which discharge instructions should be provided to the client? l 1. Have the PTT levels checked routinely to maintain a therapeutic level. l 2. When traveling, the client should plan rest stops to exercise the legs. l 3. Eat a diet high in green leafy vegetables and expect the urine to be red-tinted. l 4. Wear knee stockings with an elastic band around the top.

91. 92. Correct answer 2: The client should perform fre- quent active and passive leg exercises. In an airplane the client should be instructed to drink plenty of fluids and move the legs up and down and flex the muscles. In an automobile the client should take frequent breaks to walk around. PT/INR should be monitored.

93. The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which intervention should the nurse implement to prevent complications? l 1. Percutaneous tube feedings once a day. l 2. Encouraging the client to verbalize feelings. l 3. Administer a narcotic pain medication PRN. l 4. Frequent passive range-of-motion to the legs.

93. 94. Correct answer 4: Passive range of motion will help prevent deep vein thrombosis as well as contractures of the limbs. Venous blood returns to the heart in part because of the action of the muscles against the walls of the veins.

95. The client diagnosed with a DVT in the right leg is admitted to the medical unit. Which nursing interventions should be implemented? Select all that apply. l 1. Place an antiembolism hose on the unaffected calf. l 2. Instruct the client to ambulate in the hallway frequently. l 3. Encourage fluids and a diet high in roughage. l 4. Monitor the intravenous site every 24 hours l 5. Assess for calf tenderness in the left leg.

95. 96. Correct answer 1, 3, 5: An antiembolism hose should be put on to prevent a thrombosis from forming in the other calf. The client is on bedrest for 5-7 days. Drinking lots of fluids and a diet high in roughage will help prevent constipation and provide adequate fluid volume. The intravenous site should be monitored more frequently than every 24 hours, and the nurse should assess for signs of DVT in the unaffected calf.

99. The client is being admitted with Coumadin (anticoagulant) toxicity. Which medication should the nurse prepare to administer ? l 1. Protamine sulfate intravenously. l 2. Warfarin sodium orally. l 3. Aquamephyton (vitamin K) intravenously. l 4. Sodium heparin subcutaneously.

99. 100. 101. Correct answer 3: AquaMephyton (vitamin K), is the antidote for Coumadin. Warfarin is the generic form of Coumadin. Protamine sulfate is the anti- dote for heparin.

58. The nurse is discussing essential hypertension with a group of clients. Which interventions should be included in the discussion? Select all that apply. l 1. Discuss the importance of a low-cholesterol, low-fat, low-salt diet. l 2. Encourage isotonic exercises at least three times a week. l 3. Explain that uncontrolled diabetes increases blood pressure. l 4. Recommend relaxation classes to help decrease stress. l 5. Tell them to elevate the head of the bed to sleep.

Correct answer 1, 2, 3, 4: Diet, isotonic exercises, diabetes, and stress are modifiable risk factors for essential hypertension. Elevating the head of the bed will not help clients with essential hypertension.

92. The nurse is caring for clients on a surgical floor. Which client should be assessed first? l 1. The postoperative abdominal surgery client who has a red swollen left calf l 2. The postoperative hernia client who just voided 350 mL of clear amber urine. l 3. The postoperative cholecystectomy client who is refusing to turn and cough. l 4. The postabdominal hysterectomy client who is complaining of gas pains.

Correct answer 1: A complication of immobility after surgery is developing a deep vein thrombosis (DVT). This client should be assessed for a DVT. The other clients are exhibiting expected findings that are not life-threatening.

97. Which client should the nurse assess first after receiving the shift report? l 1. The client diagnosed with DVT who complains of chest pain on inspiration. l 2. The immobile client who has not been turned from the left side for 3 hours . l 3. The client who had a partial pancreatectomy and who is refusing a blood glucose test. l 4. The client who has had an inguinal hernia repair and must void before discharge.

Correct answer 1: A potentially life-threatening complication of DVT is pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a pulmonary embolus.

100. The charge nurse observes the primary nurse assessing the client diagnosed with DVT. Which action by the nurse warrants immediate intervention by the charge nurse? l 1. The nurse assesses for the Homan sign in the affected leg . l 2. The nurse instructs the client to stay in bed as much as possible. l 3. The nurse tells the client to notify the nurse if developing chest discomfort. l 4. The nurse reminds the client not to pull on the intravenous tubing.

Correct answer 1: Assessing for the Homan sign used to be standard practice, but current research indicates that there is a possibility of dislodging the clot from the vein wall. The charge nurse should intervene to prevent this from occurring.

84. The nurse is caring for a client diagnosed with an AAA who is scheduled for surgery in the morning. Which statement would require immediate intervention by the nurse? l 1. "I just started having pain in my lower back." l 2. "When I urinate I can't quit dribbling." l 3. "I am having loose runny stools." l 4. "I feel my heart beating when I lie down."

Correct answer 1: Low back pain is present because of the pressure of the aneurysm on the lumbar nerves; this is a serious symptom usually indicating that the aneurysm is expanding rapidly and about to rupture. A sign/symptom of AAA is "heart beating in the abdomen." ContentArea-Surgical; Category of Health Alteration-Cardiovascular;

42. The client is diagnosed with acute pericarditis. During the shift assessment, the nurse notes muffled heart sounds. Which intervention should the nurse implement?l 1. Notify the HCP. l 2. Continue to monitor the client . l 3. Get an order to place the client on telemetry. l 4. Recheck the client in 4 hours.

Correct answer 1: Muffled heart sounds require the nurse to notify the HCP. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output, resulting in muffled heart sounds.

69. The nurse is admitting a client diagnosed with CHF. Which HCP's admission order would the nurse question? l 1. Oxygen 2 L via nasal cannula. l 2. Fursosemide (Lasix) 40 mg IVP daily. l 3. Low-cholesterol, low-fat, low-salt diet. l 4. Activity as tolerated.

Correct answer 1: The client does not have chronic obstructive pulmonary disease; therefore; the client does not need a low oxygen rate. This order should be questioned.

59. The nurse is taking blood pressure readings at a com- munity health fair. The 68-year-old client's blood pressure is 168/98. Which action should the nurse implement? l 1. Recommend the client see a HCP within 2 days. l 2. Tell the client to go to the nearest emergency department. l 3. Explain the blood pressure is all right for an elderly person. l 4. Instruct the client to go home and rest for the remainder of the day.

Correct answer 1: The client should be seen by an HCP because the diastolic blood pressure is greater than 85, but the client does not need to go to the emergency department.

60. The UAP tells the nurse the client whose T is 98.9ºF, P 92, R 18, and B/P 164/92 is complaining ofa headache. Which action should the nurse implement? l 1. Assess the client as soon as possible. l 2. Administer acetaminophen (Tylenol), a non-narcotic analgesic. l 3. Tell the UAP to check on the client in 1 hour. l 4. Request the charge nurse to check on the client.

Correct answer 1: The nurse should assess the client because the blood pressure is elevated along with the complaint of a headache. The nurse should not administer medication without assessing the client; the UAP cannot assess the client; and this client is not in a life-threatening situation so the charge nurse does not need to check the client.

64. The clinic nurse is checking laboratory data for clients seen yesterday. Which laboratory data would warrant contacting the client at home? l 1. The client whose serum digoxin level is 2.4 mg/dL. l 2. The client whose serum potassium level is 4.2 mEq/L. l 3. The client whose serum brain or beta natriuretic peptide (BNP) level is 92 mg/mL. l 4. The client whose glycosylated hemoglobin is 5.3%.

Correct answer 1: The therapeutic level for digoxin is 0.8-2.0 mg/dL; therefore, the nurse should notify this client concerning the potential for digoxin toxicity. All other data are within normal limits.

46. The client diagnosed with pericarditis complains of pressure in the chest and shortness of breath. The intensive care nurse assesses a decreasing systolic blood pressure and jugular vein distention. Which collaborative intervention should the nurse anticipate for this client? l 1. Prepare for a pericardiocentesis. l 2. Send the client for a cardiac catheterization. l 3. Have Respiratory Therapy draw arterial blood gases. l 4. Refer the client to the chaplain for anticipatory grief counseling.

Correct answer 1: These are symptoms of cardiac tamponade, and the treatment is an emergency peri- cardiocentesis. A pericardiocentesis removes fluid from the pericardial sac, which requires collaboration with the health-care provider. The other options are collaborative but not appropriate for the client's condition.

48. The nurse is planning the care of a client diagnosed with acute bacterial endocarditis who has been admitted for intravenous therapy. Which intervention should the nurse include in the plan of care? l 1. Limit interruptions to allow for uninterrupted rest and sleep. l 2. Refer the client to inpatient cardiac rehabilitation. l 3. Maintain oxygen via nasal cannula at 2 L/min. l 4. Discuss the need for valve replacement surgery.

Correct answer 1: This helps decrease the workload of the heart and helps ensure the restoration of phys- ical and emotional health. The client is placed on bedrest to decrease the workload of the heart. Endocarditis may lead to valve damage and the need for valve replacement, but not in the acute phase.

96. The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to decrease the IV rate by 50 units/hour if the PTT is greater than 85 seconds. The current PTT level is 92 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 24 mL/hr. At what rate should the pump be set? Answer: ____________________

Correct answer 23 mL/hr: The nurse must first determine the number of units of heparin in each mL of solution. Divide 25,000 by 500 to equal 50 units per mL of solution. If the current rate is 24 mL/hr, then decreasing by 50 units results in 23 mL an hour. 24 mL-1 mL = 23 mL/hr.

40. Which client problem is priority for the client with a cardiac dysrhythmia? l 1. Knowledge deficit. l 2. Altered cardiac output. l 3. Impaired gas exchange. l 4. Activity intolerance.

Correct answer 2: Any abnormal electrical activity of the heart causes an altered or decreased cardiac output.

78. The client is diagnosed with venous insufficiency. Which discharge teaching should the nurse discuss with the client? l 1. Take one baby aspirin every day with food. l 2. Check the feet daily for cuts and blisters . l 3. Monitor the popliteal and pedal pulses daily. . Perform passive range-of-motion exercise daily.

Correct answer 2: In a client with venous insuffi- ciency, the feet are edematous; the skin is fragile; and the sensation is decreased. Cuts will not heal effectively; therefore, the client should check the feet daily. Baby aspirin is for arterial insufficiency, not venous insufficiency. The client does not check pulses. The client should perform active range-of- motion exercises.

94. The nurse and a UAP are bathing an immobile client. Which instruction should the nurse provide the UAP? l 1. Place a clean gown on the client before beginning the bath. l 2. Wash the calves, but do not massage the muscles. l 3. Use lots of soap and water to get the client clean. l 4. Dispose of the linens in a red container in the room.

Correct answer 2: Massaging the calves can dislodge a thrombus and create an embolus. The calves can be washed and lotion applied gently, but they should not be massaged. Clean gowns are put on the client after the bath. Minimal soap and water are used to prevent drying of the client's skin. Linens are not thrown away in the biohazard trash.

76. Which data would require the nurse to notify the HCP for the client diagnosed with arterial occlusive disease? l 1. The client has 1+ bilateral dorsalis pedis pulses. l 2. The client has bilateral leg pain while resting. l 3. The client has numbness and tingling of the legs . l 4. The client has cool, pale extremities.

Correct answer 2: Resting pain indicates the client is not receiving any blood supply to the calf muscles, and this would require notifying the HCP. Weak pedal pulses, paresthesia, and cool extremities are expected in the client diagnosed with arterial occlusive disease.

26. The nurse is assisting the client diagnosed with cardiac valve disease to choose a menu for the next day. Which menu is most appropriate for this client? l 1. A ham and cheese sandwich, potato chips, and 2% milk. l 2. Roast beef, lettuce salad with low-fat dressing, and water. l 3. Eggs, bacon, whole wheat toast, jelly, and black coffee. l 4. Chicken-fried steak, mashed potatoes and gravy, and iced tea.

Correct answer 2: The client should be on a heart- healthy diet, limiting caffeine (black coffee) and alcohol, salt, and fat- and cholesterol-containing foods (ham, cheese, potato chips, eggs, bacon, fried steak, etc.).

33. The client is exhibiting sinus bradycardia on the telemetry monitor. Which intervention should the nurse implement first? l 1. Administer the antidysrhythmic atropine. l 2. Determine if the client is symptomatic. l 3. Prepare for an insertion of a pacemaker. l 4. Notify the client's HCP.

Correct answer 2: The nurse must first determine if the client is weak, lightheaded, or experiencing other symptoms of syncope and hypotension. If the client is symptomatic, atropine is the drug of choice, along with insertion of a pacemaker, which must be done by 34. 35. the HCP.

35. Which intervention should the nurse implement first when defibrillating a client who is in ventricular fibrillation? l 1. Defibrillate the client at 360 joules. l 2. Remove the client's oxygen source l 3. Energize the defibrillator source. l 4. Shout "all clear" prior to defibrillation.

Correct answer 2: The oxygen source should be removed to prevent any type of spark during defibril lation. Then the nurse should shout "all clear," energize the source, and defibrillate at 360 joules.

34. The telemetry nurse is unable to read the telemetry monitor at the nurse's station. Which intervention should the telemetry nurse implement? l 1. Go to the client's room to check the client. l 2. Instruct the primary nurse to assess the client. l 3. Notify the charge nurse of the emergency situation. l 4. Request the UAP to take the crash cart to the client's room.

Correct answer 2: The telemetry nurse cannot leave the monitors; therefore, the primary nurse should be instructed to go and assess the client immediately. The primary nurse must assess the client before contacting the charge nurse and taking the crash cart to the room.

85. The client is 2 days postoperative AAA repair. Which assessment data would require immediate intervention from the nurse? l 1. The client refuses to perform range-of-motion exercises. The client urinary output is 300 mL in 8 hours. The client's dorsalis pedis pulse is not palpable. The client's vital signs are T 98ºF, P 90, R 18, B/P 130/70.

Correct answer 3: Any neurovascular abnormality, such as nonpalpable dorsalis pedis pulse in the client's lower extremities, indicates the graft is occluded or there is possibly internal bleeding and requires immediate intervention by the nurse. The client should be ambulating on the second postoper- ative day; urine output should be greater than 30 mL/hr—which it is; and the vital signs are stable.

52. The nurse is completing discharge teaching for a client diagnosed with essential hypertension. Which statement indicates the client understands the discharge teaching? l 1. "I can eat bacon, eggs, and wheat toast for breakfast." l 2. "I will walk for 30 minutes a day at least once a week." l 3. "I am going to lose 2-3 pounds a week until I lose 30 pounds." l 4. "When I feel all right I do not need to take my medication."

Correct answer 3: Being overweight is a risk factor for essential hypertension; therefore; losing weight indicates the client understands the discharge teaching. Bacon is high in salt, and eggs are high in cholesterol. The client should walk at least three times a week, and medication should be taken every day, no matter how the client feels.

50. The client with infective endocarditis is admitted to the medical department. Which HCP's order should be implemented first? l 1. Administer the intravenous antibiotic. l 2. Schedule an echocardiogram. l 3. Insert a 20-gauge intravenous catheter. l 4. Bedrest with bathroom privileges.

Correct answer 3: Initiation of antibiotics is prior- ity, so the nurse must start the intravenous line for the antibiotics. Obtaining cultures would be done before starting the antibiotics.ContentArea-Medical; Category of Health Alteration-Cardiovascular;

98. The client diagnosed with a DVT is on a heparin (anticoagulant) drip at 1200 units per hour, and the HCP has ordered Coumadin (warfarin sodium), an anticoagulant, 5 mg daily. Which should be the nurse's first action? l 1. Check the client's laboratory values for PTT and PT/INR. l 2. Call the HCP to see which drug should be discontinued. l 3. Administer both medications as prescribed. l 4. Discontinue the heparin when the client receives the first dose of Coumadin.

Correct answer 3: It will take several days for the client to reach a therapeutic level of anticoagulation with the Coumadin. The client should not be removed from the heparin until appropriate levels of oral anticoagulant can be achieved.

90. The nurse is discussing discharge teaching with the client who is 3 days postoperative AAA repair. Which statement indicates the client needs more discharge teaching? l 1. "I will notify my doctor if there is any redness or irritation of my incision." l 2. "I will not lift any objects that weigh more than 5 pounds for 4-6 weeks." l 3. "I will have abdominal pain that will not be relieved by my pain medication." l 4. "I should increase my fluid intake and make sure I do not get constipated."

Correct answer 3: Pain medication should keep the client comfortable, and if it does not help, the client should call the HCP; this statement indicates the client needs more teaching. Redness or irritation of the incision indicates infection; lifting more than 5 pounds may cause dehiscence; and constipation will increase pressure on the incision.

56. The nurse is caring for clients on a medical unit. Which task would be appropriate for the nurse to delegate to a UAP? l 1. Vital signs of a client who is having chest pain. l 2. Take the client downstairs to smoke a cigarette. l 3. Remove the telemetry leads from the client who is being discharged. l 4. Help the client who is scheduled for a cardiac catheterization to eat.

Correct answer 3: The UAP can remove the telemetry leads from a client's chest. A client with chest pains is unstable so cannot be assigned to the UAP. The UAP also needs to be on the unit, not downstairs with a client smoking, and the client scheduled for a cardiac catheterization should have nothing by mouth.

70. The nurse is completing discharge teaching for a client diagnosed with end-stage congestive heart failure. Which statement indicates the client understands the discharge teaching? l 1. "I will notify my HCP ifI lose more than 2 lb in a week." l 2. "I will check my digoxin level daily and write down the results." l 3. "I will increase my intake of foods that are high in potassium." l 4. "I will drink at least 3000 mL of fluid every day."

Correct answer 3: The client with congestive heart failure will be on digoxin and a diuretic; therefore, the client should increase foods high in potassium. Weight loss would not warrant notifying the HCP; the digoxin level is not done daily; and the client should drink about 2000 mL a day unless on a fluid restriction.

44. The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? l 1. Explain the importance of keeping a pain diary to show the HCP. l 2. Discuss not driving or operating machinery while taking the medication . l 3. Instruct the client not to take the medication on an empty stomach. l 4. Alternate the medication with acetaminophen (Tylenol) every 8 hours.

Correct answer 3: The medication must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain. Steroids are tapered; NSAIDs do not make the client drowsy; and NSAIDs should be taken routinely to decrease inflammation, not alter- nated with Tylenol.

53. The nurse is caring for the client diagnosed with essential hypertension who is prescribed hydrochlorothiazide (HTCZ), a thiazide diuretic. Which intervention should the nurse implement when administering this medication? l 1. Check the client's apical pulse for 1 minute. l 2. Question administering if the client's potassium level is less than 5.5 mEq/L. l 3. Instruct the client to rise slowly from a lying to a sitting position. l 4. Tell the client to drink 1000 mL of fluid daily.

Correct answer 3: The nurse must teach the client about orthostatic hypotension. The blood pressure, not the apical pulse, should be checked. The normal potassium level is 3.5-5.5 mEq/L, and the client should not be on fluid restriction.

80. The client diagnosed with arterial occlusive disease asks the nurse, "What caused me to have this problem?" Which statement is the nurse's best response l 1. "Being overweight can lead to incompetent valves, which caused your problem." l 2. "Sometimes people who stand all the time can have arterial occlusive disease. " l 3. "There is not a definite cause for developing arterial occlusive disease." l 4. "Increased plaque in your arteries is the cause of peripheral vascular disease."

Correct answer 4: Arterial occlusive disease is due to atherosclerosis, which is a buildup of plaque in the ar- teries. Incompetent valves cause venous insufficiency. Occupations where clients stand all the time lead to varicose veins.

72. The client is diagnosed with peripheral vascular disease. Which statement indicates the client understands the discharge teaching? l 1. "I will buy my new shoes first thing in the morning." "I use a heating pad when my feet are really cold." "I need to wear knee-high socks when wearing shoes." "I should not cross my legs when I am sitting down."

Correct answer 4: The client should not perform activity that will impede blood flow to the lower extremities; therefore, the client should not cross the legs. New shoes should be bought in the after- noon when the feet are swollen. The legs may have decreased feeling; therefore, a heating pad should not be applied to the lower extremities.

74. The client diagnosed with arterial occlusive disease is 1 day postoperative right femoral popliteal bypass. Which intervention should the nurse implement? l 1. Keep the right leg in the dependent position. l 2. Maintain the leg in alignment with abductor pillow. l 3. Monitor the client's continuous passive motion (CPM) machine. l 4. Assess the client's right leg for paralysis and paresthesia.

Correct answer 4: The nurse should assess the 6 Ps: paralysis, paresthesia, poikilothermia (temperature), pain, pulses, and pallor. The leg should be elevated to decrease postoperative edema; the abductor pillow is used for total hip replacement, not for femoral popliteal bypass; and the CPM machine is used with total knee replacement.

62. The client is preparing to administer the initial dose of digoxin (Lanoxin), a cardiac glycoside, to the client diagnosed with CHF. Which intervention should the nurse implement? l 1. Check the client's serum potassium level. l 2. Assess the client's blood pressure. l 3. Monitor the client's digoxin level. l 4. Take the client's apical pulse.

Correct answer 4: The nurse should check the client's apical pulse, and if it is less than 60, the nurse should question administering the digoxin. The client's potassium level and digoxin level would not be affected by the first dose of the medication. The blood pressure does not have to be assessed prior to administering digoxin.

54. The charge nurse is checking laboratory results for clients on a medical unit. Which laboratory data would warrant notifying the HCP? l 1. The client who has an arterial blood gases (ABGs) of pH 7.38, PaO2 90, PaCO2 38, and HCO3 34. l 2. The client who has a serum potassium level of 3.8 mEq/L. l 3. The client who has a serum sodium level of 138 mEq/L. l 4. The client who has an INR of 4.2.

Correct answer 4: The therapeutic INR is 2-3; therefore, this laboratory information should be reported to the HCP. All other laboratory data are within normal limits.

13. The client diagnosed with peripheral vascular disease is overweight, has smoked two packs of cigarettes a day for 20 years, and sits behind a desk all day. Which statement by the client refers to the strongest factor in the development of atherosclerotic lesions? l 1. "I am going to try and lose at least 20 pounds." l 2. "I have to get out from behind the desk more often." l 3. "I am going to eat foods that are high in fiber." l 4. "I have to quit smoking cigarettes but it will be hard."

Correct answer 4: Tobacco use is the strongest fac- tor in the development of atherosclerosis. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure. In addition it increases the risk of clot formation by increasing the aggrega- tion of platelets.

88. The client is diagnosed with a 2-cm AAA. Which interventions should be included in the client's teaching? Select all that apply. l 1. Perform isometric exercises for 30 minutes three times a week. Encourage a low-fat, low-cholesterol, low-salt diet. Use an abdominal binder when amputating. 4. Discuss with the client the importance of losing weight. 5. Demonstrate the correct way to apply a truss.

Correct answer: 2, 4: The most common cause of AAA is atherosclerosis and essential hypertension; therefore, a low-fat, low-cholesterol diet will help decrease development of atherosclerosis. Losing weight will help decrease the pressure on the AAA and will help address decreasing cholesterol level. A truss is worn for a client with a hernia, not an AAA, and an abdominal binder should not be worn because it will increase abdominal pressure.