PERFUSION THE CONCEPT OF PERFUSION
) A client admitted with a cardiac dysrhythmia reports being easily fatigued and frustrated with the inability to perform normal daily activities. Which nursing diagnosis should the nurse select to address this client's issue? A) Excess Fluid Volume B) Activity Intolerance C) Depression D) Situational Low Self-Esteem
B
7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.
B
5) The nurse is caring for an infant diagnosed with patent ductus arteriosus. Which medication should the nurse plan to provide this client? A) Indomethacin B) NSAIDS C) Antidepressant D) Insulin
A
9) A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute. What is the client's cardiac output (CO) rounded to the nearest whole number?
6 LITERS Explanation: CO = SV × HR 85mL = 0.085 L CO = 0.085 × 71 = 6.035 = 6L
) While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion."
A
10) A nurse caring for clients with heart failure must be aware of the compensatory mechanisms activated in heart failure. Which physiology is not associated with the neuroendocrine compensatory mechanism? A) Increased cardiac workload causes myocardial muscle to hypertrophy and ventricles to dilate. B) Decreased CO stimulates the sympathetic nervous system and catecholamine release. C) Decreased CO and decreased renal perfusion stimulate the renin-angiotensin system. D) Antidiuretic hormone is released from posterior pituitary.
A
10) A nurse is caring for a client who has been successfully resuscitated after a myocardial infarction. The client has now developed an arrhythmia. The nurse understands that the causes of this arrhythmia are all of the following except: A) Tissue alkalosis. B) Cellular acidosis. C) Electrolyte imbalance. D) Hypoxia.
A
10) A nurse is performing an assessment on a client diagnosed with aortic stenosis. The nurse will hear the client's murmur best at: A) Right sternal border, second intercostal space. B) Left sternal border, second intercostal space. C) Right sternal border, third intercostal space. D) Left sternal border, third to fifth intercostal space.
A
11) A nurse is caring for a client with cardiomyopathy who has a nursing diagnosis of Activity Intolerance. The nurse plans all interventions except: A) Spacing out nursing activities so client fatigue is lessened. B) Assisting with client ADLs as necessary. C) Using passive and active range-of-motion (ROM) exercises as tolerated. D) Consulting with a physical therapist on an activity plan.
A
11) A physician caring for a client with hypoplastic left heart syndrome has provided the client's family with information regarding the surgical repair necessary for this condition. The client's nurse knows that this procedure is named the: A) Glenn procedure. B) Jatene procedure. C) Fontan procedure. D) Damus-Kaye-Stansel procedure.
A
12) A client diagnosed with systolic heart failure is admitted to the Intensive Care Unit (ICU). The nurse assigned to this client understands that systolic heart failure: A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. B) Results when the heart cannot completely relax in diastole, disrupting normal filling. C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload. D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired relaxation of the heart muscle.
A
12) A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which nursing action does not support this diagnosis? A) Place client in low-Fowler position to improve gas exchange. B) Monitor the client's oxygen saturation continuously. C) Maintain bed rest. D) Encourage deep breathing and coughing.
A
2) A client with a history of myocardial infarctions tells the nurse that he has been smoking for 35 years and it does not matter now if he stops. What should the nurse respond to this client? A) "Your risk of continued coronary heart disease will decrease by half when you stop." B) "It will enhance the effects of your medications." C) "It will reduce your risk of lung cancer." D) "It will decrease any complications you might develop."
A
2) The nurse is planning care for several clients. Which client has the greatest risk of developing heart failure? A) A 69-year-old African-American male with hypertension B) A 50-year-old African-American female who smokes C) A 75-year-old Caucasian male who is overweight D) A 52-year-old Caucasian female with asthma
A
3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be indicated for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids
A
3) The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status? A) Encourage fluids. B) Limit fluids. C) Monitor output. D) Maintain intravenous therapy until day before discharge.
A
4) During an assessment, a client with congestive heart failure and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care? A) Excess Fluid Volume related to shortness of breath B) Ineffective Family Management of Therapeutic Regime related to inability to purchase medications C) Fatigue related to shortness of breath D) Activity Intolerance related to shortness of breath
A
5) The nurse has identified Ineffective Tissue Perfusion as a diagnosis for a client with disseminated intravascular coagulation. What intervention would be appropriate for the client? A) Carefully repositioning the client every 2 hours B) Administering oxygen C) Monitoring oxygen saturation D) Encouraging deep breathing and coughing
A
6) The nurse instructs a client about the medication nifedipine (Procardia) for hypertension. Which client statement indicates that additional teaching is needed? A) "This medication will cause my ankles to swell, which is normal." B) "I need to drink 6-8 glasses of water each day." C) "I will call my doctor if I gain weight or become short of breath." D) "I need to eat foods high in fiber when taking this medication."
A
8) The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position would the client find the most comfortable? A) Seated in a recliner with 2-3 pillows under feet B) Lying on the left side with the head of the bed elevated 30° C) Seated in a recliner with 2-3 pillows under head D) Lying on either side with the head of the bed elevated 30°
A
A nurse working in Labor and Delivery cares for clients with preeclampsia. The nurse understands that the exact cause of this condition is not known; however, research suggests: A) It is a disorder of placental dysfunction. B) It is a disorder of fetal liver compromise. C) It is a disorder of maternal hyporesponsiveness to vasoactive peptides. D) It is a disorder of excess trophoblast invasion within the placenta.
A
CONGENITAL HEART DEFECTS 1) The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. About what should the nurse ask the mother during the assessment? A) Use of alcohol during the pregnancy B) Maternal father's history of diabetes C) Father's exposure to toxins in the work environment D) History of hypertension
A
During a routine prenatal visit, a client who is 24 weeks pregnant has an increased blood pressure. The nurse identifies which nursing diagnosis as appropriate for the client at this time? A) Fluid Volume Excess B) Anxiety C) Excess Fluid Volume D) Ineffective Coping
A
HYPERTENSION 1) A client reports morning headache that extends into the neck and goes away as the day wears on. What should the nurse suspect this client is describing? A) A symptom of hypertension B) A sinus headache C) A migraine headache D) Spinal stenosis
A
HYPERTENSIVE DISORDER IN PREGNANCY The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A) Blood pressure of 142/92 B) Pulse of 92 beats per minute C) Respiratory rate of 24 per minute D) Weight gain of 16 oz per week
A
PERIPHERAL VASCULAR DISEASE A client diagnosed with peripheral vascular disease is obese, has a 30-year history of cigarette smoking, and works as a contractor. What should the nurse instruct the client about the diagnosis? A) Nicotine is a vasoconstrictor. B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease. C) Nicotine primarily affects coronary arteries and the lungs. D) The client's occupation is a major risk factor.
A
STROKE While completing a health history with an older client, the nurse learns that the client experienced a transient ischemic attack several months ago. What does this information suggest to the nurse? A) The client is at risk for an ischemic thrombotic stroke. B) The client will have minimal symptoms should a stroke occur. C) The client will not experience a stroke in the future. D) The client is at high risk for a hemorrhagic stroke.
A
The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? A) "My urine may become darker and smaller in amount each day." B) "I should call the doctor if I develop a headache or blurred vision." C) "Pain in the top of my abdomen is a sign my condition is worsening." D) "Lying on my left side as much as possible is good for the baby."
A
The nurse is assessing an older client with a cardiac dysrhythmia. What finding would the nurse identify as contributing to this client's dysrhythmia? A) Drinks caffeinated coffee in the morning and for lunch. B) Does not smoke or ingest any alcohol. C) Plays golf three times a week and gardens daily. D) Takes antihypertensive medication as prescribed.
A
The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. What assessment information caused the nurse to come to this conclusion? A) Body mass index (BMI) 35.8 B) Former cigarette smoker C) Blood pressure 132/88 mmHg D) Age 45 years
A
The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of non-affected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly
A
11) A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator. The client appears comfortable at rest but displays dyspnea with ADLs. In which stage of heart failure does the nurse classify this client? A) I B) II C) III D) IV
C
) A client has a nighttime cough related to taking enalapril (Vasotec). What is the best nursing intervention to promote rest in this client? A) Have the client sit up at an 80° angle in a comfortable chair at night. B) Have the client sleep on 2 or 3 pillows at night. C) Contact the physician for an order for a cough-suppressant medication. D) Contact the physician for an order for a sedative-hypnotic medication.
B
) A nurse caring for a client in the in the ICU notes that the client's cardiac rhythm indicates a ventricular tachycardia dysrhythmia. Which rhythm is classified as supraventricular? A) Sinus tachycardia B) Atrial flutter C) Junctional escape D) Torsades de Pointes
B
) The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective? A) "I won't be able to run in marathons anymore." B) "I know I need to give up my cigarettes and alcohol." C) "I need to get started on my medications right away." D) "My father had hypertension, did nothing, and lived to be 90 years old."
B
10) A nurse working in the Intensive Care Unit (ICU) is caring for a client in a hypertensive emergency due to acute nephritis. The nurse understands that the client's renal system affects blood pressure by: A) Releasing the catecholamines epinephrine and norepinephrine. B) Stimulating the release of renin. C) Stimulating the release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). D) Synthesizing and releasing adrenomedullin
B
11) A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Tissue Perfusion. Which nursing action does not support this diagnosis? A) Monitor the client's level of consciousness and mental status. B) Elevate the client's knees on the bed or with a pillow. C) Minimize the use of tape on the client's skin. D) Assess extremity pulses, warmth, and capillary refill.
B
11) A nurse is caring for a pregnant client who is hypertensive. What additional symptom likely indicates this client has early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain
B
12) A community care nurse is providing education to a group of adults regarding myocardial infarction (MI). When discussing ways to decrease the number of MI-related deaths, the nurse will include all of the following statements except: A) "It is important to learn how to perform cardiopulmonary resuscitation (CPR) techniques." B) "Be sure to take a baby aspirin every day to help prevent an MI." C) "Increase your knowledge of cardiac health and cardiac-related disease." D) "Seek immediate medical attention when you suspect an MI."
B
12) A nurse is educating a client with cardiomyopathy about diet choices which are appropriate for the client's condition. The nurse will include all statements except: A) "It is important to monitor your sodium intake." B) "Increasing your dietary protein helps with cardiac cell repair." C) "Here is a list of high-fat, high-cholesterol foods to avoid." D) "I have notified the dietitian regarding your condition in order to provide you with more information."
B
2) The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Cluster activities. B) Instruct on deep breathing. C) Medications appropriate to increase heart rate D) Positioning to increase blood return
B
3) An older client diagnosed with cardiomyopathy reports having to rest between activities during the day. What should the nurse realize is the reason for this client's fatigue? A) Increased stroke volume B) Decreased cardiac output C) An elongated and dilated aorta D) Increased blood pressure
B
4) A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which nursing diagnosis is the most appropriate for the client at this time? A) Pain B) Impaired Gas Exchange C) Ineffective Tissue Perfusion D) Anxiety
B
4) The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching provided to these parents has been effective? A) "Our child should be restricted in play and activity for at least 6 months." B) "Our child will need to take antibiotics prior to having dental surgery." C) "Fluids should be restricted to maximize lung function." D) "Our child should not return to normal activities for at least 2 years."
B
4) The nursing diagnosis Noncompliance related to unknown factors is established for a client with hypertension who admits to occasionally taking prescribed antihypertensive medications. Which behavior should the nurse demonstrate when discussing reasons for noncompliance with this client? A) Indifference B) Nonjudgmental C) Direct D) Confrontational
B
5) An older client receiving medication for hypertension had a recent fall at home. What should the nurse include in this client's plan of care? A) Monitor serum sodium levels. B) Assess postural blood pressures. C) Monitor serum creatinine levels. D) Monitor blood pressure every 2 hours.
B
5) The nurse is instructing an older client about atorvastatin (Lipitor) to treat elevated cholesterol. What side effects should the nurse advise the client to report to the healthcare provider? A) Headaches B) Muscle pain and weakness C) Bruising and excessive bleeding D) Shortness of breath
B
5) The nurse is planning care for an infant with congestive heart failure. What should the nurse include in this child's care? A) Give larger feedings less often to conserve energy. B) Organize activities to allow for uninterrupted sleep. C) Monitor respirations during active periods. D) Force fluids appropriate for age.
B
6) A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery? A) Restricting immunizations until after the surgery B) Preventing exposure to infection C) Implementing no particular precautions D) Restricting fluids
B
6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not sleeping well. What should the nurse suspect this client is experiencing? A) Pancreatic disease B) Cardiac disease C) Normal changes of aging D) Signs of anemia
B
7) A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, what action should the nurse perform first? A) Assess pulse, respirations, and blood pressure. B) Apply oxygen and elevate the head of the bed. C) Reassure the client and notify family members. D) Increase the rate of heparin infusion.
B
8) A client with disseminated intravascular coagulation is experiencing joint pain. Which nursing intervention should the nurse use to help the client at this time? A) Splints B) Cool compresses C) Heat D) Ice
B
8) A nurse working in the Neonatal Intensive Care Unit (NICU) is caring for a preterm infant with a congenital heart defect. The nurse knows that these conditions are categorized by: A) Severity of defect. B) Pathophysiology and hemodynamics of defect. C) Location of defect. D) Age when defect diagnosed
B
9) A client has a blood pressure of 142/92. The nurse recognizes this as: A) Normal. B) Hypertension Stage I. C) Prehypertension. D) Hypertension Stage II.
B
9) A nurse is providing discharge education to a client who has been diagnosed with angina. Which statement would the nurse exclude from teaching? A) "Stable angina is the most common form of angina." B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise." C) "Unstable angina occurs with increasing frequency, severity, and duration." D) "Clients with unstable angina are at risk for a heart attack."
B
A client is admitted to the hospital in order to have surgical intervention due to peripheral vascular disease (PVD). Which procedure is the likely intervention? A) Stent placement B) Endarterectomy C) Percutaneous transluminal angioplasty D) Atherectomy
B
A client is receiving procainamide hydrochloride (Pronestyl) for treatment of a dysrhythmia. Which outcome indicates the client is adhering to the provided medication instruction? A) The client will monitor the pulse and not take the medication if the pulse is less than 60. B) The client will take the medication as directed, even when feeling well. C) The client will take the medication on an empty stomach. D) The client will take the medication with food.
B
A client with peripheral vascular disease is experiencing pain. What can the nurse do to assist this client? A) Elevate legs in bed with pillows under the knees. B) Keep the extremities warm with blankets. C) Encourage to ambulate and stand on legs 4 times each day. D) Apply cool compresses to the extremities.
B
A client with preeclampsia begins to seize. What should the nurse should do to protect the client and fetus from injury? A) Elevate the client's legs. B) Place the client on the left side and protect the airway. C) Place the client in the supine position. D) Elevate the head of the bed.
B
A client with sepsis has a temperature of 40°Celsius. Which potentially life-threatening dysrhythmia is most likely to occur in this client? A) Bradyarrhythmia B) Tachyarrhythmia C) Wolff-Parkinson-White dysrhythmia D) Long QT dysrhythmia
B
CORONARY ARTERY DISEASE 1) A client with angina complains that the pain is prolonged and severe, and occurs at the same time each day while at rest. There are no precipitating factors to the pain. How should the nurse describe this type of angina pain? A) Non-anginal pain B) Atypical angina (Prinzmetal angina) C) Unstable angina D) Stable angina
B
DISSEMINATED INTRAVASCULAR COAGULATION 3) The nurse is caring for a child with disseminated intravascular coagulation (DIC).What will the nurse include as a priority intervention for this client? A) Frequent ambulation B) Maintenance of skin integrity C) Preparation for radiograph procedures D) Monitoring of fluid restriction
B
HEART FAILURE ) During hospitalization for congestive heart failure, a client awakens during the night frightened and short of breath. What is this client most likely experiencing? A) Cardiomyopathy B) Paroxysmal nocturnal dyspnea C) High-output failure D) Multisystem heart failure
B
The home care nurse assesses an older client's blood pressure as being 150/100 mmHg. When reviewing medications, the client reports taking the blood pressure medication only when feeling tense. What should the nurse instruct this client to do? A) Continue to take medication when feeling tense. B) Take the blood pressure medication as prescribed regardless of feeling tense. C) Take the blood pressure medication at twice the prescribed dosage for 1 day and then resume the daily schedule. D) Contact the physician for an increase in blood pressure medication.
B
The nurse explains the purpose of an infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement indicates that the client understands the instructions? A) "It is a protein that causes my kidneys to conserve fluid." B) "It is a protein that pulls water into my blood vessels." C) "It is a liquid that has electrolytes in it to pull water into my blood vessels." D) "It is a super-concentrated salt solution that helps me conserve body fluid."
B
The nurse has instructed a client recovering from a pulmonary embolism on long-term anticoagulant therapy. Which client statement indicates that instruction has been effective? A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor, and avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."
B
The nurse is administering albumin 5% to a client in shock. What should the nurse include in this client's plan of care? A) Auscultate breath sounds for inspiratory stridor. B) Auscultate breath sounds for crackles. C) Auscultate breath sounds for hyperresonance. D) Auscultate for an absence of breath sounds in the lower lobes.
B
The nurse is evaluating teaching provided to a client with peripheral vascular disease. Which client observation indicates teaching has been effective? A) Sitting in a chair with a pillow behind knees B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer C) Sitting in a chair with left leg crossed over the right D) Smoking a pipe instead of cigarettes
B
The nurse is planning care for a client with peripheral vascular disease who is at risk for Impaired Skin Integrity. What would be included in this client's plan of care? A) Restrict fluids. B) Keep the skin clean and dry, and moisturize areas of dryness. C) Encourage bed rest with legs elevated on pillows. D) Consult a dietitian for low-protein diet.
B
The nurse is planning care for an older client with chronic venous insufficiency. What should the nurse plan to teach this client? A) Keep the legs dependent as much as possible and elevate only when asleep. B) Wear elastic hose as prescribed. C) Standing will prevent the progression of the disease. D) Cross legs only at the knees.
B
Which client is at highest risk for a nonthrombotic pulmonary embolism? A) The pregnant client with gestational diabetes B) The client who postoperative from a femur fracture repair C) The client with a primary lung tumor D) The client who uses intravenous illicit drugs
B
Which clinical consideration should the nurse implement for the client in labor who has been diagnosed with preeclampsia? A) Place the client in the room closest to the nurse's station, even if it is a shared room. B) Place the client in left lateral position when the client feels the urge to push. C) Monitor client's fetus intermittently while client is in first stage of labor. D) Encourage the client to be alone in the room without family in order to maintain a quiet environment.
B
) A client with a suspected TIA presents to the Emergency Department with aphasia. Which is the pathophysiology causing aphasia? A) Middle cerebral artery involvement B) Posterior cerebral artery involvement C) Ischemia of the left hemisphere D) Ischemia of the right hemisphere
C
) A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. The nurse caring for this client understands that intermittent claudication: A) Causes pain that occurs during periods of inactivity. B) Causes pain that increases when the legs are elevated and decreases when the legs are dependent. C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. D) Is often described as a burning sensation in the lower legs.
C
) A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,500 mL of blood. Which type of hemorrhagic shock describes this client?
C
) A nurse working in the Emergency Department is aware that there are various cultural and ethnic risk factors for stroke. The nurse understands that which of the following is an example of this? A) African-Americans have an increased incidence of intracerebral hemorrhage. B) Hispanics have almost twice the number of first-ever strokes compared with whites. C) African-Americans are more likely to die following a stroke than whites. D) The prevalence of hypertension among Hispanics is the highest in the world.
C
1) What will the nurse most likely assess in a client with right heart failure? A) Leg cramps B) Indigestion C) Reduced circulation to the pulmonary structures D) Reduced urine output
C
10) A client with cardiomyopathy is experiencing tachycardia. Which medication order does the client's nurse anticipate? A) ACE Inhibitor B) Angiotensin II receptor blocker C) Beta blocker D) Cardiac glycoside
C
10) A nurse working in labor and delivery is caring for a client with suspected DIC. The nurse is aware that DIC most often occurs in which pregnancy complication? A) Gestational diabetes B) Polyhydramnios C) Placental abruption D) Placenta previa
C
11) A nurse is caring for a client suspected of a cocaine-induced myocardial infarction. Cocaine may cause a myocardial infarction because the drug: A) Significantly increases the serum triglyceride level, leading to the development of an atheroma. B) Alters the body's clotting mechanisms, leading to thrombus formation. C) Increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction. D) Alters electrolyte balance, leading to arrhythmias.
C
11) The nurse is caring for a client with hypertension. The nurse understands that the client's blood pressure is determined by all the following factors except: A) Pumping action of the heart. B) Peripheral vascular resistance. C) Heart rate. D) Blood volume.
C
2) The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client? A) Risk for Infection related to engorged pulmonary vasculature B) Interrupted Family Processes C) Decreased Cardiac Output D) Excess Fluid Volume
C
3) A client recovering from a cesarean section is afebrile but is experiencing tenderness, localized heat, and redness of the left leg. What would be the best intervention for the client at this time? A) Encourage to ambulate freely. B) Provide aspirin 650 mg by mouth. C) Place on bed rest. D) Provide Methergine IM.
C
3) The nurse is preparing preoperative teaching for an older client scheduled for a ventricular assist device. What should the nurse include in these instructions? A) Need to stay on bed rest for a week or more B) Cardiac pain postoperatively is to be expected. C) Risk for postoperative infection D) Expect to be ambulating the evening of surgery.
C
4) A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating, and fatigued with routine care activities. The nurse would identify which of the following nursing diagnoses as being appropriate for this client? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Knowledge C) Activity Intolerance D) Self-Care Deficit
C
4) A client is admitted with complaints of lower extremity edema and occasional shortness of breath. Which electrocardiogram finding supports that the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric
C
4) A client, admitted with irregular chest pain and shortness of breath, complains of fatigue with activity. The client's body mass index (BMI) is 30.5. Which nursing diagnosis would be a priority for the client at this time? A) Ineffective Coping B) Fear C) Imbalanced Nutrition: More than Body Requirements. D) Fluid Volume Deficit
C
4) The nurse is planning care for a client with deep venous thrombosis. Which nursing diagnosis would be a priority for this client? A) Risk for Infection related to obstructed venous return B) Excess Fluid Volume related to tissue edema C) Ineffective Tissue Perfusion related to obstructed venous return D) Disturbed Sleep Pattern related to tissue hypoxia
C
6) A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What does the nurse identify as the priority outcome for this client? A) The client will not disturb the intravenous infusion. B) The client will comply with dietary restrictions. C) The client will not experience bleeding. D) The client will keep the right leg elevated on two pillows.
C
6) The nurse is providing care to a client who has experienced several episodes of angina. What is the primary outcome for this client? A) The client will experience relief of chest pain with therapeutic lifestyle changes. B) The client will experience relief of chest pain with aspirin therapy. C) The client will experience relief of chest pain with nitrate therapy. D) The client will experience relief of chest pain with anticoagulant therapy.
C
7) A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. What will the nurse expect to provide for the client? A) Aspirin B) Coumadin C) Fresh frozen plasma and platelets D) Heparin
C
7) A client is prescribed enalapril (Vasotec) for treatment of heart failure. What assessment finding should cause the nurse concern following the initial administration of this drug? A) Serious rash B) Ototoxicity C) Low blood pressure D) Irregular pulse
C
8) A client with cardiomyopathy receiving diuretic therapy has a urine output of 300 cc in 8 hours. What should the nurse do to assist this client? A) Assist the client to ambulate. B) This is a normal urine output and the client does not need anything. C) Notify the physician, as the client could be dehydrated. D) Measure abdominal girth as a true assessment of the client's fluid status.
C
9) A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. The nurse will include all except: A) Dilated. B) Restrictive. C) Hypotrophic. D) Arrythmogenic right ventricular.
C
9) A nurse caring for a client with disseminated intravascular coagulation (DIC) is reviewing the client's diagnostic tests. Which test result is common in DIC? A) Decreased prothrombin time B) Increased platelet count C) Decreased fibrinogen level D) Decreased partial thromboplastin time
C
9) A nurse is caring for a client with heart failure secondary to an acute non-cardiac condition. Which condition would be excluded from the client's cause of heart failure? A) Massive pulmonary embolus B) Hyperthyroidism C) Rheumatic fever D) Volume overload
C
A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. The nurse would identify which diagnosis as a priority for this client? A) Ineffective Tissue Perfusion B) Anxiety C) Impaired Gas Exchange D) Impaired Physical Mobility
C
A client with peripheral vascular disease asks the nurse what types of exercise would improve the client's condition and overall health. About what should the nurse instruct this client? A) Bicycling B) Weight lifting C) Yoga D) Jogging
C
A nurse working in the ICU is caring for a client in progressive hemorrhagic shock. Which clinical manifestation is likely present? A) A sustained decrease of 10mmHg of the client's mean arterial pressure (MAP) B) A blood loss of 25% C) A change from aerobic to anaerobic metabolism D) A decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space
C
A pregnant client is diagnosed with HELLP syndrome. The client's nurse understands that which clinical finding is not a manifestation of this condition? A) Elevated liver enzymes B) Hemolysis C) Elevated lipid panel D) Decreased platelet count
C
A young client with a history of multiple allergies is prescribed epinephrine (EpiPen) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." What is the best response by the nurse? A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."
C
CARDIOMYOPATHY 2) A client tells the nurse that he knows he has high blood pressure but does not want to take any medication. Which health problem is the client at risk of developing? A) Gastritis B) Diabetes C) Cardiomyopathy D) Metabolic syndrome
C
DEEP VEIN THROMBOSIS 1) The nurse is completing an assessment on a newly admitted client. What assessment finding would suggest to the nurse that a client is experiencing a deep venous thrombosis? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with pitting edema D) Bilateral calf tenderness after walking up a flight of stairs
C
LIFE-THREATNING DYSRHYTHMIAS During a blood pressure screening, an older client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. How should the nurse interpret this client's finding? A) Exercise intolerance B) Nonspecific cardiac changes with aging C) Underlying illness that requires a medical evaluation D) Hypothyroidism
C
PULMONARY EMBOLISM The nurse caring for a client recovering from an abdominal hysterectomy suspects the client is experiencing a pulmonary embolism. What did the nurse assess in this client? A) Nausea B) Decreased urine output C) Dyspnea and shortness of breath D) Activity intolerance
C
The nurse identifies assessment findings for an African-American client with preeclampsia. Blood pressure is 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 158/100 B) Platelet count 150,000 C) Urinary output 20 mL/hour D) Reflexes 2+
C
The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client? A) Restrict fluids. B) Encourage bed rest. C) Monitor serum electrolyte levels. D) Instruct in a low-fat diet.
C
The nurse is planning care for a client with a pulmonary embolism. Which intervention would assist with the client's decrease in cardiac output? A) Provide oxygen. B) Keep protamine sulfate at the bedside. C) Monitor pulmonary arterial pressures. D) Assess for bleeding.
C
The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism. The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.
C
A client being treated for hypovolemic shock is prescribed a low dose of dopamine. What will the nurse assess after administering this medication? A) Stabilization of fluid loss B) Increased cardiac output C) Vasoconstriction and increased blood pressure D) Urinary output of at least 30 mL/hour
D
A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. For the prevention of which postoperative complication are these instructions being provided? A) Infection B) Delayed wound healing C) Contractures D) Deep vein thrombosis
D
A client is scheduled for permanent pacemaker instruction. What instruction will this client need? A) Dizziness is to be expected. B) There are no special precautions. C) Wear a tight-fitting shirt to help hold the pacemaker in place. D) Use battery-powered equipment.
D
A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase. What should the nurse explain to the client's family about the use of this medication? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to dissolve the clot that is occluding the cerebral circulation and reestablish circulation to the involved part of the brain
D
) A client recovering from a stroke is being discharged on warfarin sodium (Coumadin). During discharge teaching, which statement by the client would reflect an understanding of the effects of this medication? A) "It will be okay for me to eat anything, as long as it is low-fat." B) "I will stop taking this medicine if I notice any bruising." C) "I'll check my blood pressure frequently while taking this medication." D) "I will not eat spinach while I'm taking this medicine."
D
10) A nurse is educating the parents of a child born with tetralogy of Fallot. Which statement will the nurse include regarding this defect? A) "Increased pulmonary blood flow causes symptoms with this disease." B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta." C) "Your child has a decreased amount of red blood cells because of this disease." D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta."
D
12) A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. The nurse caring for this client understands that the mechanism of action for this medication is: A) Prevents conversion of angiotensin I to angiotensin II. B) Prevents beta-receptor stimulation in the heart. C) Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells. D) Blocks alpha-receptors in the vascular smooth muscle.
D
2) The nurse is planning care for a group of clients. Which client should the nurse realize has the greatest risk for developing deep venous thrombosis? A) The client recovering from laparoscopic gallbladder surgery B) The client admitted with new-onset type II diabetes mellitus C) The client admitted with community-acquired pneumonia D) The client recovering from knee replacement surgery
D
6) A client diagnosed with cardiomyopathy is being discharged to home. What client statement indicates discharge teaching has been effective? A) "I will exercise as much as possible, regardless of feeling weak and short of breath." B) "My pants getting tight around the waist, means I'm eating too much and should cut back on food." C) "I will eat foods containing sodium only if drinking water with them." D) "I will see the physician to discuss implanting a cardiac defibrillator next week."
D
6) The nurse is evaluating care provided to a client with disseminated intravascular coagulation. Which observation indicates care has been successful for this client? A) Heart rate 110 beats per minute B) Oxygen saturation level 86% C) Urine output 20 cc per hour D) No evidence of bleeding
D
A client, diagnosed with Impaired Swallowing, complains of frequent heartburn. What should the nurse do? A) Teach the client the "chin tuck" technique when swallowing. B) Assist the client to a 90° sitting position, or as high as tolerated, during meals. C) Check the client's mouth for pocketing of food. D) Assist the client in maintaining a sitting position for 30 minutes after the meal.
D
A home care nurse is applying an Unna boot on a client with a stasis ulcer. Which statement will the nurse include when providing client education regarding this therapy? A) "A nurse will change this dressing every 2 days." B) "It is important that you maintain strict bed rest." C) "The dressing will be applied to the entire length of your leg." D) "The dressing I am applying is semi-rigid."
D
A nurse caring for a client with a pulmonary embolism expects to find which diagnostic result? A) Patchy infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG
D
A nurse working in Labor and Delivery is caring for a client with preeclampsia. Which clinical manifestation is the nurse most likely to find in this client? A) Increased nitric oxide production B) Decreased serum sodium C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine
D
A nurse working in Labor and Delivery is teaching a group of pregnant clients regarding seizures associated with eclampsia. The nurse will include which statement? A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."
D
A nurse working in the Emergency Department is participating in the resuscitation of a client experiencing sudden cardiac death. After 5 cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse? A) Administer epinephrine. B) Immediately defibrillate the client. C) Assess the cardiac monitor electrodes. D) Assess the client's pulse.
D
An older client is experiencing hypovolemic shock. Which treatment measure would be given the highest priority for this client? A) Administering analgesics for control of pain B) Assessing the cause of bleeding C) Providing replacement of volume D) Establishing invasive cardiac monitoring
D
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which of the following would be the priority nursing diagnosis for this client? A) Deficient Fluid Volume B) Ineffective Coping C) Ineffective Airway Clearance D) Decreased Cardiac Output
D
The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased arterial flow to extremities as appropriate for a client. What should the nurse instruct the client to do to improve blood flow? A) Cross the legs at the knees when seated. B) Use a heating pad to increase warmth. C) Elevate the feet while reclining. D) Position with the extremities dependent
D
The nurse identifies the diagnosis of Risk for Injury as appropriate for a client with preeclampsia. What should the nurse include in this client's plan of care? A) Suggest family and friends phone frequently. B) Place in a semiprivate room. C) Provide stimulation with television and visitors. D) Limit phone calls and visitors.
D
The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse recognize as increasing this client's risk for the development of eclampsia? A) Treatment for vitamin D deficiency B) Surgery for ruptured appendix 1 year prior C) Fibrocystic breast disease D) Obesity
D
The nurse is instructing the spouse of a client with a stroke on how to do passive range of motion to the affected limbs. What should the nurse explain regarding the purpose of these exercises? A) Improve muscle strength. B) Maintain cardiopulmonary function. C) Improve endurance. D) Maintain joint flexibility
D
The nurse is preparing teaching for a client with hypertrophic cardiomyopathy. For which medication classification should the nurse prepare to instruct this client? A) Digitalis B) Vasodilators C) Nitrates D) Beta blocker
D
