NUR 452 - EAQ 1
Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply. One, some, or all responses may be correct. 1 Weight 2 Inactivity 3 Cholesterol 4 Tobacco use
All
When a client is admitted to the postanesthesia care unit after surgery, how frequently will the nurse plan to assess the blood pressure? 1 Every 3 to 5 minutes 2 Every 10 to 15 minutes 3 Every 20 to 30 minutes 4 Every 40 to 60 minutes
Every 10 to 15 minutes
Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? 1 P wave 2 T wave 3 PR interval 4 QRS interval
Atrial and ventricular depolarization and repolarization are represented on the ECG as a series of waves: the P wave followed by the QRS complex and the T wave. The QRS represents ventricular depolarization. The P wave occurs with depolarization of the atria. The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and of the atrioventricular node.
Which electrical activity of the cardiac conduction system is reflected in the P wave? 1 Atrial depolarization 2 Atrial repolarization 3 Ventricular depolarization 4 Ventricular repolarization
Atrial depolarization The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization. Atrial repolarization also occurs simultaneously to ventricular depolarization, but because of the larger muscle mass of the ventricles, the QRS complex obscures visualization of atrial repolarization. The T wave represents ventricular repolarization.
Which statement by an unlicensed assistive personnel (UAP) who is assisting the nurse in caring for a group of clients indicates a correct understanding of the UAP's role? 1 "I will turn off clients' intravenous lines that have infiltrated." 2 "I will take clients' vital signs after their procedures are over." 3 "I will use unit written materials to teach clients before surgery." 4 "I will help by giving medications to clients who are slow in taking pills."
Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, evaluate for intravenous fluid infiltration. Client teaching is performed by registered nurses or licensed practical nurses, not UAPs. Medication administration is performed by registered nurses or licensed practical nurses, not UAPs.
Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage? 1 Peripheral vasoconstriction 2 Elevation of serum cortisol level 3 Release of immature erythrocytes 4 Increased antidiuretic hormone (ADH)
Peripheral vasoconstriction The initial response to hemorrhage is activation of the sympathetic nervous system, leading to increases in heart rate and peripheral vasoconstriction, which shunts blood to essential core organs. The other responses also occur, but more slowly. Cortisol increases as part of the stress response, leading to fluid retention, but this process occurs more slowly. Immature red blood cells (erythrocytes) are released from the bone marrow, but this occurs more slowly than vasoconstriction. An increase in ADH causes fluid retention, but this occurs more slowly.
Which finding by the nurse may indicate ruptured spleen in a client admitted with abdominal pain? 1 Weak radial pulses 2 Warm, flushed skin 3 Slow apical pulse rate 4 Increased pulse pressure
weak radial pulse
When a client develops iron-deficiency anemia, which of the client's laboratory test results would the nurse expect to be decreased? 1 Ferritin level 2 Platelet count 3 White blood cell count
Ferritin level
When hypokalemia is suspected, which diagnostic test will the nurse use to confirm the diagnosis? 1 Complete blood cell count 2 Serum potassium level 3 X-ray film of long bones 4 Blood Cultures x3
A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood cell count, x-ray film of long bones, and blood cultures ×3 will have no significance in the diagnosis of a potassium deficit.
Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. 1 Fatigue 2 Orthopnea 3 Pitting edema 4 Dry hacking cough
All Signs of worsening heart failure include fatigue, weakness, and difficulty breathing when lying flat (orthopnea). Other manifestations include pitting edema, weight gain, and a dry, hacking cough.
Which action would the home health nurse suggest to decrease risk for injury for an older adult with peripheral arterial disease? 1 Move into an assisted living community. 2 Lower the thermostat setting on the hot water tank. 3 Reduce fluid intake to less than 2500 mL/day.
Lower the thermostat setting on the hot water tank. Because peripheral arterial disease may decrease the ability to feel extremes of heat and increases risk for burn injuries, lowering the temperature of the hot water tank can reduce injury risk. There is no indication that this client needs assistance with any activities of daily living, so there is no need to move the client to an assisted living community. Reduction of fluid intake is not indicated for clients with peripheral arterial disease. Walking is encouraged because it improves blood flow and encourages collateral circulation to the legs.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.
Which laboratory value would the nurse use to determine whether a client is receiving a therapeutic dose of intravenous heparin? 1 International normalized ratio (INR) is between 2 and 3 2 Prothrombin time (PT) is 2.5 times the control value 3 Activated partial thromboplastin time (APTT) is 70 seconds 4 Activated clotting time (ACT) is in the range of 70 to 120 seconds
When a client is receiving intravenous heparin, the APTT should be 1.5 to 2 times the normal APTT of 40 seconds, or 60 to 80 seconds. INR and PT are used to evaluate therapeutic levels of warfarin. The ACT is not commonly used for monitoring of heparin, but ACT increases to a range of 150 to 200 seconds when heparin reaches therapeutic levels.
When assessing a client with a diagnosis of peripheral arterial disease before a scheduled arteriogram, the nurse is unable to palpate the pedal pulses. Which action would the nurse take next? 1 Check the pulses with a Doppler device. 2 Notify the primary health care provider. 3 Notify the staff in the catheterization laboratory. 4 Document the findings in the client's medical record.
Check the pulses with a Doppler device.
When a client is experiencing acute coronary syndrome, which factor would the nurse identify as the cause of the pain experienced by a client? 1 Arterial aneurysm 2 Heart muscle ischemia 3 Blocking of the coronary veins 4 Irritation of nerve endings in the cardiac plexus
Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain. Arterial aneurysms are not a common cause of myocardial ischemia or infarction. Arteries, not veins, are involved in the pathology of an acute coronary syndrome. Tissue injury and pain occur in the myocardium, not the cardiac plexus.
How would the nurse document a drop in blood pressure when a client moves rapidly from a lying to a standing position? 1 Malignant hypotension 2 Orthostatic dehydration 3 Orthostatic hypotension
Orthostatic hypotension specifically refers to an abnormally low blood pressure that occurs when an individual assumes a standing position. Orthostatic hypotension is also known as postural hypotension. It may be a result of internal bleeding, fluid depletion, or loss of neurovascular control preventing vasoconstriction from regulating blood pressure. Malignant hypotension and orthostatic dehydration are inaccurate terms that are not used. Vasomotor instability occurs during menopause and results in hot flashes and night sweats.STUDY TIP: A word of warning: Do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.
When a client is diagnosed with Hodgkin disease, which lymph nodes would the nurse expect to be affected first? 1 Cervical 2 Axillary 3 Inguinal
Painless enlargement of the cervical lymph nodes often is the first sign of Hodgkin disease, a malignant lymphoma of unknown etiology. Axillary node enlargement occurs after cervical lymph node enlargement. Inguinal node enlargement occurs later. Mediastinal node involvement follows the disease progresses.Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.
A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication would the nurse consider the client may be experiencing based on these responses? 1 Bladder spasms 2 Polycythemia vera 3 Hypovolemic shock 4 Pulmonary hypertension
These signs occur with hypovolemic shock because less blood is being circulated to vital centers in the brain. A large loss of blood may occur during and after orthopedic surgery. Urinary retention, not bladder spasms, may occur after general anesthesia. Anemia and deep vein thrombosis, not an increase in the total red blood cells (polycythemia vera), tend to occur after a total hip replacement. Atelectasis and pneumonia are possible complications of general anesthesia, but pulmonary hypertension is a not a postoperative complication.
A client who has multiple myeloma tells the nurse about plans for airline travel to visit family members. Which topic will the nurse include in discharge planning? 1 Avoidance of travel to prevent fatigue 2 Need to restrict fluid intake when flying 3 Ways to prevent infection during travel 4 How to fill prescriptions away from home
Ways to prevent infection during travel Prevention of infection is important in this client with impaired bone marrow production of leukocytes and immunoglobulins. Fatigue is a concern with multiple myeloma, but travel can be managed with careful planning and use of rest periods. Increased fluid intake is needed with airline travel, because dehydration should be avoided due to the risk for kidney stones and renal failure with multiple myeloma. The nurse would assist the client to be sure all prescriptions were filled before leaving home, because it can be difficult to fill prescriptions when traveling to different states or countries.
Which of these clients seen at a health fair will be most at risk for hypertension? 1 23-year-old white man 2 44-year-old white woman 3 50-year-old Mexican-American woman 4 62-year-old African American man
62-year-old African American man African Americans have the highest risk for hypertension; before the age of 45, men are at higher risk than women. A 23-year-old white man would be a low risk for hypertension. A 44-year-old white woman would be a somewhat higher risk, but still much less than an African American man or woman. Mexican-American clients are less likely to seek treatment for hypertension, but they are not at higher risk than African Americans.
A client with type 1 diabetes asks what causes several brown spots on the skin. What would be the best response by the nurse? 1 "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." 2 "Those spots indicate a high glucose content in the skin that may get infected if left untreated." 3 "They are the result of diseased small vessels in the shins and may spread if not treated soon." 4 "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."
"Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the definition of a xanthoma. A high glucose content in the skin that has become infected is not the cause of brown spots on the skin; increased glucose in the skin is not observable by inspection. Brown spots result from the deposition of hemosiderin. Blood vessels may become diseased with diabetes, but this does not cause brown spots.Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.
When a client has type A negative blood, which blood types can potentially be used for transfusion? 1 Type O positive 2 Type AB positive 3 Type A or O negative 4 Type A or AB negative
Both A and O negative blood are compatible with the client's blood. A negative is the same as the client's blood type and preferred; in an emergency, type O negative blood also may be given. Although type O blood may be used, it will have to be Rh negative; Rh positive blood is incompatible with the client's blood and will cause hemolysis. Type AB positive blood is incompatible with the client's blood and will cause hemolysis. Type A negative blood is compatible with the client's blood, but type AB negative is incompatible and will cause hemolysis.
A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give? 1 Compression of the heart muscle 2 Release of myocardial isoenzymes 3 Rapid vasodilation of the coronary arteries 4 Inadequate oxygenation of the myocardium
Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.
Which of the following would the client with palpitations from premature heartbeats be taught to avoid? 1 Bananas 2 Tomatoes 3 Energy drinks 4 Green leafy vegetables
Energy drinks should be avoided in the client with palpitations from premature heartbeats because they contain caffeine and can increase ectopic beats. Bananas and tomatoes are high in potassium and are not a contraindication for the client with ectopic beats. Dark green leafy vegetables should be avoided by the client taking warfarin, because the vitamin K content counteracts the medication's therapeutic blood thinning.
Which type of shock is associated with a ruptured abdominal aneurysm? 1 Vasogenic shock 2 Neurogenic shock 3 Cardiogenic shock 4 Hypovolemic shock
Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.
Which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? 1 Increased blood pH 2 Decreased hematocrit 3 Increased blood viscosity
Increased blood viscosity
How would anxiety affect outcomes for a client with heart failure? 1 Increases the cardiac workload 2 Interferes with usual respirations 3 Produces an elevation in temperature
Increases the cardiac workload Anxiety increases sympathetic nervous system activity, leading to increases in heart rate, vasoconstriction, and increased metabolic rate, which increase cardiac workload and worsen outcomes in clients with heart failure. Anxiety does not directly interfere with respirations. Anxiety alone usually does not elevate the body temperature. Anxiety can cause an increase in the amount of oxygen needed for body functions.
Which action would the nurse take first when using an automated external defibrillator (AED) for a pulseless and unresponsive client? 1 Attach the AED pads. 2 Push the "analyze" button. 3 Remove any medication patches. 4 Tell bystanders to "stand clear."
Medication patches that interfere with electrode placement must be removed before application of AED pads because the patches may conduct electricity and interfere with defibrillation or cause burns on the chest. The AED pads would be attached after removing the medication patches. The analyze button would be pushed once the patches were attached. Bystanders would be instructed to "stand clear" after the rhythm had been analyzed and before pushing the "shock" button.Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.
After receiving 75 mL of packed red blood cells (PRBCs), a client complains of chills and low back pain. Which action would the nurse take first? 1 Check the client's temperature. 2 Stop the client's infusion of PRBCs. 3 Cover the client with a warm blanket. 4 Take the client's blood pressure and pulse.
Stop the client's infusion of PRBCs. The client's symptoms suggest a transfusion reaction, and the nurse's initial action would be to stop infusing PRBCs and infuse normal saline. The nurse will send the blood bag to the laboratory for hemolysis testing. The other actions are also appropriate, once the transfusion has been stopped. Chills and fever may also occur with a transfusion reaction, and the temperature should be assessed and the client may be covered with a warmed blanket for comfort. Hypotension and tachycardia may occur with transfusion reaction and the nurse should check the blood pressure and pulse.
When a client is admitted with chest pain, a family member asks about the purpose of the prescribed 12-lead electrocardiogram (ECG). Which response would the nurse give? 1 Indicates whether a heart attack is occurring 2 Detects changes in the structures in the heart 3 Shows whether the heart muscle is pumping 4 Evaluates for prognosis after heart attack
The ECG waveform can indicate myocardial ischemia or injury (such as a heart attack) as evidenced by ST waveform depression or elevation. An ECG reflects electrical activity and is not used to assess structures in the heart. An ECG does not show the effectiveness of cardiac contractility ("whether the heart muscle is pumping"). Prognosis after myocardial infarction depends on many factors, but an ECG does not show prognosis.
Which client finding would the nurse document as a pulse deficit? 1 Blood pressure of 130/70 mm Hg indicating pulse deficit of 60 2 Capillary refill greater than 3 seconds indicating pulse deficit 3 Apical pulse 86 and radial pulse 78 indicating pulse deficit of 8 4 Radial pulse 80 and pedal pulse 70 indicating pulse deficit of 10
The apical rate is more rapid than the radial rate when a pulse deficit exists. An apical pulse of 86 with a radial pulse of 78 is a pulse deficit of 8. A blood pressure of 130/70 mm Hg is a pulse pressure of 60. Capillary refill greater than 3 seconds indicates circulation is sluggish. Radial pulse of 80 and a pedal pulse of 70 do not indicate a pulse deficit; a pulse deficit is the difference between the apical and peripheral pulses.
To check a client's carotid pulse, where would the nurse palpate? 1 Below the mandible 2 In the lateral neck region 3 Along the clavicle at the base of the neck 4 At the anterior neck, lateral to the trachea
The carotid artery is located along the anterior edge of the sternocleidomastoid muscle at the level of the lower margin of the thyroid cartilage. Below the mandible, in the lateral neck region, and along the clavicle at the base of the neck are not the anatomical landmarks for locating the carotid artery.
Which clinical manifestations would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? Select all that apply. One, some, or all responses may be correct. 1 Tachycardia 2 Restlessness 3 Warm, moist skin 4 Decreased urinary output 5 Bradypnea
The heart rate increases (tachycardia) and the respiratory rate increases (tachypnea, not bradypnea) in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/h because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.