Vascular and MS Study Guide Questions

A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min

31 drops/min

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

c. Occupational therapist (The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.)

A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.

a. Compare the results with previous pulmonary artery pressure readings. (Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although this clients readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications. There is no need to increase intravenous fluids or notify the provider.)

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

a. Heart rate of 34 beats/min c. Urine output less than 30 mL/hr d. Decreased level of consciousness (Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.)

Which action does the nurse delegate to experienced unlicensed assistive personnel (UAP) working in the cardiac catheterization laboratory? a. Assess preprocedure medications the client took that day. b. Have the client sign the consent form before the procedure is performed. c. Educate the client about the need to remain on bedrest after the procedure. d. Obtain client vital signs and a resting electrocardiogram (ECG).

d. Obtain client vital signs and a resting electrocardiogram (ECG) (Vital signs and 12-lead ECGs can be obtained by UAP. The health care provider will explain the catheterization procedure and have the client sign the consent form. Assessments and client teaching should be done by the RN.)

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. I get short of breath when I climb stairs. b. I see halos floating around my head. c. I have trouble remembering things. d. I have lost weight over the past month.

a. I get short of breath when I climb stairs. (Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other findings are not specific to early occurrence of heart failure.)

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Tape a halo wrench to the clients vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the clients oral fluid intake. e. Assess the chest and back for skin breakdown.

a. Tape a halo wrench to the clients vest. b. Assess the pin sites for signs of infection e. Assess the chest and back for skin breakdown

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

a. Assess for allergies to iodine b. Administer intravenous fluids c. Assess blood urea nitrogen (BUN) and creatinine results. (If the client has kidney disease (as indicated by BUN and creatinine results), fluids and Mucomyst may be given 12 to 24 hours before the procedure for renal protection. The client should be assessed for allergies to iodine, including shellfish; the contrast medium used during the catheterization contains iodine. A Foley catheter and central venous catheter are not required for the procedure and would only increase the clients risk for infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.)

The nurse is educating a group of women about the differences in symptoms of myocardial infarction (MI) in men versus those in women. Which information should be included? a. Men do not tend to report chest pain. b. Men are more likely than women to die after MI. c. Men more than women tend to deny the importance of symptoms. d. Women may experience extreme fatigue and dizziness as sole symptoms.

d. Women may experience extreme fatigue and dizziness as sole symptoms. (Women may have atypical symptoms, including absence of chest pain. Women often present with a "triad" of symptoms. In addition to indigestion or a feeling of abdominal fullness, chronic fatigue despite adequate rest and feeling an inability to "catch the breath" (dyspnea) are also common in heart disease. The client may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or vise-like. Men do report chest pain. Women have higher mortality from MI than men. Because of differences in symptoms, denial may occur more often in women.)

Which statement reflects correct cardiac physical assessment technique? a. Auscultate the aortic valve in the second intercostal space at the right sternal border. b. Evaluate for orthostatic hypotension by moving the client from a standing to a reclining position. c. Palpate the apical pulse over the third intercostal space in the midclavicular line. d. Assess for carotid bruit by auscultating over the anterior neck.

a. Auscultate the aortic valve in the second intercostal space at the right sternal border. (The aortic valve is auscultated at the second intercostal space at the right sternal border. Orthostatic hypotension is measured when a person moves from a reclining to a standing position. The apical pulse is palpated over the fifth intercostal space in the midclavicular line. A bruit is assessed by auscultating the carotid artery in the neck.)

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

a. Auscultated stridor (Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.)

After teaching a client with a spinal cord tumor, the nurse assesses the clients understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. Even though turning hurts, I will remind you to turn me every 2 hours. b. Radiation therapy can shrink the tumor but also can cause more problems. c. Surgery will be scheduled to remove the tumor and reverse my symptoms. d. I put my affairs in order because this type of cancer is almost always fatal. e. My family is moving my bedroom downstairs for when I am discharged home.

a. Even though turning hurts, I will remind you to turn me every 2 hours. b. Radiation therapy can shrink the tumor but also can cause more problems. e. My family is moving my bedroom downstairs for when I am discharged home. (Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.)

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

c. A 45-year-old male with osteoarthritis (Osteoarthritis causes changes to support structures, increasing the clients risk for low back pain. The other clients are not at high risk.)

A client who is suffering dyspnea on exertion and congestive heart failure will likely report which symptom during the health history? a. Fatigue b. Swelling of one leg c. Slow heart rate d. Brown discoloration of lower extremities

a. Fatigue (Although fatigue in itself is not diagnostic of heart disease, many people with heart failure are limited by leg fatigue during exercise. Fatigue that occurs after mild activity and exertion usually indicates inadequate cardiac output (due to low stroke volume) and anaerobic metabolism in skeletal muscle. Unilateral swelling is more typical with a local finding such as deep vein thrombosis, not a systemic problem such as heart failure. Tachycardia, rather than bradycardia, develops with heart failure and decreased cardiac output. Brown discoloration of the lower extremities is indicative of long-standing venous stasis, such as occurs with varicose veins.)

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

a. Heart rate of 120 beats/min (When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.)

After teaching a client with a spinal cord injury, the nurse assesses the clients understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. Ill use my incentive spirometer every 2 hours while Im awake. b. Ill drink thinned fluids to prevent choking. c. Ill take cough medicine to prevent excessive coughing. d. Ill position myself on my right side so I don't aspirate.

a. I'll use my incentive spirometer every 2 hours while I'm awake (Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowlers position to prevent aspiration.)

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

a. Location A (The aortic valve is auscultated in the second intercostal space just to the right of the sternum.)

Which client has the highest risk for cardiovascular disease? a. Man who smokes and whose father died at 49 of myocardial infarction (MI) Correct b. Woman with abdominal obesity who exercises three times per week c. Woman with diabetes whose high-density lipoprotein (HDL) cholesterol is 75 mg/dL d. Man who is sedentary and reports four episodes of strep throat

a. Man who smokes and whose father died at 49 of myocardial infarction (MI) (Smoking is a major risk factor for MI, and family history is a stronger risk factor than hypertension, obesity, diabetes, or sudden cardiac death. Although abdominal obesity is a risk factor, exercising three times weekly is not. Diabetes is a major risk factor for MI; however, HDL cholesterol of 75 mg/dL is in the optimal range of greater than 55 mg/dL. Sedentary lifestyle is a risk factor but is not a major risk. Frequent strep infections may be associated with valvular disease rather than coronary artery disease.)

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. Participate in an exercise program to strengthen muscles. b. Purchase a mattress that allows you to adjust the firmness. c. Wear flat instead of high-heeled shoes to work each day. d. Keep your weight within 20% of your ideal body weight.

a. Participate in an exercise program to strengthen muscles. (Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.)

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the clients coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

a. Spiritual beliefs c. Family support d. Level of independence f. Previous coping strategies (Information about the clients preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the clients level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the clients spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.)

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade

a. Thromophlebitis c. Pulmonary embolism e. Cardiac tamponade (Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart catheterizations. Stroke and myocardial infarction are complications of left-sided heart catheterizations.)

A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL

a. Total cholesterol: 280 mg/dL c. Triglycerides: 200 mg/dL e. Low-density lipoprotein cholesterol: 160 mg/dL (A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density lipoprotein cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.)

Which laboratory findings are consistent with acute coronary syndrome (ACS)? (Select all that apply.) a. Troponin 3.2 ng/mL b. Myoglobin 234 mcg/L c. C-reactive protein 13 mg/dL d. Triglycerides 400 mg/dL e. Lipoprotein-a 18 mg/dL

a. Troponin 3.2 ng/mL Correct b. Myoglobin 234 mcg/L (Normal troponin should be less than 0.03 ng/mL. Normal myoglobin should be less than 90 mcg/L. Normal C-reactive protein should be less than 1 mg/dL; however, this tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides should be less than 150 mg/dL; however, this tests for risk for CAD, not ACS. Normal lipoprotein-a is 18 mg/dL; however, this tests for risk for CAD, not ACS.)

Which statement by the client with a recent cardiovascular diagnosis indicates maladaptive denial? a. "I don't know how I am going to change my lifestyle." b. "I don't need to change. It hasn't killed me yet." Correct c. "I don't think it is as bad as the doctors say." d. "I will have to change my diet and exercise more."

b. "I don't need to change. It hasn't killed me yet." (A common and normal response is denial, which is a defense mechanism that enables the client to cope with threatening circumstances. He or she may deny the current cardiovascular condition, may state that it was present but is now absent, or may be excessively cheerful. Denial becomes maladaptive when the client is noncompliant or does not adhere to the interdisciplinary plan of care. The statement about not changing because "it hasn't killed me yet" indicates maladaptive denial. Not knowing how to change indicates that the client is overwhelmed, not in denial. Not thinking it is that bad indicates denial, but not maladaptive denial. Changing diet and exercising more indicates a willingness to change.)

A client who is to undergo cardiac catheterization should be taught which essential information by the nurse? a. "Monitor the pulses in your feet when you get home." Incorrect b. "Keep your affected leg straight for 2 to 6 hours." c. "Do not take your blood pressure medications on the day of the procedure." d. "Take your oral hypoglycemic with a sip of water on the morning of the procedure."

b. "Keep your affected leg straight for 2 to 6 hours." (The client will remain in bed and the affected leg must remain straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding. The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure; therefore, antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating; they are not taken when the client is NPO for procedures or surgery.)

An RN and an LPN/LVN, both of whom have several years of experience in the intensive care unit, are caring for a group of clients. Which client is appropriate for the RN to assign to the LPN/LVN? a. A client with pulmonary edema who requires hourly monitoring of pulmonary artery wedge pressures b. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index c. A client who has intermittent chest pain and requires teaching about myocardial nuclear perfusion imaging d. A client with acute coronary syndrome who has just been admitted and needs an admission assessment

b. A client who was admitted with peripheral vascular disease and needs assessment of the ankle-brachial index. (The scope of practice of the LPN/LVN includes assessment of blood pressure in the arm and lower extremity. The scope of practice for the LPN/LVN does not include interpretation of hemodynamic monitoring results. The scope of practice of the RN includes providing client education; the LPN/LVN may reinforce that teaching. The role of the professional nurse is to perform assessment and develop the plan of care; the LPN/LVN may implement the plan.)

Which statement about diagnostic cardiovascular testing is correct? a. Complications of coronary arteriography include stroke, nonlethal dysrhythmias, arterial bleeding, and thromboembolism. b. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. c. Holter monitoring allows periodic recording of cardiac activity during an extended period of time. d. The left side of the heart is catheterized first and may be the only side examined.

b. An alternative to injecting a medium into the coronary arteries is intravascular ultrasonography. (Intravascular ultrasonography is an alternative to the medium injection method of diagnostic cardiovascular testing. Lethal, not nonlethal, dysrhythmias are a complication of diagnostic cardiovascular testing. Holter monitoring allows periodic recording of cardiac activity during short periods of time. Several parts of the heart are examined during diagnostic cardiovascular testing.)

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this clients discharge teaching? a. Take warm baths to promote muscle relaxation. b. Avoid crowds and people with colds. c. Relying on a walker will weaken your gait. d. Take prescribed medications when symptoms occur.

b. Avoid crowds and people with colds (The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the clients symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.)

Which signs and symptoms are seen with suspected pericarditis? (Select all that apply.) a. Squeezing, vise-like chest pain b. Chest pain relieved by sitting upright Correct c. Chest and abdominal pain relieved by antacids d. Sudden-onset chest pain relieved by anti-inflammatory agents Correct e. Pain in the chest described as sharp or stabbing

b. Chest pain relieved by sitting upright d. Sudden-onset chest pain relieved by anti-inflammatory agents Correct e. Pain in the chest described as sharp or stabbing (The pain of pericarditis is relieved when sitting upright or forward, may appear abruptly, and is relieved by anti-inflammatory agents. The inflammatory pain of pericarditis tends to be sharp, stabbing, and related to breathing; squeezing, vise-like chest pain is characteristic of myocardial infarction. Chest and abdominal pain relieved by antacids is characteristic of peptic ulcer.)

Which client should the charge nurse assign to a graduate RN who has completed 2 months of orientation to the coronary care unit? a. Client with a new diagnosis of heart failure who needs a pulmonary artery catheter inserted b. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes c. Client with acute electrocardiographic changes who is requesting nitroglycerin for left anterior chest pain d. Client who has many questions about the electrophysiology studies (EPS) scheduled for today

b. Client who has just arrived after a coronary arteriogram and has vital signs requested every 15 minutes. (The client returning from angiography is stable, requiring vital signs and checks of the insertion site every 15 minutes; this is within the scope of practice of a newly licensed RN. An experienced critical care nurse is needed to assist with insertion of a pulmonary artery catheter for hemodynamic monitoring. A client with electrocardiographic changes is potentially unstable; the experienced nurse will need to monitor the electrocardiogram, administer nitroglycerin, and identify additional interventions as needed. The experienced critical care nurse needs to provide extensive teaching about the invasive procedure of EPS; the newly licensed nurse just off orientation may not have the depth of knowledge to perform this teaching independently.)

Which client has pain most consistent with myocardial infarction (MI) requiring notification of the health care provider? a. Client with abdominal pain and belching b. Client with pressure in the mid-abdomen and profound diaphoresis c. Client with dyspnea on exertion (DOE) and inability to sleep flat who sleeps on four pillows d. Client with claudication and fatigue

b. Client with pressure in the mid-abdomen and profound diaphoresis. (Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety. Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.)

The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4 L/min. Which action should be taken by the nurse? a. No intervention is needed; this is a normal reading. b. Collaborate with the health care provider to administer a positive inotropic agent. c. Administer a STAT dose of metoprolol (Lopressor). d. Ask the client to perform the Valsalva maneuver.

b. Collaboate with the health care provider to administer a positive inotropic agent. (A positive inotropic agent will increase the force of contraction (stroke volume [SV]), thus increasing cardiac output (CO). Recall that SV × HR = CO (heart rate [HR]). Normal cardiac output is 4 to 7 L/min. The beta blocker metoprolol (Lopressor) has side effects of bradycardia and decreased contractility; cardiac output would be further reduced. The Valsalva maneuver, or bearing down, will decrease the heart rate and thus cardiac output.)

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. Are you taking a nonsteroidal anti-inflammatory drug? b. Do you have a mental health disorder? c. Are you able to swallow medications? d. Do you smoke cigarettes or any illegal drugs?

b. Do you have a mental health disorder? (Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.)

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.

b. Document the finding (The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.)

Which of these factors contribute to the risk for cardiovascular disease? (Select all that apply.) a. Consuming a diet rich in fiber b. Elevated C-reactive protein levels c. Low blood pressure d. Elevated high-density lipoprotein (HDL) cholesterol level e. Smoking

b. Elevated C-reactive protein levels e. Smoking (Elevation in C-reactive protein, suggestive of inflammation, is a risk factor for atherosclerosis and cardiac disease. Smoking cessation should be emphasized; smoking is a major modifiable risk factor for cardiovascular disease. A diet rich in fiber is not a risk factor for cardiovascular disease; rather, it is a desirable behavior. Hypertension, not low blood pressure, is a risk for cardiovascular disease. Elevated low-density lipoprotein cholesterol is a risk for atherosclerosis; elevated HDL cholesterol is desirable and may be cardioprotective.)

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

c. Nystagmus (Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.)

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

b. Fatigue despite adequate rest c. Indigestion e. Shortness of breath (Women may not have chest pain with myocardial infarction, but may feel discomfort or indigestion. They often present with a triad of symptomsindigestion or feeling of abdominal fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their breath. Frequently, women are not diagnosed and therefore are not treated adequately. Hypertension and abdominal pain are not associated with acute coronary syndrome.)

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

b. Initiation of an external pacemaker (The RCA supplies the right atrium, the right ventricle, the inferior portion of the left ventricle, and the atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client. Furosemide, intubation, and central venous access will not address the primary complication of RCA occlusion, which is AV node malfunction.)

The nurse is caring for a client with an arterial line. How does the nurse recognize that the client is at risk for insufficient perfusion of body organs? a. Right atrial pressure is 4 mm Hg. b. Mean arterial pressure (MAP) is 58 mm Hg. c. Pulmonary artery wedge pressure (PAWP) is 7 mm Hg. d. PO2 is reported as 78 mm Hg.

b. Mean arterial presure (MAP) is 58 mmHg (To maintain tissue perfusion to vital organs, the MAP must be at least 60 mm Hg. A MAP of between 60 and 70 mm Hg is necessary to maintain perfusion of major body organs such as the kidneys and brain. An arterial line will not measure atrial pressure, PAWP, or oxygenation. Normal right atrial pressure is 1 to 8 mm Hg. Normal PAWP is 4 to 12 mm Hg. A normal PO2 is greater than 75 mm Hg.)

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

b. Methylprednisolone (Medol) (Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.)

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema? a. I wake up to go to the bathroom at night. b. My shoes fit tighter by the end of the day. c. I seem to be feeling more anxious lately. d. I drink at least eight glasses of water a day.

b. My shoes fit tighter by the end of the day. (Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse should note whether the client feels that his or her shoes or rings are tight, and should observe, when present, an indentation around the leg where the socks end. The other answers do not describe edema.)

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.

b. Notify the health care provider before scheduling the MRI. (The magnetic fields of the MRI can deactivate the pacemaker. The nurse should call the health care provider and report that the client has a pacemaker so the provider can order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes, or increased fluids.)

The nurse is reviewing the medical record of a client admitted with heart failure. Which laboratory result warrants a call to the health care provider by the nurse for further instructions? a. Calcium 8.5 mEq/L b. Potassium 3.0 mEq/L c. Magnesium 2.1 mEq/L d. International normalized ratio (INR) of 1.0

b. Potassium 3.0 mEq/L (Normal potassium is 3.5 to 5.0 mEq/L; hypokalemia may predispose to dysrhythmia, especially if the client is taking digitalis preparations. A normal calcium level is 8.5 to 10.5 mEq/L. A normal magnesium level is 1.7 to 2.4 mEq/L. INR of 1.0 reflects a normal value.)

A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination. ANS: B, D, E

b. Prepare for continuous blood pressure and pulse monitoring. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination. (Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours prior to the procedure. Education about dobutamine, which will be administered during the procedure, should be performed. Beta blockers are often held prior to the procedure.)

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this clients constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

b. Provide a diet high in fluids and fiber. d. Implement a consistent daily time for elimination f. Perform manual disimpaction (For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.)

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor

b. Serum potassium level of 2.9 mEq/L d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor (In the first few hours postprocedure, the nurse monitors for complications such as bleeding from the insertion site, hypotension, acute closure of the vessel, dye reaction, hypokalemia, and dysrhythmias. The clients blood pressure is slightly elevated but does not need immediate action. Warmth and redness at the site would indicate an infection, but this would not be present in the first few hours.)

All of this information is obtained by the nurse who is admitting a client for a coronary arteriogram. Which information is most important to report to the health care provider before the procedure begins? a. The client has had intermittent substernal chest pain for 6 months. b. The client develops wheezes and dyspnea after eating crab or lobster. c. The client reports that a previous arteriogram was negative for coronary artery disease. d. The client has peripheral vascular disease, and the dorsalis pedis pulses are difficult to palpate.

b. The client develops wheezes and dyspnea after eating crab or lobster. (The contrast agent injected into the coronary arteries during the arteriogram is iodine-based; the client with a shellfish allergy is likely to have an allergic reaction to the contrast and should be medicated with an antihistamine or a steroid before the procedure. The reason the client is having the procedure is to determine whether atherosclerotic plaque obstructing the coronary arteries is the underlying cause of the chest pain; the intermittent substernal chest pain does not need to be reported to the provider. The provider does not need information about the previous arteriogram at this time; it is nice to know, but does not change the current need for the procedure. The nurse will palpate the distal pulses after the procedure; they can be assessed with a Doppler device and marked in ink. Therefore, this information is not needed before the procedure is performed.)

After a cardiac catheterization, the client should increase his or her fluid intake for which reason? a. NPO status will cause the client to be thirsty. b. The dye causes an osmotic diuresis. c. The dye contains a heavy sodium load. d. The pedal pulses will be more easily palpable.

b. The dye causes an osmotic diuresis. (The dye is osmotically heavy, causing increased urine output, possible decreased blood flow to the kidney, and renal impairment. Although the client may report thirst while NPO, the reason to increase fluids is related to osmotic diuresis from the contrast medium. The contrast medium is iodine-based. Although maintaining fluid volume may make pulses more obvious, this is not the reason to encourage fluids.)

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this clients postoperative instructions? a. Only lift items that are 10 pounds or less. b. Wear your brace whenever you are out of bed. c. You must remain in bed for 3 weeks after surgery. d. You are prescribed medications to prevent rejection.

b. Wear your brace whenever you are out of bed. (Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.)

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you wont need to change your diet.

b. You should balance weight loss with consuming necessary nutrients. (Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and improve cardiac health. The nurse should encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with client education, the nurse should include nutrition education and assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both important components in reducing cardiovascular risk.)

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma b. A 32-year-old Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy

c. A 45-year-old American Indian woman with diabetes mellitus (The incidence of coronary artery disease and hypertension is higher in American Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for hypertension and coronary artery disease in people of any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do not increase risk for cardiovascular disease.)

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this clients plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

c. Apply a heating pad for 20 minutes at least four times daily. (Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.)

A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.

c. Assess the client's medications. (Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.)

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as left pedal pulse of +1/4.

c. Assess the color and temperature of the left leg. Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The pulse may be faint because of edema. The left pulse should be compared with the right, and pulses should be compared with previous assessments, especially before the procedure. Assessing color (pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data are acquired, the primary health care provider should be notified. Simply documenting the findings is inappropriate. The leg should be positioned below the level of the heart or dangling to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not address the clients problem.)

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

c. Bradycardia (Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.)

A client with heart failure reports a 7.6-pound weight gain in the past week. What intervention does the nurse anticipate from the health care provider? a. Dietary consult b. Sodium restriction c. Daily weight monitoring d. Restricted activity

c. Daily weight monitoring (A sudden weight increase of 2.2 pounds (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. It is possible for weight gains of up to 10 to 15 pounds (4.5 to 6.8 kg, or 4 to 7 L of fluid) to occur before excess fluid accumulation (edema) is apparent. The weight change is most likely from excessive fluid, so a dietary consult, sodium restrictions, and restricted activity are not appropriate interventions.)

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm

c. Disorientation and confusion (In older adults, disorientation or confusion may be the major manifestation of myocardial infarction caused by poor cardiac output. Pain manifestations and numbness and tingling of the arm could also be related to the myocardial infarction. However, the nurse should be more concerned about the new onset of disorientation or confusion caused by decreased perfusion.)

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. I will explore other ways besides intercourse to please my partner. b. I will not be able to have an erection because of my injury. c. Ejaculation may not be as predictable as before. d. I may urinate with ejaculation but this will not cause infection. e. I should be able to have an erection with stimulation.

c. Ejaculation may not be as predictable as before d. I may urinate with ejaculation but this will not cause infection e. I should be able to have an erection with stimulation (Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the clients partner will not get an infection.)

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache (Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.)

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

c. Lumbar puncture for cerebrospinal fluid sampling (A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.)

A nurse assesses a client with a spinal cord injury at level T5. The clients blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker.

c. Palpate the bladder for distention. (The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.)

A client recovering from cardiac angiography develops slurred speech. What does the nurse do first? a. Maintains NPO (nothing by mouth) until this resolves b. Calls in another nurse for a second opinion c. Performs a complete neurologic assessment and notifies the health care provider d. Explains to the client and family that this is expected after sedation

c. Performs a complete neurologic assessment and notifies the health care provider (Based on this assessment, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness should be reported immediately for prompt intervention. Be confident in this decision; this assessment does not warrant a second opinion. Keeping the client NPO and waiting for symptoms to resolve is not appropriate. Slurred speech is not expected after sedation.)

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the clients hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

c. Re-position the client off of the reddened areas. e. Obtain a low-air-loss mattress to minimize pressure (Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the clients risk of respiratory complications but will not decrease pressure on the clients hips and sacrum.)

A 72-year-old client admitted with fatigue and dyspnea has elevated levels of all of these laboratory results. Which finding is consistent with acute coronary syndrome (ACS) and should be communicated immediately to the health care provider? a. White blood cell count b. Low-density lipoproteins c. Serum troponin I level d. C-reactive protein

c. Serum troponin I level (Elevation in serum troponin levels is associated with acute myocardial injury and indicates a need for immediate interventions such as angioplasty, anticoagulant administration, or administration of fibrinolytic medications. The white blood cell count does not reflect ACS; a mild leukocytosis may occur secondary to inflammation, but this does not constitute an emergency. Although elevated lipoproteins may have contributed to development of atherosclerosis, which is the cause of ACS, the results are not emergent. C-reactive protein indicates inflammation and is increased in people at risk for atherosclerosis and ACS, but it does not indicate an acute problem.)

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

c. Slurred speech and confusion. (A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status needs to be acted on immediately. Discomfort and bruising are expected at the site. If intake decreases, a client can become dehydrated because of dye excretion. The second intervention would be to increase the clients fluid status. Neurologic changes would take priority.)

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? a. This is a routine surgery and the risk of death is very low. b. Would you like to speak with a chaplain prior to surgery? c. Tell me more about your concerns about the surgery. d. What support systems do you have to assist you?

c. Tell me more about your concerns about the surgery. (The nurse should discuss the clients feelings and concerns related to the surgery. The nurse should not provide false hope or push the clients concerns off on the chaplain. The nurse should address support systems after addressing the clients current issue.)

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better. How should the nurse respond? a. If you dont want to participate in the rehabilitation program, Ill let the provider know. b. Rehabilitation programs have helped many clients with your injury. You should give it a chance. c. The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability. d. When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first.

c. The rehabilitation program will teach you how to maintain the functional ablity you have and prevent further disability. (Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this clients needs.)

Which statement best reflects correct client education for a client with a blood pressure of 136/86 mm Hg? a. This blood pressure is good because it is a normal reading. b. This blood pressure indicates that the client has hypertension or high blood pressure. c. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. d. This blood pressure seems a little low; the client should be further assessed for orthostatic hypotension.

c. This blood pressure increases the workload of the heart; the client should consider modifying his or her lifestyle. (Although not considered hypertension because the blood pressure is not greater than 140/90 mm Hg, it is consistent with increased risk for heart disease; the client requires further education. Hypertension is defined as blood pressure greater than 140/90 mm Hg. A blood pressure that exceeds 135/85 mm Hg increases the workload of the left ventricle and oxygen consumption of the myocardium. Orthostatic hypotension is defined as blood pressure less than 90/60 mm Hg.)

A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?

c. What do you understand about what happened to you? (Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse should ask the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the clients misconception about recent pain and the cause of that pain.)

The nurse is teaching a client about the purpose of electrophysiology studies (EPS). Which statement by the nurse reflects the most correct teaching? a. "This is a noninvasive test performed to assess your heart rhythm." b. "You will receive an injection of dobutamine (Dobutrex) and will walk on a treadmill to reveal whether you have coronary artery disease." c. "This is a painless test that is done to assess the structure of your heart using sound waves." d. "This test evaluates you for potentially fatal cardiac rhythms."

d. "This test evaluates you for potentially fatal cardiac rhythms." (EPS are invasive tests performed to determine whether the client has lethal dysrhythmias and conduction abnormalities. A noninvasive test to assess the heart rhythm best describes the electrocardiogram. Injection of dobutamine (Dobutrex) followed by walking on a treadmill best describes an exercise stress test. Using sound waves to assess the structure of the heart best describes echocardiography.)

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest, (All clients who have chest pain should be assessed more thoroughly. To determine which client should be seen first, the nurse must understand common differences in pain descriptions. Intense stabbing, vise-like substernal pain that spreads through the clients chest, arms, jaw, back, or neck is indicative of a myocardial infarction. The nurse should plan to see this client first to prevent cardiac cell death. A dull ache with numbness in the fingers is consistent with anxiety. Pain that gets worse with inspiration is usually related to a pleuropulmonary problem. Pain that spreads to the abdomen is often associated with an esophageal-gastric problem, especially when this pain is experienced by a male client. Female clients may experience abdominal discomfort with a myocardial event. Although clients with anxiety, pleuropulmonary, and esophageal-gastric problems should be seen, they are not a higher priority than myocardial infarction.)

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

d. Allergies to iodine-based agents. (Before the procedure, the nurse should ascertain whether the client has an allergy to iodine-containing preparations, such as seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening reaction, so it is a high priority. Second, it is important for the nurse to assess anxiety, mobility, and baseline cardiac status.)

A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis

d. Bladder palpated above pubis (A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.)

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

d. Evaluate respiratory status. (The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.)

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

d. Impairment of respiratory muscles (In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.)

The nurse is caring for a client with hemodynamic monitoring. Right atrial pressure is 8 mm Hg. The nurse anticipates which request by the health care provider? a. Saline infusion b. Morphine sulfate c. No treatment, continue monitoring d. Intravenous furosemide

d. Intravenous furosemide (Normal right atrial pressure is 0 to 5 mm Hg; thus the health care provider may prescribe furosemide, a diuretic, to reduce the fluid volume and right atrial pressure. Administering saline will increase the right atrial fluid balance and pressure. Morphine is indicated to reduce preload, measured by left ventricular end-diastolic pressure or left atrial pressure. Because this is an abnormal finding, the nurse should collaborate with the provider to decrease the right atrial pressure.)

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

d. Methylpredisolone (Medrol) (Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.)

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

d. Place the client in a gown that has cloth ties instead of metal snaps (Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.)

A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min

d. Pulse decreased from 100 beats/min to 80 beats/min (Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.)

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this clients teaching? a. Stroke the inner aspect of your thigh to initiate voiding. b. Use a clean technique for intermittent catheterization. c. Implement digital anal stimulation when your bladder is full. d. Tighten your abdominal muscles to stimulate urine flow.

d. Tighten your muscles to stimulate urine flow. (In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.)

A client has been admitted to the hospital with chest pain radiating down the left arm. The pain has been unrelieved by rest and antacids. Which test result best confirms that the client sustained a myocardial infarction? a. C-reactive protein of 1 mg/dL b. Homocysteine level of 13 mmol/L c. Creatine kinase (CK) of 125 mg/dL d. Troponin of 5.2 ng/mL

d. Toponin of 5.2 ng/mL (The presence of elevated troponin indicates myocardial damage; normal troponin should be less than 0.03 ng/mL. A C-reactive protein level lower than 1 mg/dL is optimal for identifying inflammation and risk for heart disease. A homocysteine level lower than 12 mmol/dL is optimal, but elevation indicates risk, not myocardial damage. CK totals must be broken down into isoenzyme MB to evaluate for heart damage. Elevations in the CK total may be caused by stroke or skeletal muscle damage.)

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.

d. Use pillows to elevate your head and chest while you are sleeping. (The client is experiencing orthopnea (shortness of breath while lying flat). The nurse should teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a client with orthopnea.)

The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential? a. Auscultate the client's precordium for murmurs. b. Teach the client about the reason for the TEE. c. Reassure the client that the test is painless. d. Validate that the client has remained NPO.

d. Validate that the client has remained NPO. (Owing to the risk for aspiration, the client must be NPO before the procedure. It is anticipated that the client with mitral stenosis may have an audible murmur; auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test because it is uncomfortable.)

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, I do not want to be placed on a mechanical ventilator. How should the nurse respond? a. You should discuss this with your family and health care provider. b. Why are you afraid of being placed on a breathing machine? c. Using the incentive spirometer each hour will delay the need for a ventilator. d. What would you like to be done if you begin to have difficulty breathing?

d. What would you like to be done if you begin to have difficulty breathing? (ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the clients needs.)