Respiratory System and heart failure NCLEX
Identify initial assessment findings for a patient with EARLY STAGE LEFT sided heart failure
- fatigue - breathlessness - dizziness - confusion as a result of tissue hypoxia from the diminished CO
A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds
10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min
2 L/min Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.
A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum
A cough with the expectoration of mucoid sputum One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.
A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increase oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray
A hyperinflated chest noted on the chest x-ray Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, - hypercapnia, - dyspnea on exertion and at rest - oxygen desaturation with exercise - and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
Which of the following complications is of greatest concern when caring for a preoperative abdominal aneurysm client? a. HPN b. Aneurysm rupture c. Cardiac arrhythmias d. Diminished pedal pulses
Aneurysm rupture
Identify what is included during the assessment phase of the nursing process for a cardiopulmonary focus.
Assessment • In-depth history of the client's normal and present cardiopulmonary function • Past impairments in circulatory or respiratory functioning • Patient history including a review of drug, food, and other allergies • Physical examination of the client's cardiopulmonary status reveals the extent of existing signs and symptoms. • Use PQRST for pain / HPI for other symptoms • Review of laboratory and diagnostic test results
A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physicians? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum
Bronchospasm If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.
Which ofthe following symptoms is most commonly associated with left-sided heart failure? a. Crackles b. Arrhythmias c. Hepatic engorgement d. Hypotension
Crackles
An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory b. Diminished breathe sounds c. The presence of a barrel chest d. A sucking sound at the site of injury
Diminished breathe sounds This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.
2. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding. b. Immediately clamp the chest tube and notify the physician. c. Check for an air leak because the bubbling should be intermittent. d. Increase the suction pressure so that bubbling becomes vigorous.
Do nothing, because this is an expected finding. Continuous gentle bubbling should be noted in the suction control chamber. Option B is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option C is incorrect. Bubbling should be continuous and not intermittent. Option D is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism? a. Dyspnea b. Bradypnea c. Bradycardia d. Decreased respiratory
Dyspnea The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain
Presence of overdistended and non-functional alveoli is a condition called: a. Bronchitis b. Emphysema c. Empyema d. Atelectasis
Emphysema An overdistended and non-functional alveoli is a condition called emphysema. Atelectasis is the collapse of a part or the whole lung. Empyema is the presence of pus in the lung.
A nurse is assessing a male client with chronic airflow limitations and notes that the client has a "barrel chest." The nurse interprets that this client has which of the following forms of chronic airflow limitations? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis
Emphysema The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as "barrel chest." The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.
A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client? a. Administering atropine intravenously b. Administering small doses of midazolam (Versed) c. Encouraging additional fluids for the next 24 hours d. Ensuring the return of the gag reflex before offering food or fluids
Ensuring the return of the gag reflex before offering food or fluids After bronchoscopy, the nurse keeps the client on NPO status until the gag reflex returns because the preoperative sedation and local anesthesia impair swallowing and the protective laryngeal reflexes for a number of hours. Additional fluids are unnecessary because no contrast dye is used that would need flushing from the system. Atropine and midazolam would be administered before the procedure, not after.
What does FIO2 stand for?
Fraction of Inspired oxygen concentration
Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen? a. Limiting fluids b. Having the clients take three deep breaths c. Asking the client to split into the collection container d. Asking the client to obtain the specimen after eating
Having the clients take three deep breaths To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning
A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the development of a concurrent problem? a. Cough b. High-grade fever c. Chills and night sweats d. Anorexia and weight loss
High-grade fever The client with tuberculosis USUALLY experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever
A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler correctly. The nurse instructs the client to: a. Inhale quickly b. Inhale through the nose c. Hold the breath after inhalation d. Take two inhalations during one breath
Hold the breath after inhalation Instructions for using a metered-dose inhaler include - shaking the canister, - holding it right side up, - inhaling slowly and evenly through the mouth, - delivering one spray per breath, - and holding the breath after inhalation.
What does central cyanosis indicate?
Hypoexmia
A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate
Increased respiratory rate The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client indicates a need for further teaching? a. Inhales the mist and quickly exhales b. Removes the cap and shakes the inhaler well before use c. Presses the canister down with the finger as he breathes in d. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
Inhales the mist and quickly exhales The client should be instructed to hold his or her breath for at least 10 to 15 seconds before exhaling the mist. Options B, C, and D are accurate instructions regarding the use of the inhaler.
An unconscious male client is admitted to an emergency room. Arterial blood gas measurements reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level, and an elevated potassium level. These results indicate the presence of: a. Metabolic acidosis b. Respiratory acidosis c. Overcompensated respiratory acidosis d. Combined respiratory and metabolic acidosis
Metabolic acidosis In an acidotic condition, the pH would be low, indicating the acidosis. In addition, a low bicarbonate level along with the low pH would indicate a metabolic state. Therefore, options B, C, and D are incorrect.
A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration
Pain, especially with inspiration Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and Sx include - pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation - shallow respirations - splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
4. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician. b. Place the tube in a bottle of sterile water. c. Immediately replace the chest tube system. d. Place the sterile dressing over the disconnection site.
Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake. b. Strengthen the diaphragm. c. Strengthen the intercostal muscles. d. Promote carbon dioxide elimination.
Promote carbon dioxide elimination. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute respiratory distress syndrome
Right pneumothorax Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction. b. Notify the physician immediately. c. Stop the procedure and reoxygenate the client. d. Ensure that the suction is limited to 15 seconds.
Stop the procedure and reoxygenate the client. During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate of 24 breaths/min
Stridor The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction
How often should a nurse assess the skin and nares of the patient with a nasal cannula?
The nurse should assess the client's nares and ears for skin breakdown every 6 hours.
What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying? a. "Tell me about your feeling right now." b. "When the doctor arrives, everything will be fine." c. "This is a bad situation, but you'll feel better soon." d. "Please be assured we're doing everything we can to make you feel better."
a. "Tell me about your feeling right now." Validation of the client's feelings is the most appropriate response. It gives the client a feeling of comfort and safety. The other three responses give the client false hope. No one can determine if a client experiencing MI will feel or get better and therefore, these responses are inappropriate.
A pulsating abdominal mass usually indicates which of the following conditions? a. Abdominal aortic aneurysm b. Enlarged spleen c. Gastic distention d. Gastritis
a. Abdominal aortic aneurysm The presence of a pulsating mass in the abdomen is an abnormal finding, usually indicating an outpouching in a weakened vessel, as in abdominal aortic aneurysm. The finding, however, can be normal on a thin person. Neither an enlarged spleen, gastritis, nor gastric distention cause pulsation.
What is the most common symptom in a client with abdominal aortic aneurysm? a. Abdominal pain b. Diaphoresis c. Headache d. Upper back pain
a. Abdominal pain Abdominal pain in a client with an abdominal aortic aneurysm results from the disruption of normal circulation in the abdominal region. Lower back pain, not upper, is a common symptom, usually signifying expansion and impending rupture of the aneurysm. Headache and diaphoresis aren't associated with abdominal aortic aneurysm.
Which of the following parameters should be checked before administering digoxin? a. Apical pulse b. Blood pressure c. Radial pulse d. Respiratory rate
a. Apical pulse An apical pulse is essential or accurately assessing the client's heart rate before administering digoxin. The apical pulse is the most accurate point in the body. Blood pressure is usually only affected if the heart rate is too low, in which case the nurse would withhold digoxin. The radial pulse can be affected by cardiac and vascular disease and therefore, won't always accurately depict the heart rate. Digoxin has no effect on respiratory function.
What is the most common cause of abdominal aortic aneurysm? a. Atherosclerosis b. DM c. HPN d. Syphilis
a. Atherosclerosis Atherosclerosis accounts for 75% of all abdominal aortic aneurysms. Plaques build up on the wall of the vessel and weaken it, causing an aneurysm. Although the other conditions are related to the development of an aneurysm, none is a direct cause.
Which of the following conditions most commonly results in CAD? a. Atherosclerosis b. DM c. MI d. Renal failure
a. Atherosclerosis Atherosclerosis, or plaque formation, is the leading cause of CAD. DM is a risk factor for CAD but isn't the most common cause. Renal failure doesn't cause CAD, but the two conditions are related. Myocardial infarction is commonly a result of CAD.
Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? a. Beta-adrenergic blockers b. Calcium channel blockers c. Narcotics d. Nitrates
a. Beta-adrenergic blockers Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infarction by decreasing the workload of the heart and decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decreased anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure (preload) and systemic vascular resistance (afterload).
What is the term used to describe an enlargement of the heart muscle? a. Cardiomegaly b. Cardiomyopathy c. Myocarditis d. Pericarditis
a. Cardiomegaly Cardiomegaly denotes an enlarged heart muscle. Cardiomyopathy is a heart muscle disease of unknown origin. Myocarditis refers to inflammation of heart muscle. Pericarditis is an inflammation of the pericardium, the sac surrounding the heart.
Which of the following heart muscle diseases is unrelated to other cardiovascular disease? a. Cardiomyopathy b. Coronary artery disease c. Myocardial infarction d. Pericardial Effusion
a. Cardiomyopathy Cardiomyopathy isn't usually related to an underlying heart disease such as atherosclerosis. The etiology in most cases is unknown. Coronary artery disease and myocardial infarction are directly related to atherosclerosis. Pericardial effusion is the escape of fluid into the pericardial sac, a condition associated with pericarditis and advanced heart failure.
Which of the following is the most common symptom of myocardial infarction? a. Chest pain b. Dyspnea c. Edema d. Palpitations
a. Chest pain The most common symptom of an MI is chest pain, resulting from deprivation of oxygen to the heart. Dyspnea is the second most common symptom, related to an increase in the metabolic needs of the body during an MI. Edema is a later sign of heart failure, often seen after an MI. Palpitations may result from reduced cardiac output, producing arrhythmias.
Toxicity from which of the following medications may cause a client to see a green halo around lights? a. Digoxin b. Furosemide c. Metoprolol d. Enalapril
a. Digoxin One of the most common signs of digoxin toxicity is the visual disturbance known as the green halo sign. The other medications aren't associated with such an effect.
Which of the following types of cardiomyopathy can be associated with childbirth? a. Dilated b. Hypertrophic c. Myocarditis d. Restrictive
a. Dilated Although the cause isn't entirely known, cardiac dilation and heart failure may develop during the last month of pregnancy of the first few months after birth. The condition may result from a preexisting cardiomyopathy not apparent prior to pregnancy. Hypertrophic cardiomyopathy is an abnormal symmetry of the ventricles that has an unknown etiology but a strong familial tendency. Myocarditis isn't specifically associated with childbirth. Restrictive cardiomyopathy indicates constrictive pericarditis; the underlying cause is usually myocardial.
a 48-year-old client doesn't smoke cigarettes yet is demonstrating signs of lung irritation. Which of the following questions could help with the assessment of this client? a. Do you smoke or inhale marijuana or other herbal products? b. Have you had allergy testing? c. Have you received a flu or pneumonia vaccination? d. Have you tried to stop smoking?
a. Do you smoke or inhale marijuana or other herbal products?
The position of a conscious client during suctioning is: a. Fowler's b. Supine position c. Side-lying d. Prone
a. Fowler's Position a conscious person who has a functional gag reflex in the semi fowler's position with the head turned to one side for oral suctioning or with the neck hyper extended for nasal suctioning. If the client is unconscious place the patient a lateral position facing you.
Which of the following recurring conditions most commonly occurs in clients with cardiomyopathy? a. Heart failure b. DM c. MI d. Pericardial effusion
a. Heart failure Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. Myocardial infarction results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. Pericardial effusion is most predominant in clients with percarditis. Diabetes mellitus is unrelated to cardiomyopathy.
After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of crackles in the lungs? a. Left-sided heart failure b. Pulmonic valve malfunction c. Right-sided heart failure d. Tricuspid valve malfunction
a. Left-sided heart failure The left ventricle is responsible for the most of the cardiac output. An anterior wall MI may result in a decrease in left ventricular function. When the left ventricle doesn't function properly, resulting in left-sided heart failure, fluid accumulates in the interstitial and alveolar spaces in the lungs and causes crackles. Pulmonic and tricuspid valve malfunction causes right-sided heart failure.
During a physical assessment, the nurse documents eupnea on the client's medical record. What does this finding suggest? a. Normal respirations b. Slow respirations c. Irregular respirations d. Rapid respirations
a. Normal respirations
After inspecting a client's thorax, the nurse writes "AP:T 1:2, bilateral symmetrical movements, sternum midline, respiratory rate 16 and regular." What do these findings suggest? a. Nothing. These findings are normal. b. The client has pneumonia. c. The client has a respiratory illness. d. The client has allergies.
a. Nothing. These findings are normal.
23. The accumulation of fluids in the pleural space is called: a. Pleural effusion b. Hemothorax c. Hydrothorax d. Pyothorax
a. Pleural effusion
A client with a strained trapezius muscle complains of having occasional shortness of breath. What might be the reason for this symptom? a. The strained muscle is an accessory muscle of respiration. b. The diaphragm muscle is also injured. c. There is an undiagnosed heart problem. d. There is a blood clot in his lung.
a. The strained muscle is an accessory muscle of respiration.
Prior to listening to a client's lung sounds, the nurse palpates the sternum and feels a horizontal bump on the bone. What does this finding suggest to the nurse? a. This is the angle of Louis. b. The manubrium is damaged. c. The costal angle is greater than normal. d. The xiphoid process is misshaped.
a. This is the angle of Louis.
A 57-year-old client tells the nurse, "I need two to three pillows to sleep." How should this information be documented? a. Two to three pillow orthopnea b. Dyspnea on excursion c. Resting apnea d. Dyspnea at rest
a. Two to three pillow orthopnea
Which of the following complications is indicated by a third heart sound (S3)? a. Ventricular dilation b. Systemic hypertension c. Aortic valve malfunction d. Increased atrial contractions
a. Ventricular dilation Rapid filling of the ventricles causes vasodilation that is auscultated as S3. Increased atrial contraction or systemic hypertension can result is a fourth heart sound. Aortic valve malfunction is heard as a murmur.
The nurse is planning to assess the apex of a client's lungs. Which area of the body will the nurse be assessing? a. Left of the sternum, third intercostal space b. Above the clavicles c. Below the scapula d. Right of the sternum, sixth intercostal space
b. Above the clavicles The apex of each lung is slightly superior to the inner third of the clavicle.
What is the first intervention for a client experiencing myocardial infarction? a. Administer morphine b. Administer oxygen c. Administer sublingual nitroglycerin d. Obtain an electrocardiogram
b. Administer oxygen Administering supplemental oxygen to the client is the first priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and sublingual nitroglycerin are also used to treat MI, but they're more commonly administered after the oxygen. An ECG is the most common diagnostic tool used to evaluate MI.
What is the definitive test used to diagnose an abdominal aortic aneurysm? a. Abdominal X-ray b. Arteriogram c. CT scan d. Ultrasound
b. Arteriogram An arteriogram accurately and directly depicts the vasculature; therefore, it clearly delineates the vessels and any abnormalities. An abdominal aneurysm would only be visible on an X-ray if it were calcified. CT scan and ultrasound don't give a direct view of the vessels and don't yield as accurate a diagnosis as the arteriogram.
Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy? a. Antihypertensive b. Beta-adrenergic blockers c. Calcium channel blockers d. Nitrates
b. Beta-adrenergic blockers By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy. Antihypertensives aren't usually indicated because they would decrease cardiac output in clients who are often already hypotensive. Calcium channel blockers are sometimes used for the same reasons as beta-adrenergic blockers; however, they aren't as effective as beta-adrenergic blockers and cause increase hypotension. Nitrates aren't' used because of their dilating effects, which would further compromise the myocardium.
Which of the following illnesses is the leading cause of death in the US? a. Cancer b. Coronary artery disease c. Liver failure d. Renal failure
b. Coronary artery disease Coronary artery disease accounts for over 50% of all deaths in the US. Cancer accounts for approximately 20%. Liver failure and renal failure account for less than 10% of all deaths in the US.
In which of the following areas is an abdominal aortic aneurysm most commonly located? a. Distal to the iliac arteries b. Distal to the renal arteries c. Adjacent to the aortic branch d. Proximal to the renal arteries
b. Distal to the renal arteries The portion of the aorta distal to the renal arteries is more prone to an aneurysm because the vessel isn't surrounded by stable structures, unlike the proximal portion of the aorta. Distal to the iliac arteries, the vessel is again surrounded by stable vasculature, making this an uncommon site for an aneurysm. There is no area adjacent to the aortic arch, which bends into the thoracic (descending) aorta.
When do coronary arteries primarily receive blood flow? a. During inspiration b. During diastole c. During expiration d. During systole
b. During diastole Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are irrelevant to blood flow
Which of the following actions is the first priority care for a client exhibiting signs and symptoms of coronary artery disease? a. Decrease anxiety b. Enhance myocardial oxygenation c. Administer sublingual nitroglycerin d. Educate the client about his symptoms
b. Enhance myocardial oxygenation Enhancing myocardial oxygenation is always the first priority when a client exhibits signs and symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. Sublingual nitroglycerin is administered to treat acute angina, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care delivery, nether are priorities when a client is compromised.
While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube. b. Grasp the retention sutures to spread the opening. c. Call the respiratory therapy department to reinsert the tracheotomy. d. Cover the tracheostomy site with a sterile dressing to prevent infection.
b. Grasp the retention sutures to spread the opening.
Which of the following conditions is linked to more than 50% of clients with abdominal aortic aneurysms? a. DM b. HPN c. PVD d. Syphilis
b. HPN Continuous pressure on the vessel walls from hypertension causes the walls to weaken and an aneurysm to occur. Atherosclerotic changes can occur with peripheral vascular diseases and are linked to aneurysms, but the link isn't as strong as it is with hypertension. Only 1% of clients with syphilis experience an aneurysm. Diabetes mellitus doesn't have direct link to aneurysm.
With which of the following disorders is jugular vein distention most prominent? a. Abdominal aortic aneurysm b. Heart failure c. Myocardial infarction d. Pneumothorax
b. Heart failure Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump. Jugular vein distention isn't a symptom of abdominal aortic aneurysm or pneumothorax. An MI, if severe enough, can progress to heart failure; however, in and of itself, an MI doesn't cause jugular vein distention.
Which of the following types of cardiomyopathy does not affect cardiac output? a. Dilated b. Hypertrophic c. Restrictive d. Obliterative
b. Hypertrophic Cardiac output isn't affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged. Dilated cardiomyopathy, and restrictive cardiomyopathy all decrease cardiac output.
Which of the following landmarks is the correct one for obtaining an apical pulse? a. Left intercostal space, midaxillary line b. Left fifth intercostal space, midclavicular line c. Left second intercostal space, midclavicular line d. Left seventh intercostal space, midclavicular line
b. Left fifth intercostal space, midclavicular line The correct landmark for obtaining an apical pulse is the left intercostal space in the midclavicular line. This is the point of maximum impulse and the location of the left ventricular apex. The left second intercostal space in the midclavicular line is where the pulmonic sounds are auscultated. Normally, heart sounds aren't heard in the midaxillary line or the seventh intercostal space in the midclavicular line.
Atherosclerosis impedes coronary blood flow by which of the following mechanisms? a. Plaques obstruct the vein b. Plaques obstruct the artery c. Blood clots form outside the vessel wall d. Hardened vessels dilate to allow the blood to flow through
b. Plaques obstruct the artery Arteries, not veins, supply the coronary arteries with oxygen and other nutrients. Atherosclerosis is a direct result of plaque formation in the artery. Hardened vessels can't dilate properly and, therefore, constrict blood flow.
The nurse is assessing the client's lung bases posteriorly. At which area can the nurse assess this portion of the lung? a. Right anterior axillary line b. Scapular line c. Midsternal line d. Left midclavicular line
b. Scapular line
Which of the following groups of symptoms indicated a ruptured abdominal aneurysm? a. Lower back pain, increased BP, decreased RBC, increased WBC b. Severe lower back pain, decreased BP, decreased RBC, increased WBC c. Severe lower back pain, decreased BP, decreased RBC, decreased WBC d. Intermittent lower back pain, decreased BP, decreased RBC, increased WBC
b. Severe lower back pain, decreased BP, decreased RBC, increased WBC Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When rupture occurs, the pain is constant because it can't be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn't increase. For the same reason, the RBC count is decreased - not increase. The WBC count increases as cells migrate to the site of injury.
In planning a patient education session, the nurse sees one area of focus for Healthy People 2010 is chronic obstructive pulmonary disease (COPD). Which of the following information should the nurse include in the education session to address this focus area? a. Screening for environmental triggers b. Smoking cessation c. Develop action plans d. Identify those at risk
b. Smoking cessation
Stimulation of the sympathetic nervous system produces which of the following responses? a. Bradycardia b. Tachycardia c. Hypotension d. Decreased myocardial contractility
b. Tachycardia Stimulation of the sympathetic nervous system causes tachycardia and increased contractility. The other symptoms listed are related to the parasympathetic nervous system, which is responsible for slowing the heart rate.
The mother of a four-year-old child tells the nurse, "I think there's something wrong with him; his chest is round like a ball." Which of the following would be an appropriate response for the nurse to make to the mother? a. I see what you mean. That seems odd. b. The chest of a child appears round and is normal. c. I wouldn't worry about that. d. Did you tell the doctor about this?
b. The chest of a child appears round and is normal.
What is the most common complication of a myocardial infarction? a. Cardiogenic shock b. Heart failure c. Arrhythmias d. Pericarditis
c. Arrhythmias Arrhythmias, caused by oxygen deprivation to the myocardium, are the most common complication of an MI. cardiogenic shock, another complication of MI, is defined as the end stage of left ventricular dysfunction. The condition occurs in approximately 15% of clients with MI. Because the pumping function of the heart is compromised by an MI, heart failure is the second most common complication. Pericarditis most commonly results from a bacterial of viral infection but may occur after MI.
Which of the following conditions is most commonly responsible for myocardial infarction? a. Aneurysm b. Heart failure c. Coronary artery thrombosis d. Renal failure
c. Coronary artery thrombosis Coronary artery thrombosis causes occlusion of the artery, leading to myocardial death. An aneurysm is an outpouching of a vessel and doesn't cause an MI. Renal failure can be associated with MI but isn't a direct cause. Heart failure is usually the result of an MI.
The client tells the nurse he sometimes coughs up "thick yellow mucous." What does this information suggest to the nurse? a. He might have an allergy. b. He might have a fungal infection. c. He might have episodic lung infections. d. He might have tuberculosis.
c. He might have episodic lung infections Rationale: The color and odor of any mucus is associated with specific diseases or problems. Green or yellow mucus often signals a lung infection.
Which of the following risk factors for coronary artery disease cannot be corrected? a. Cigarette smoking b. DM c. Heredity d. HPN
c. Heredity Because "heredity" refers to our genetic makeup, it can't be changed. Cigarette smoking cessation is a lifestyle change that involves behavior modification. Diabetes mellitus is a risk factor that can be controlled with diet, exercise, and medication. Altering one's diet, exercise, and medication can correct hypertension.
Septal involvement occurs in which type of cardiomyopathy? a. Congestive b. Dilated c. Hypertrophic d. Restrictive
c. Hypertrophic In hypertrophic cardiomyopathy, hypertrophy of the ventricular septum - not the ventricle chambers - is apparent. This abnormality isn't seen in other types of cardiomyopathy.
Prolonged occlusion of the right coronary artery produces an infarction in which of he following areas of the heart? a. Anterior b. Apical c. Inferior d. Lateral
c. Inferior The right coronary artery supplies the right ventricle, or the inferior portion of the heart. Therefore, prolonged occlusion could produce an infarction in that area. The right coronary artery doesn't supply the anterior portion ( left ventricle ), lateral portion ( some of the left ventricle and the left atrium ), or the apical portion ( left ventricle ) of the heart.
1. Which of the following arteries primarily feeds the anterior wall of the heart? a. Circumflex artery b. Internal mammary artery c. Left anterior descending artery d. Right coronary artery
c. Left anterior descending artery The left anterior descending artery is the primary source of blood for the anterior wall of the heart. The circumflex artery supplies the lateral wall, the internal mammary artery supplies the mammary, and the right coronary artery supplies the inferior wall of the heart.
Which hereditary disease is most closely linked to aneurysm? a. Cystic fibrosis b. Lupus erythematosus c. Marfan's syndrome d. Myocardial infarction
c. Marfan's syndrome Marfan's syndrome results in the degeneration of the elastic fibers of the aortic media. Therefore, clients with the syndrome are more likely to develop an aortic aneurysm. Although cystic fibrosis is hereditary, it hasn't been linked to aneurysms. Lupus erythematosus isn't hereditary. Myocardial infarction is neither hereditary nor a disease.
Which of the following blood vessel layers may be damaged in a client with an aneurysm? a. Externa b. Interna c. Media d. Interna and Media
c. Media The factor common to all types of aneurysms is a damaged media. The media has more smooth muscle and less elastic fibers, so it's more capable of vasoconstriction and vasodilation. The interna and externa are generally no damaged in an aneurysm.
When assessing a client for an abdominal aortic aneurysm, which area of the abdomen is most commonly palpated? a. Right upper quadrant b. Directly over the umbilicus c. Middle lower abdomen to the left of the midline d. Midline lower abdomen to the right of the midline
c. Middle lower abdomen to the left of the midline The aorta lies directly left of the umbilicus; therefore, any other region is inappropriate for palpation.
A seven-month-pregnant female is sitting quietly in the waiting room, and her respiratory rate is 20 and shallow. What does this finding suggest to the nurse? a. She has a history of smoking. b. She is using accessory muscles to breathe. b. She is in pending respiratory failure. c. Nothing. This is normal.
c. Nothing. This is normal.
Which of the following symptoms might a client with right-sided heart failure exhibit? a. Adequate urine output b. Polyuria c. Oliguria d. Polydipsia
c. Oliguria Inadequate deactivation of aldosterone by the liver after right-sided heart failure leads to fluid retention, which causes oliguria. Adequate urine output, polyuria, and polydipsia aren't associated with right-sided heart failure.
Medical treatment of coronary artery disease includes which of the following procedures? a. Cardiac catheterization b. Coronary artery bypass surgery c. Oral medication administration d. Percutaneous transluminal coronary angioplasty
c. Oral medication administration Oral medication administration is a noninvasive, medical treatment for coronary artery disease. Cardiac catheterization isn't a treatment but a diagnostic tool. Coronary artery bypass surgery and percutaneous transluminal coronary angioplasty are invasive, surgical treatments.
What supplemental medication is most frequently ordered in conjuction with furosemide (Lasix)? a. Chloride b. Digoxin c. Potassium d. Sodium
c. Potassium Supplemental potassium is given with furosemide because of the potassium loss that occurs as a result of this diuretic. Chloride and sodium aren't loss during diuresis. Digoxin acts to increase contractility but isn't given routinely with furosemide.
A murmur is heard at the second left intercostal space along the left sternal border. Which valve area is this? a. Aortic b. Mitral c. Pulmonic d. Tricuspid
c. Pulmonic Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricuspid valve abnormalities are heard at the third and fourth intercostal spaces along the sternal border.
What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention? a. High-fowler's b. Raised 10 degrees c. Raised 30 degrees d. Supine position
c. Raised 30 degrees Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 and 30 degrees. Inclined pressure can't be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowler's position, the veins would be barely discernible above the clavicle.
Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area? a. Hernia b. Stage 1 pressure ulcer c. Retroperitoneal rupture at the repair site d. Rapid expansion of the aneurysm
c. Retroperitoneal rupture at the repair site Blood collects in the retroperitoneal space and is exhibited as a hematoma in the perineal area. This rupture is most commonly caused by leakage at the repair site. A hernia doesn't cause vascular disturbances, nor does a pressure ulcer. Because no bleeding occurs with rapid expansion of the aneurysm, a hematoma won't form.
While palpating the posterior thorax of a client, the nurse notes increased fremitus. What does this finding suggest to the nurse? a. The client needs to speak up. b. The client has a thick chest wall. c. The client could either have fluid in the lungs or have an infection. d. Nothing. This is a normal finding.
c. The client could either have fluid in the lungs or have an infection.
Which of the following blood tests is most indicative of cardiac damage? a. Lactate dehydrogenase b. Complete blood count c. Troponin I d. Creatine kinase
c. Troponin I Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin I levels aren't detectable in people without cardiac injury. Lactate dehydrogenase is present in almost all body tissues and not specific to heart muscle. LDH isoenzymes are useful in diagnosing cardiac injury. CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes. Because CK levels may rise with skeletal muscle injury, CK isoenzymes are required to detect cardiac injury.
What is atelectasis?
collapse of the alveoli in the lung prevents normal exchange of O2 and co2 hypoventilation occurs
Exceeding which of the following serum cholesterol levels significantly increases the risk of coronary artery disease? a. 100 mg/dl b. 150 mg/dl c. 175 mg/dl d. 200 mg/dl
d. 200 mg/dl Cholesterol levels above 200 mg/dl are considered excessive. They require dietary restriction and perhaps medication. Exercise also helps reduce cholesterol levels. The other levels listed are all below the nationally accepted levels for cholesterol and carry a lesser risk for CAD.
Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? a. Cardiac catheterization b. Cardiac enzymes c. Echocardiogram d. Electrocardiogram
d. Electrocardiogram The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can't determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the study may not be performed immediately.
Which of the following cardiac conditions does a fourth heart sound (S4) indicate? a. Dilated aorta b. Normally functioning heart c. Decreased myocardial contractility d. Failure of the ventricle to eject all the blood during systole
d. Failure of the ventricle to eject all the blood during systole An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. This increased resistance is related to decrease compliance of the ventricle. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An s4 isn't heard in a normally functioning heart.
The most important action the nurse should do before and after suctioning a client is: a. Placing the client in a supine position b. Making sure that suctioning takes only 10-15 seconds c. Evaluating for clear breath sounds d. Hyperventilating the client with 100% oxygen
d. Hyperventilating the client with 100% oxygen
Which of the following classes of medications maximizes cardiac performance in clients with heat failure by increasing ventricular contractility? a. Beta-adrenergic blockers b. Calcium channel blockers c. Diuretics d. Inotropic agents
d. Inotropic agents Inotropic agents are administered to increase the force of the heart's contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decrease the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.
Which of the following symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm? a. Abdominal pain b. Absent pedal pulses c. Angina d. Lower back pain
d. Lower back pain Lower back pain results from expansion of the aneurysm. The expansion applies pressure in the abdominal cavity, and the pain is referred to the lower back. Abdominal pain is most common symptom resulting from impaired circulation. Absent pedal pulses are a sign of no circulation and would occur after a ruptured aneurysm or in peripheral vascular disease. Angina is associated with atherosclerosis of the coronary arteries.
After myocardial infarction, serum glucose levels and free fatty acids are both increase. What type of physiologic changes are these? a. Electrophysiologic b. Hematologic c. Mechanical d. Metabolic
d. Metabolic Both glucose and fatty acids are metabolites whose levels increase after a myocardial infarction. Mechanical changes are those that affect the pumping action of the heart, and electrophysiologic changes affect conduction. Hematologic changes would affect the blood.
Which of the following systems is the most likely origin of pain the client describes as knifelike chest pain that increases in intensity with inspiration? a. Cardiac b. Gastrointestinal c. Musculoskeletal d. Pulmonary
d. Pulmonary Pulmonary pain is generally described by these symptoms. Musculoskeletal pain only increase with movement. Cardiac and GI pains don't change with respiration.
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions? a. Pericarditis b. Hypertension c. Obliterative d. Restrictive
d. Restrictive These are the classic symptoms of heart failure. Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub. Hypertension is usually exhibited by headaches, visual disturbances and a flushed face. Myocardial infarction causes heart failure but isn't related to these symptoms.
Which of the following conditions is most closely associated with weight gain, nausea, and a decrease in urine output? a. Angina pectoris b. Cardiomyopathy c. Left-sided heart failure d. Right-sided heart failure
d. Right-sided heart failure Weight gain, nausea, and a decrease in urine output are secondary effects of right-sided heart failure. Cardiomyopathy is usually identified as a symptom of left-sided heart failure. Left-sided heart failure causes primarily pulmonary symptoms rather than systemic ones. Angina pectoris doesn't cause weight gain, nausea, or a decrease in urine output.
Which of the following treatments is the definitive one for a ruptured aneurysm? a. Antihypertensive medication administration b. Aortogram c. Beta-adrenergic blocker administration d. Surgical intervention
d. Surgical intervention When the vessel ruptures, surgery is the only intervention that can repair it. Administration of antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm.
After examining a 75-year-old male client, the nurse writes down "barrel chest." What does this finding suggest? a. The client has a history of smoking. b. The client has osteoporosis. c. The client has long-standing respiratory disease. d. This is a change associated with aging.
d. This is a change associated with aging.
The nurse sees that the client will breathe deeply and then stop breathing for a short while. Which of the following does this observation suggest? a. This client is hyperventilating. b. This client is in a diabetic coma. c. This client has pneumonia. d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.
d. This is seen in aging people, people with heart failure, and people who have suffered brain damage.
What is the primary reason for administering morphine to a client with myocardial infarction? a. To sedate the client b. To decrease the client's pain c. To decrease the client's anxiety d. To decrease oxygen demand on the client's heart
d. To decrease oxygen demand on the client's heart Morphine is administered because it decreases myocardial oxygen demand. Morphine will also decrease pain and anxiety while causing sedation, but isn't primarily given for those reasons.
Describe Tachypnea
respirations > 35 clinical significance/contributing factors: - respiratory failure - response to fever - anemia - pain - respiratory infection - anxiety (emergencies SNS system kicks in)
Describe the clinical signs of RIGHT sided heart failure.
weight gain distended neck veins hepatomegaly and splenomegaly dependent peripheral edema
