NVCC NUR 222 Test 3 Study Questions – Flashcards
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A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? a. Regular insulin b. Glipizide (Glucotrol) c. Repaglinide (Prandin) d. Metformin (Glucophage)
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Answer: D Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.
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The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics? a. Sinus bradycardia b. Sick sinus syndrome c. Normal sinus rhythm d. First degree heart block
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Answer: C Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively
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A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse? a. Call a code b. Call the HCP c. Check the client's status and lead placement d. Press the recorder button on the electrocardiogram console
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Answer: C Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.
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A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? a. Sensation of palpitations b. Causative factors, such as caffeine c. Precipitating factors, such as infection d. Blood pressure and oxygen saturation
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Answer: D Premature ventricular contractions can cause hemodynamic compromise. Therefore, the priority is to monitor the blood pressure and oxygen saturation. The shortened ventricular filling time can lead to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia, or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.
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The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse? a. Blood pressure b. Status of airway c. Oxygen flow rate d. Level of consciousness
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Answer: B Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
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The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse immediately would assess which item based on priority? a. Anxiety level of the client and family b. Presence of a Medic-Alert card for the client to carry c. Knowledge of restrictions of postdischarge physical activity d. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
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Answer: D The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.
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A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 second, the QRS complex measures 0.08 second, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? a. Sinus dysrhythmia b. Sinus tachycardia c. Sinus bradycardia d. Normal sinus rhythm
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Answer: B Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.
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The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? a. The neurovascular status is normal because of increased blood flow through the leg. b. The neurovascular status is moderately impaired, and the surgeon should be called. c. The neurovascular status is slightly deteriorating and should be monitored for another hour. d. The neurovascular status is adequate from an arterial approach, but venous complications are arising.
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Answer: A An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations.
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The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was unsuccessful? a. Rising blood pressure b. Clearly audible heart sounds c. Client expression of relief d. Rising central venous pressure
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Answer: D Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant.
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A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? a. Stable angina b. Variant angina c. Unstable angina d. Nonanginal pain
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Answer: B Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.
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The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? a. Flat neck veins b. A pulse rate of 60 beats/minute c. Muffled or distant heart sounds d. Wheezing on auscultation of the lungs
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Answer: C Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade.
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The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? a. "I need to be sure not to go barefoot around the house." b. "If I cut my toenails, I need to be sure that I cut them straight across." c. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." d. "I need to be sure that I elevate my leg above my heart level for at least an hour every day."
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Answer: D Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in options 1, 2, and 3 are correct statements.
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The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? a. Bananas b. Broccoli c. Antacids d. Cantaloupe
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Answer: C The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
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The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? a. Use nail polish to protect the nail beds from injury. b. Stop smoking because it causes cutaneous vasospasm. c. Wear gloves for all activities involving use of both hands. d. Always wear warm clothing even in warm climates to prevent vasoconstriction.
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Answer: B Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. Options 1 and 4 are incorrect. It is not necessary to wear gloves for all activities.
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The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? a. Keep the legs aligned with the heart. b. Elevate the legs higher than the heart. c. Clean the skin with alcohol every hour. d. Position the client onto the side every shift.
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Answer: B In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention.
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The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which condition? a. Heart failure b. Atrial fibrillation c. Myocardial infarction d. Ventricular tachycardia
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Answer: C Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, ventricular tachycardia, or atrial fibrillation.
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The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding? a. Hypotension b. Flat neck veins c. Complaints of nausea d. Complaints of headache
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Answer: A The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output owing to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
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The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. Listening to lung sounds b. Monitoring for organomegaly c. Assessing for jugular vein distention d. Assessing for peripheral and sacral edema
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Answer: A The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.
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The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding? a. A normal finding b. Indicative of atrial flutter c. Indicative of atrial fibrillation d. Indicative of impending reinfarction
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Answer: A The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
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The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? a. Anxiety related to the need to make lifestyle changes b. Boredom resulting from having already learned the material c. An attempt to ignore or deny the need to make lifestyle changes d. Lack of understanding of the material provided at the teaching session and embarrassment about asking questions
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Answer: C Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.
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A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? a. A stage 1 ulcer b. A vascular ulcer c. An arterial ulcer d. A venous stasis ulcer
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Answer: C Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.
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The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider will most likely prescribe which option? a. Maintain bed rest b. Maintain the affected leg in a dependent position c. Administer an opioid analgesic every 4 hours around the clock d. Apply cool packs to the affected leg for 20 minutes every 4 hours
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Answer: A Standard management for the client with DVT includes bed rest; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen (Tylenol).
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A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse to describe the procedure. Which response should the nurse make? a. "It involves tying off the veins so that circulation is redirected in another area." b. "It involves surgically removing the varicosity, so anesthesia will be required." c. "It involves tying off the veins to prevent sluggishness of blood from occurring." d. "It involves injecting an agent into the vein to damage the vein wall and close it off."
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Answer: D Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with the use of a hook and wires applied through multiple small incisions in the leg. Other treatments include the application of radiofrequency (RF) energy, in which the vein is heated from the inside by the RF energy and shrinks; collateral veins nearby take over. Laser treatment is another alternative to surgery; in this treatment a laser fiber is used to heat and close the main vessel that is contributing to the varicosity.
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A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client? a. "Apply warm packs to the leg." b. "Keep the leg elevated as much as possible." c. "Contact your health care provider right away to report this problem." d. "This normally occurs after surgery and will subside when the edema goes down."
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Answer: C A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. Options 1, 2, and 4 are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration.
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The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse should provide which information to the client? a. Oxygen has a calming effect. b. Oxygen will prevent the development of any thrombus. c. Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle. d. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.
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Answer: D The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.
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A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? a. "I need to cut down on cigarette smoking." b. "I am so relieved that my heart is repaired." c. "I need to adhere to my dietary restrictions." d. "I am so relieved that I can eat anything I want to now."
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Answer: C After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.
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The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu? a. Tea b. Cola c. Coffee d. Raspberry juice
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Answer: D A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI.
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The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question? a. Where is the pain located b. "Are you having any nausea?" c. "Are you allergic to any medications?" d. "Do you have your nitroglycerin with you?"
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Answer: A If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. Although options 2, 3, and 4 all may be components of the assessment, none of these questions would be the initial assessment question with this client.
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The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? a. "I'll need to become a strict vegetarian." b. "I should use polyunsaturated oils in my diet." c. "I need to substitute eggs and whole milk for meat." d. "I should eliminate all cholesterol and fat from my diet."
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Answer: B The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
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A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? a. "I'm not supposed to eat cold cuts." b. "I can have most fresh fruits and vegetables." c. "I'm going to weigh myself daily to be sure I don't gain too much fluid." d. "I'm going to have a ham and cheese sandwich and potato chips for lunch."
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Answer: D When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.
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The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL, and fasting blood glucose level of 184 mg/dL. The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? a. age b. hypertension c. hyperlipidemia d. glucose intolerance
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Answer: D Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors to CAD. Age greater than 40 years is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.
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The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? a. "I need to start exercising more to improve my health." b. "I will be sure to keep my appointment with the cardiologist." c. "I don't have anyone to help me with doing heavy housework at home." d. "I think I have a good understanding of what all my medications are for."
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Answer: C To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct option indicate that the client will be successful in these areas.
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The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? a. "I will eat enough daily fiber to prevent straining at stool." b. "I will try to exercise vigorously to strengthen my heart muscle." c. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." d. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."
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Answer: A Standard home care instructions for a client with this problem include, among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.
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A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? a. Ambulates 10 feet farther each day b. Verbalizes the benefits of increasing activity c. Chooses a healthy diet that meets caloric needs d. Sleeps without awakening throughout the night
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Answer: A Each of the options indicates a positive outcome on the part of the client. Both options 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.
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The health care provider has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure? a. Questions the client about allergies to iodine or shellfish b. Has the client sign an informed consent form for an invasive procedure c. Tells the client that the procedure is painless and takes 30 to 60 minutes d. Keeps the client on nothing-by-mouth (NPO) status for 2 hours before the procedure
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Answer: C Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client.
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A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure? a. Eat breakfast just before the procedure. b. Wear firm, rigid shoes, such as workboots. c. Wear loose clothing with a shirt that buttons in front. d. Avoid cigarettes for 30 minutes before the procedure.
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Answer: C The client should wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client should receive nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client should wear rubber-soled, supportive shoes, such as athletic training shoes. The client should avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result.
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A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? a. Chest pain b. Urge to cough c. Warm, flushed feeling d. Pressure at the insertion site
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Answer: A The client is taught to report chest pain or any unusual sensations immediately. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. Because a local anesthetic is used, the client is expected to feel pressure at the insertion site.
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A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? a. Sleep with the head of bed flat. b. Weigh himself or herself on a daily basis. c. Take a double dose of the diuretic if peripheral edema is noted. d. Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs.
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Answer: B The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb in a short period are reported to the health care provider (HCP). The client should sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the HCP.
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A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions? a. "It will really hurt when the catheter is first put in." b. "I will receive general anesthesia for the procedure." c. "I will have to go to the operating room for this procedure." d. "I probably will feel tired after the test from lying on a hard x-ray table for a few hours."
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Answer: D t is common for the client to feel fatigued after the cardiac catheterization procedure. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used. Other preprocedure teaching points include the fact that the procedure is done in a darkened cardiac catheterization room. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.
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A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? a. Apnea monitor b. Oxygen flowmeter c. Telemetry cardiac monitor d. Oxygen saturation monitor
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Answer: D Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.
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A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. What type of angina should the nurse determine that the client is experiencing? a. Stable b. Variant c. Unstable d. Intractable
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Answer: A Stable angina is triggered by a predictable amount of effort or emotion. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy.
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A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse knows that which ECG finding would be an indication of first-degree heart block? a. Presence of Q waves b. Tall, peaked T waves c. Prolonged PR interval d. Widened QRS complex
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Answer: C A prolonged PR interval indicates first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An ECG taken during a pain episode is intended to capture ischemic changes, which also include ST-segment elevation or depression.
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The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? a. "I will avoid using table salt with meals." b. "It is best to exercise once a week for 1 hour." c. "I will take nitroglycerin whenever chest discomfort begins." d. "I will use muscle relaxation to cope with stressful situations."
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Answer: B Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously caused the pain and to take the medication at the first sign of chest discomfort.
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The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina? a. It is most effectively managed by β-blocking agents. b. It has the same risk factors as stable and unstable angina. c. It can be controlled with a low-sodium, high-potassium diet. d. Generally it is treated with calcium-channel-blocking agents
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Answer: D Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium-channel blockers. β-Blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated.
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The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? a. The client is not experiencing dyspnea. b. The client is not experiencing nausea or vomiting. c. The pain has not been relieved by rest and nitroglycerin tablets. d. The client says the pain began while she was trying to open a stuck dresser drawer.
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Answer: C The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety).
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A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer? a. Ad lib activities as tolerated b. Strict bed rest for 24 hours after transfer c. Bathroom privileges and self-care activities d. Unsupervised hallway ambulation for distances up to 200 feet
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Answer: C On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet.
question
A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as the most likely indicator that the client is experiencing complications of this therapy? a. Tarry stools b. Nausea and vomiting c. Orange-colored urine d. Decreased urine output
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Answer: A Thrombolytic agents are used to dissolve existing thrombi, and the nurse should monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood.
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The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking? a. "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." b. "Because most of the damage has already been done, it will be all right to cut down a little at a time." c. "If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." d. "If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."
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Answer: D The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. Options 1, 2, and 3 are incorrect.
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A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? a. Rhonchi b.Wheezes c. Crackles in the bases d. Crackles throughout the lung fields
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Answer: C Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.
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A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? a. Left atrium b. Right atrium c. Left ventricle d. Right ventricle
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Answer: C Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. Options 1, 2, and 4 are not the chambers that are primarily responsible for this disease process although these chambers may become affected as the disease becomes more chronic.
question
A client has experienced a myocardial infarction. The nurse plans care for the client, knowing that the person's chest pain is caused by tissue hypoxia in which layer of the heart? a. Myocardium b. Endocardium c. Parietal pericardium d. Visceral pericardium
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Answer: A The myocardial layer of the heart is damaged when a client experiences a myocardial infarction. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral pericardium are outer layers that protect the heart from injury and infection.
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A client is admitted to the hospital with a diagnosis of mitral stenosis. The narrowing of this valve will impede circulation of blood through which structures? a. Left ventricle to aorta b. Left atrium to left ventricle c. Right atrium to right ventricle d. Right ventricle to pulmonary artery
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Answer: B The mitral valve separates the left atrium from the left ventricle. Options 1, 3, and 4 describe the aortic, tricuspid, and pulmonic valves, respectively.
question
A client is admitted to the hospital with a diagnosis of aortic regurgitation. The nurse plans care for the client, knowing that the failure of the aortic valve to close completely allows blood to flow retrograde through which structures? 1. Aorta to left ventricle 2. Left ventricle to left atrium 3. Right ventricle to right atrium 4. Pulmonary artery to right ventricle
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Answer: A The aortic valve separates the aorta from the left ventricle. Options 2, 3, and 4 describe the mitral, tricuspid, and pulmonic valves, respectively.
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A hospitalized client is experiencing a decrease in blood pressure. The nurse plans care for the client, knowing that this change will have which primary effect on his or her heart? a. decreased heart rate b. Increased contractility c. Decreased myocardial blood flow d. Increased resistance to electrical stimulation
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Answer: C The primary effect of a decrease in blood pressure is reduced blood flow to the myocardium. This in turn decreases oxygenation of the cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase, not decrease, in response to this change. The effects of tissue ischemia lead to decreased contractility over time.
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A hospitalized client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned and takes action, knowing that this level could ultimately lead to which complication? a. Stroke b. Cardiac arrest c. High blood pressure d. Urinary stone formation
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Answer: B The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move back during repolarization. Depolarization is responsible for cardiac contraction. Options 1 and 3 are unrelated to calcium levels. Elevated calcium levels can lead to urinary stone formation. The nurse would take action and contact the health care provider when a calcium level is abnormal.
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A nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? a. Bundle of His b. Purkinje fibers c. Sinoatrial (SA) node d. Atrioventricular (AV) node
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Answer: C The SA node is responsible for initiating electrical impulses that are conducted through the heart. The impulse leaves the SA node and travels down through internodal and interatrial pathways to the AV node. From there, impulses travel through the bundle of His to the right and left bundle branches and then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction system. The ability of this specialized tissue to generate its own impulses is called automaticity.
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A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further research on the anatomy and physiology of the heart? a. "The coronary arteries branch from the aorta." b. "The coronary arteries supply the heart muscle with blood." c. "The left coronary artery provides blood for the left atrium and the left ventricle." d. "The left coronary artery supplies the right atrium and right ventricle with blood."
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Answer: D The left coronary artery divides into the anterior descending artery and the circumflex artery, providing blood for the left atrium and left ventricle. The right coronary artery supplies the right atrium and right ventricle. Options 1, 2, and 3 are correct.
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A nurse is assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. The nurse plans care with the understanding that the heart normally sends out how many liters of blood per minute to the body? a. 2 L/min b. 5 L/min c. 10 L/min d. 15 L/min
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Answer: B he cardiac cycle consists of contraction and relaxation of the heart muscle. The heart normally sends out about 5 L of blood every minute to the body. Therefore, options 1, 3, and 4 are incorrect.
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A nurse is caring for a client who has lost a significant amount of blood as a result of complications of a surgical procedure. The nurse understands that which client assessment will provide the earliest indication of new decreases in fluid volume? a. Pulse rate b. Blood pressure (BP) c. Assessment for edema d. Lung auscultation for crackles
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Answer: A The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Options 3 and 4 indicate an increase in fluid volume. Although the BP will decrease, it is not the earliest indicator.
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A client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. A nurse exercising nearby is correct when the nurse cautions him to check the pulse on only one side, primarily for which reason? a. It is unnecessary to use both hands. b. The client could occlude the trachea. c. The heart rate and blood pressure could drop. d. Feeling dual pulsations may lead to an incorrect measurement.
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Answer: C pplying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to drop reflexively. In addition, the manual pressure could interfere with the flow of blood to the brain, causing possible dizziness and syncope. Although the information in options 1, 2, and 4 may be correct, these are not the primary reasons.
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A nursing student who is researching a medication at the nursing station asks the registered nurse (RN) what an α1-adrenergic receptor is. The RN responds by telling the student that these receptors are found primarily in which peripheral vascular structures and produce which actions? a. The peripheral arteries and veins, and when stimulated cause vasoconstriction b. Arterial and bronchial walls, and when stimulated cause vasodilation and bronchodilation c. The heart, and when stimulated cause an increase in heart rate, atrioventricular (AV) node conduction, and contractility d. Several tissues, and when stimulated cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation
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Answer: A Found in the peripheral arteries and veins, α1-adrenergic receptors cause a powerful vasoconstriction when stimulated. Options 2, 3, and 4 describe β1-, β2-, and α2-adrenergic receptors, respectively.
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A nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin (Lanoxin) notes that the heart rate is 52 beats/min. The nurse should make which interpretation about this information? a. Normal, because of the client's age b. Abnormal, requiring further assessment c. Normal, as a result of the effects of digoxin d. Normal, because this is the reason the client is receiving digoxin
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Answer: B The normal heart rate is 60 to 100 beats/min in an adult. On auscultating a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would report the finding to the health care provider. Digoxin increases the strength and contraction of the heart; it is not used to treat low heart rates. If a low heart rate is noted in a client taking digoxin, the medication is withheld and the health care provider is notified. Options 1, 3, and 4 are incorrect interpretations because the heart rate of 52 beats/min is not normal.
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A client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. In formulating a response, the nurse understands that this effect occurs because of the client's primary need for which increased cardiac response? a. Pulse rate b. Cardiac index c. Cardiac output d. Stroke volume
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Answer: C The client's symptoms are the direct result of the body's attempt to meet the metabolic demands generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital organs of the body. With exercise, these demands increase, and the heart must beat faster (increased heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output for body surface area.
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A nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the HCP is referring to which arteries? a. Circumflex coronary artery b. Right coronary artery (RCA) c. Posterior descending coronary artery (PDA) d. Left anterior descending coronary artery (LAD)
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Answer: D The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The circumflex coronary artery bifurcates from the left coronary artery and supplies the left atrium and the lateral wall of the left ventricle. The RCA supplies the right side of the heart, including the right atrium and right ventricle. The PDA supplies the posterior wall of the heart.
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A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? a. Increased heart rate and increased blood pressure b. Increased heart rate and decreased blood pressure c. Decreased heart rate and increased blood pressure d. Decreased heart rate and decreased blood pressure
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Answer: D Hypothermia decreases the heart rate and the blood pressure because the metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, resulting in decreased heart rate and blood pressure. Therefore, options 1, 2, and 3 are incorrect.
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A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse's response incorporates the information that bearing down or straining would trigger which physical response? 1. Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility 2. Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility 3. Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility 4. Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility
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Answer: A Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. Stimulation of the sympathetic nervous system has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis.
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A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse should respond with which statement? 1. "The work of breathing is increased when the client is anemic." 2. "Blood flows more slowly when the hemoglobin or hematocrit is low." 3. "The body has to work harder to fight infection in the presence of anemia." 4. "Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."
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Answer: D Oxygen is required to meet the metabolic needs of the body. With decreased hemoglobin, such as in iron deficiency anemia, the oxygen-carrying capacity of the blood is less than normal. The client feels the effects of this change as fatigue. Options 1, 2, and 3 are incorrect.
question
Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)? 1. Chloride level of 98 mEq/L 2. Sodium level of 135 mEq/L 3. Potassium level of 6.8 mEq/L 4. Magnesium level of 1.6 mEq/L
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Answer: C Hyperkalemia can cause tall, peaked or tented T waves on the ECG. Levels of potassium 5.0 mEq/L or greater indicate hyperkalemia. Options 1, 2, and 4 are normal levels.
question
A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? 1. Oxygen saturation decreased from 96% to 91%. 2. Pulse rate increased from 80 to 104 beats per minute. 3. Blood pressure decreased from 140/86 to 112/72 mm Hg. 4. Respiratory rate increased from 16 to 19 breaths per minute.
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Answer: D Vital signs that remain near baseline indicate good cardiac reserve with exercise. Only the respiratory rate remains within the normal range. Additionally, it reflects a minimal increase. A pulse rate increase to a rate over 100 beats per minute during mild exercise does not show tolerance, nor does a 5% decrease in oxygen saturation levels. In addition, blood pressure decreasing by more than 10 mm Hg is not a sign indicating tolerance of activity.
question
A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction? 1. Take antibiotics until the chest pain is fully resolved. 2. Take acetaminophen (Tylenol) if the chest pain worsens. 3. Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4. Notify all health care providers (HCP) of the history of infective endocarditis before any invasive procedures.
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Answer: D The client should alert any HCP about the history of infective endocarditis before any procedure that involves instrumentation. The HCP should place the client on prophylactic antibiotics if an invasive procedure is needed. Antibiotics should be taken for the full course of therapy. The client should notify the HCP if chest pain worsens or if dyspnea or other symptoms occur. The client should use a soft toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for bacterial infection.
question
The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client? 1. Use the knee-gatch on the bed. 2. Cover the legs lightly when sitting in a chair. 3. Encourage the client to cross legs when sitting in a chair. 4. Provide pillows for the client to place under the knees as desired.
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Answer: B Covering the legs with a light blanket during sitting promotes warmth and vasodilation of the leg vessels. The nurse plans postoperative measures to prevent venous stasis. These include applying elastic stockings or leg wraps, use of pneumatic compression boots, and discouraging leg-crossing. Clients should be encouraged to perform passive and active range of motion exercises. The knee gatch on the bed and pillows under the knees should be avoided because it places pressure on the blood vessels in the popliteal area, impeding venous return.
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The nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks after hospital discharge. The nurse should include which item in the instructions? 1. Driving is permitted so long as the lap and shoulder seat belts are worn. 2. Lifting should be restricted to objects that do not weigh more than 25 pounds. 3. Use the arms for balance, not weight support, when getting out of bed or a chair. 4. Activities that involve straining may be resumed so long as they do not cause pain.
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Answer: C The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining on the sternum. Typical discharge activity instructions for the first 6 weeks include instructing the client to lift nothing heavier than 5 pounds, to not drive, and to avoid any activities that cause straining. These limitations are to allow for sternal healing, which takes approximately 6 weeks.
question
The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The P waves and QRS complexes are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse interprets the cardiac rhythm to be which rhythm? 1. Sinus bradycardia 2. Sick sinus syndrome 3. Normal sinus rhythm 4. First-degree heart block
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Answer: C Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.
question
A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/min. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse interpret this rhythm? 1. Sinus tachycardia 2. Sinus dysrhythmia 3. Sinus bradycardia 4. Normal sinus rhythm
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Answer: B Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.
question
The nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. No P waves or QRS complexes are seen; instead, the monitor screen shows an irregular wavy line. The nurse interprets that the client is experiencing which rhythm? 1. Sinus tachycardia 2. Ventricular fibrillation 3. Ventricular tachycardia 4. Premature ventricular contractions (PVCs)
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Answer: B Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Sinus tachycardia has a recognizable P wave and QRS. Ventricular tachycardia is a regular pattern of wide QRS complexes. PVCs appear as irregular beats within a rhythm. Each of the incorrect options has a recognizable complex that appears on the monitoring screen.
question
A client with myocardial infarction is experiencing new, multiform premature ventricular contractions (PVCs). Knowing that the client is allergic to lidocaine hydrochloride, the nurse plans to have which medication available for immediate use? 1. Procainamide 2. Digoxin (Lanoxin) 3. Verapamil (Calan SR) 4. Metoprolol (Lopressor)
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Answer: A Procainamide is an antidysrhythmic that may be used to treat ventricular dysrhythmias in clients who are allergic to lidocaine. Digoxin is a cardiac glycoside; verapamil is a calcium-channel blocking agent; metoprolol is a β-adrenergic blocking agent.
question
A client has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). The nurse evaluates this therapy as most effective if the client's PVCs continued to exhibit which finding? 1. Occur in pairs 2. Appear to be multifocal 3. Fall on the second half of the T wave 4. Decrease to a frequency of less than 6 per minute
answer
PVCs are considered dangerous when they are frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the client's cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly dysrhythmias.
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The nurse is assessing the client's condition after cardioversion. Which observation should be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness
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Answer: B Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway, however, is always the highest priority.
question
The home health nurse makes a home visit to a client who has an implantable cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? 1. "If I feel an internal defibrillator shock, I should sit down." 2. "I won't be able to have a magnetic resonance imaging test (MRI)." 3. "My wife knows how to call the emergency medical services (EMS) if I need it." 4. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker."
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Answer: D Clients with an ICD usually continue to receive antidysrhythmic medications after discharge from the hospital. The nurse should stress the importance of continuing to take these medications as prescribed. The nurse should provide clear instructions about the purposes of the medications, dosage schedule, and side effects or adverse effects to report. Clients should sit down if they feel an internal defibrillator shock. They cannot have an MRI because of the possible magnetic properties of the device. Also, knowledge of how to reach EMS is important.
question
A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? 1. Before each P wave 2. Just after each P wave 3. Just after each T wave 4. Before each QRS complex
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Answer: D If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted. A demand pacemaker fires only when needed and should therefore discharge only when no electrical activity is occurring in the client's own heart.
question
A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? 1. Bilateral edema 2. Increased calf circumference 3. Diminished distal peripheral pulses 4. Coolness and pallor of the affected limb
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Answer: B The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication.
question
The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's prescriptions? Select all that apply. 1. Elevation of the right leg 2. Ambulation in the hall every 4 hours 3. Application of moist heat to the right leg 4. Administration of acetaminophen (Tylenol) 5. Monitoring for signs of pulmonary embolism
answer
Answer: A,C,D,E Standard management of the client with deep vein thrombosis includes possible bed rest for 5 to 7 days or as prescribed; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated because it increases the likelihood of dislodgement of the tail of the thrombus, which could travel to the lungs as a pulmonary embolism.
question
A client has been diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse is identifying measures to help the client cope with lifestyle changes needed to control the disease process. The nurse plans to refer the client to which member of the health care team? 1. Dietitian 2. Medical social worker 3. Pain management clinic 4. Smoking-cessation program
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Answer: D Buerger's disease is a vascular occlusive disease that affects the medium and small arteries and veins. Smoking is highly detrimental to the client with Buerger's disease, so stopping smoking completely is recommended. Because smoking is a form of chemical dependency, referral to a smoking-cessation program may be helpful for many clients. For many clients with Buerger's disease, symptoms are relieved or alleviated once smoking stops. A dietitian, a medical social worker, and a pain management clinic are not specifically associated with the lifestyle changes required in this disorder although they may be needed if secondary problems arise.
question
The home health nurse is visiting a client who has had a prosthetic valve replacement for severe mitral valve stenosis. Which statement by the client reflects an understanding of specific postoperative care after this surgery? 1. "I need to count my pulse every day." 2. "I have to do deep breathing exercises every 2 hours." 3. "I threw away my straight razor and bought an electric razor." 4. "I have to go to the bathroom frequently because of my medication."
answer
Answer: C Prosthetic valves require long-term anticoagulation to prevent clots from forming on the "foreign" tissue implanted in the client's body. Anticoagulation therapy requires clients to avoid any trauma or potential means of causing bleeding, such as the use of straight razors. Counting pulse, deep breathing exercises, and going to the bathroom frequently are not specifically related to postoperative care after prosthetic valve replacement.
question
The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. 1. Soak the feet in hot water daily. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.
answer
Aswer: B, D, E Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.
question
The home health nurse visits a client recovering from cardiogenic shock secondary to an anterior myocardial infarction and provides home care instructions to the client. Which statement by the client indicates an understanding of these home care measures? 1. "I exercise every day after breakfast." 2. "I've gained 8 pounds since discharge." 3. "I take an antacid when I experience epigastric pain." 4. "I have planned periods of rest at 10:00 am and 3:00 pm daily."
answer
Answer: D The client recovering from cardiogenic shock secondary to a myocardial infarction will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated myocardial infarction. The complication of cardiogenic shock increases the recovery period for healing. Paced activities with planned rest periods will decrease the chance of experiencing angina or delayed healing. It is best to allow the meal to settle prior to activity in order to improve circulation to the heart during exercise. Epigastric pain or a weight gain of 8 pounds is significant and should be reported to the health care provider, at which point follow-up should occur.
question
A client who had coronary artery bypass surgery states to the home health nurse: "get so frustrated. I can't even do my gardening." The nurse then assesses the client for activity level since the surgery. Which client statement indicates a need for further teaching? 1. "I pace my activities throughout the day." 2. "I plan regular rest periods during the day." 3. "I avoid outdoor physical activity during the heat of the day." 4. "I try to walk immediately after lunch, after I've finished my morning housecleaning."
answer
Exercise is an integral part of the rehabilitation program. It is necessary for optimal physiological functioning and psychological well-being. Postoperative physical rehabilitation must be progressive with planned periods of rest. Exercise tolerance is judged by the client's response, such as heart rate and endurance. Planning regular rest periods, pacing activities, and avoiding outdoor activities during the heat of the day are appropriate client activities. The correct option lacks planned periods of rest, and the client has grouped too many activities in a brief period of time, which will decrease endurance. Also, exercise after meals can decrease the client's tolerance because of shunting of blood to the gastrointestinal tract for digestion.
question
The nurse notes that a client's cardiac rhythm shows absent P waves and no PR interval. How should the nurse interpret this rhythm? 1. Bradycardia 2. Tachycardia 3. Atrial fibrillation 4. Normal sinus rhythm (NSR)
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Answer: C In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is normal and constant. Bradycardia is a slowed heart rate, and tachycardia is a fast heart rate. In NSR a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 seconds in duration, and the QRS interval is 0.06 to 0.10 seconds in duration.
question
The nurse is assigned the care of a client with a diagnosis of heart failure who is receiving intravenous doses of furosemide (Lasix). The client is attached to cardiac telemetry, and the nurse is monitoring the client's cardiac status. The nurse notes that the client's cardiac rhythm has changed to this pattern. The nurse determines that the most likely cause of this cardiac rhythm in the client is which problem? Refer to Figure. 1. Pacemaker dysfunction 2. The presence of hypokalemia 3. The effectiveness of the furosemide 4. An impending myocardial infarction (MI)
answer
Answer: B This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant, or they may occur with myocardial ischemia or MI; heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, a diuretic that causes the excretion of potassium. The most likely cause of the PVCs in this client is hypokalemia. Option 3 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has signs or symptoms of an impending MI.
question
A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on the monitor. The nurse quickly assesses the client, knowing that this rhythm is indicative of which rhythm? Refer to Figure. 1. Atrial fibrillation 2. Ventricular fibrillation (VF) 3. Ventricular tachycardia (VT) 4. Premature ventricular complexes
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Answer: C In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more.
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A nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? 1. 1+ edema 2. 2+ edema 3. 3+ edema 4. 4+ edema
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Answer: A Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, and leg is very swollen.
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The postmyocardial infarction client is scheduled for a technetium 99m ventriculography (multigated acquisition [MUGA] scan). The nurse ensures that which item is in place before the procedure? 1. A Foley catheter 2. Signed informed consent 3. A central venous pressure (CVP) line 4. Notation of allergies to iodine or shellfish
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Answer: B MUGA is a radionuclide study used to detect myocardial infarction and decreased myocardial blood flow, and to determine left ventricular function. A radioisotope is injected intravenously; therefore a signed informed consent is necessary. A Foley catheter and CVP line are not required. The procedure does not use radiopaque dye; therefore allergies to iodine and shellfish are not a concern.
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The nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse should address with the client which most important measure to ensure client safety? 1. Assessing pain 2. Administering vasodilators 3. Avoiding over-the-counter medications 4. Moving slowly from a sitting to a standing position
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Answer: D Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy. Options 1 and 3, although important, are not directly related to the issue of safety.
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A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. Which nursing action should be included in the client's plan of care? 1. Limiting oral and intravenous fluids 2. Measuring the client's pulse each shift 3. Providing the client with short, frequent walks 4. Eliminating sources of caffeine from meal trays
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Answer: D Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Fluid restriction and exercise will not alleviate tachycardia. Option 2 will not decrease the heart rate. Additionally, the pulse should be taken more frequently than each shift.
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A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. Which finding indicates that further preparation is needed for the procedure? 1. The client is wearing a nasal cannula delivering oxygen at 2 L/min. 2. The client's digoxin (Lanoxin) has been withheld for the last 48 hours. 3. The defibrillator has the synchronizer turned on and is set at 50 joules (J). 4. The client has received an intravenous dose of a conscious sedation medication.
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Answer: A During the procedure, any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after the countershock. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation. Energy level typically is set at 50 to 100 J. The client typically receives a dose of an intravenous sedative or antianxiety agent.
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The nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which starting energy range level, depending on the specific health care provider (HCP) prescription? 1. 50 to 100 joules 2. 150 to 300 joules 3. 300 to 350 joules 4. 350 to 400 joules
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Answer: A For cardioversion procedures, the defibrillator is charged to the energy level prescribed by the HCP. Countershock usually is started at 50 to 100 joules. Options 2, 3, and 4 are incorrect.
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A client has developed uncontrolled atrial fibrillation with a ventricular rate of 150 beats/min. What manifestation should the nurse observe for when performing the client's focused assessment? 1. Flat neck veins 2. Nausea and vomiting 3. Hypotension and dizziness 4. Clubbed fingertips and headache
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Answer: C The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
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The nurse has provided self-care activity instructions to a client after insertion of an automatic internal cardioverter-defibrillator (AICD). The nurse determines that further instruction is needed if the client makes which statement? 1. "I can perform activities such as swimming, driving, or operating heavy equipment as I need to." 2. "I need to avoid doing anything that could involve rough contact with the AICD insertion site." 3. "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cutoff on the AICD." 4. "I should keep away from electromagnetic sources such as transformers, large electrical generators, metal detectors, and I shouldn't lean over running motors."
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Answer: A Post discharge instructions typically include avoiding tight clothing or belts over AICD insertion sites; rough contact with the AICD insertion site; and electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert health care providers (HCP) or dentists to the presence of the device because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a HCP regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating heavy equipment.
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A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which fruit? 1. Apples 2. Pears 3. Bananas 4. Cranberries
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Answer: C Triamterene is a potassium-retaining diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, fresh oranges, mangos, nectarines, papayas, and prunes.
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A client is admitted to the hospital with a diagnosis of pericarditis. The nurse should assess the client for which manifestation that differentiates pericarditis from other cardiopulmonary problems? 1. Anterior chest pain 2. Pericardial friction rub 3. Weakness and irritability 4. Chest pain that worsens on inspiration
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Answer: B A pericardial friction rub is heard when inflammation of the pericardial sac is present during the inflammatory phase of pericarditis. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a wide variety of disorders. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy.
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Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse most anticipate in this client if PVCs are occurring? 1. A P wave preceding every QRS complex 2. QRS complexes that are short and narrow 3. Inverted P waves before the QRS complexes 4. Premature beats followed by a compensatory pause
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Answer: D PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.
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PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy. 1. Using a bedside commode 2. Sleeping in the supine position 3. Elevating the legs when in bed 4. Using seasonings to improve the taste of food
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Answer: A Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. The supine position increases respiratory effort and decreases oxygenation. Elevating the client's legs increases venous return to the heart, increasing cardiac workload. This increases cardiac workload. Seasonings may be high in sodium.
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The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? 1. Checking for a rash on the digits 2. Observing for softening of the nails or nail beds 3. Palpating for a rapid or irregular peripheral pulse 4. Palpating for diminished or absent peripheral pulses
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Answer: D Raynaud's disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted.
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The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1. Place in Fowler's position for eating. 2. Encourage coughing with deep breathing. 3. Encourage increased oral intake of water daily. 4. Place thigh-length elastic stockings on the client. 5. Place sequential compression boots on the client. 6. Encourage the intake of dark green, leafy vegetables.
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Answer: B, C, D The client with DVT may require bedrest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism.
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Spironolactone (Aldactone) is prescribed for a client with heart failure. In providing dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which electrolyte? 1. Calcium 2. Potassium 3. Magnesium 4. Phosphorus
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Answer: B Spironolactone (Aldactone) is a potassium-retaining diuretic, and the client should avoid foods high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client does not need to avoid foods that contain calcium, magnesium, or phosphorus while taking this medication.
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A client is seen in the emergency department for complaints of chest pain that began 3 hours ago. The nurse should suspect myocardial injury or infarction if which laboratory value came back elevated? 1. Myoglobin 2. Cardiac troponin 3. C-reactive protein 4. Creatine kinase (CK)
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Answer: B Cardiac troponin elevations indicate myocardial injury or infarction. Although the remaining options may also rise, they are not definitive enough to draw a conclusive diagnosis.
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The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? 1. Walk for as long as possible each day. 2. Cross the legs at the ankle only, not at the knee. 3. Lie down with the legs elevated and avoid sitting. 4. Sit in a chair 3 times a day for 3 hours at a time.
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Answer: C The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days after the procedure. Prolonged standing or sitting increases the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same reason.
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The nurse obtains the vital signs on an older client and notes that the client's heart rate is 60 beats/min and the respiratory rate is 20 breaths per minute. What should the nurse do? 1. Document the findings. 2. Check the client for signs of infection. 3. Recheck the heart and respiratory rates in 30 minutes. 4. Contact the health care provider to report the heart and respiratory rates.
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Answer: A Respiratory rates are generally 16 to 20 breaths per minute. The heart rate usually decreases with age. Therefore, because the data in the question indicate normal findings, the nurse should document the heart rate and respiratory rate. The remaining options are unnecessary based on the data in the question.
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A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question should best help a nurse discriminate pain caused by a noncardiac problem? 1. "Can you describe the pain to me?" 2. "Have you ever had this pain before?" 3. "Does the pain get worse when you breathe in?" 4. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"
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Answer: C Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). The remaining options may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.
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A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. The nurse should plan to allow for which client activity? 1. Strict bed rest for 24 hours after transfer 2. Bathroom privileges and self-care activities 3. Ad lib activities because the client is monitored 4. Unsupervised hallway ambulation with distances under 200 feet
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Answer: B On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Strict bedrest is unnecessary and can be harmful and promote emboli. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).
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A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply. 1. Emotional stress 2. Atrial fibrillation 3. Nutritional anemia 4. Peptic ulcer disease 5. Recent upper respiratory infection
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Answer: A,B,C, E Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia.
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The nurse should recognize that a client who has developed severe pulmonary edema would most likely exhibit which symptom? 1. Mild anxiety 2. Slight anxiety 3. Extreme anxiety 4. Moderate anxiety
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Answer: C Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. Therefore the client will experience extreme anxiety.
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A client with pulmonary edema has been receiving diuretic therapy. The client has a prescription for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), which laboratory result should the nurse review as the priority? 1. Sodium level 2. Digoxin level 3. Creatinine level 4. Potassium level
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Answer: D The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias.
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A nurse is caring for a client with unstable ventricular tachycardia. The nurse should instruct the client to take which action, if prescribed, during an episode of ventricular tachycardia? 1. Lie down flat in bed. 2. Remove any metal jewelry. 3. Breathe deeply, regularly, and easily. 4. Inhale deeply and cough forcefully every 1 to 3 seconds.
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Answer: D Restorative coughing techniques are sometimes used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. The other options will not assist in terminating the dysrhythmia.
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A nurse employed in a cardiac unit determines that which client is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)?
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Answer: C An AICD detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have syncopal episodes related to ventricular tachycardia, those who are refractive to medication therapy, and those who have survived sudden cardiac death unrelated to myocardial infarction.
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A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which activity will assist with preventing dislodgement of the pacing catheter? 1. Limiting both movement and abduction of the left arm 2. Limiting both movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range-of-motion exercises to the right arm
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Answer: B In the first several hours after insertion of a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client's activities of the arm on the side of the insertion site. Therefore, options 1, 3, and 4 are incorrect.
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A client seeks treatment in a health care provider's office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, "Can you tell me again how this sclerotherapy is done?" Which statement would reflect accurate teaching by the nurse? 1. "The varicosity is surgically removed." 2. "The vein is tied off at the upper end to prevent stasis from occurring." 3. "The vein is tied off at the lower end to prevent stasis from occurring." 4. "An agent is injected into the vein to damage the vein wall and close the vein off."
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Answer: D Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removing the vein with hook and wires via multiple small incisions in the leg. Laser treatment is another alternative to surgery and uses a laser fiber to heat and close the main vessel that is contributing to the varicosity. Another less invasive procedure is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein.
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A client is having a follow-up health care provider (HCP) office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which would be an appropriate action by the nurse based on evaluation of the client's comment? 1. Report the complaint to the HCP. 2. Instruct the client to apply warm packs. 3. Reassure the client that this is only temporary. 4. Advise the client to take acetaminophen (Tylenol) until it is gone.
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Answer: A Hypersensitivity or a sensation of pins and needles in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported. Options 2, 3, and 4 are incorrect action and could be harmful; in addition, they delay the possible need for intervention about the client's complaint
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A client is scheduled for a cardiac catheterization using a radiopaque dye. Which assessments are most critical before the procedure? 1. Intake and output 2. Height and weight 3. Allergy to iodine or shellfish 4. Baseline peripheral pulse rates
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Answer: C A cardiac catheterization requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is a concern, and the presence of allergies must be assessed before the procedure. Although the remaining options are accurate, they are not the most critical pre-procedure assessments.
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A nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is most likely unrelated to the aneurysm? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of "heart beating" in the abdomen
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Answer: B Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass.
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A nurse is providing postoperative care for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse should be most concerned about monitoring for which potential complications? 1. Bleeding and infection 2. Thrombosis and infection 3. Bleeding and wound dehiscence 4. Wound dehiscence and evisceration
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Answer: A After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Heparin therapy also predisposes the client to bleeding. Thrombosis is unlikely because the client is on heparin therapy. Wound dehiscence and evisceration are not concerns because no abdominal incision is made.
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A client with angina has a 12-lead electrocardiogram taken during an episode of chest pain. The nurse should examine the tracing for which electrocardiographic (ECG) change caused by myocardial ischemia? 1. Tall, peaked T waves 2. Prolonged PR interval 3. Widened QRS complex 4. ST segment elevation or depression
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Answer: D An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block.
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A nurse is preparing to ambulate a client on the third day after cardiac surgery. What should the nurse plan to do to enable the client to best tolerate the ambulation? 1. Remove telemetry equipment. 2. Provide the client with a walker. 3. Premedicate the client with an analgesic. 4. Encourage the client to cough and breathe deeply.
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Answer: C The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Providing the client with a walker and encouraging the client to cough and breathe deeply will not help in tolerating ambulation. Removal of telemetry equipment is contraindicated unless prescribed.
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A client with rapid-rate atrial fibrillation asks a nurse why the health care provider is going to perform carotid sinus massage. Which is a correct explanation? 1. The vagus nerve slows the heart rate. 2. The diaphragmatic nerve slows the heart rate. 3. The diaphragmatic nerve overdrives the rhythm. 4. The vagus nerve increases the heart rate, overdriving the rhythm.
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Answer: A Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. Others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm. The remaining options 2, 3, and 4 are incorrect descriptions of this procedure.
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A nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is non-reddened, with no apparent drainage. The client's temperature is 99° F orally. The white blood cell count is 7500 cells/mm3. How should the nurse interpret these findings? 1. Incision is slightly edematous but shows no active signs of infection. 2. Incision shows early signs of infection, although the temperature is nearly normal. 3. Incision shows no sign of infection, although the white blood cell count is elevated. 4. Incision shows early signs of infection, supported by an elevated white blood cell count.
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Answer: A Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. An elevated temperature and white blood cell count 3 to 4 days postoperatively usually indicate infection. Therefore, option 1 is correct.
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A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. Based on this observation, what should the nurse plan to do next? 1. Review intake and output records for the last 2 days. 2. Prescribe daily weights starting on the following morning. 3. Request a sodium restriction of 1 g/day from the health care provider. 4. Change the time of diuretic administration from morning to evening.
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Answer: A Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Therefore, the nurse should review intake and output records for the last 2 days. Strict sodium restrictions are reserved for clients with severe symptoms. Diuretics should be given in the morning whenever possible to avoid nocturia.
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The nurse is evaluating a client's cardiac rhythm strip to determine if there is proper function of the VVI mode pacemaker. Which denotes proper functioning? 1. Spikes precede all P waves and QRS complexes. 2. There are consistent spikes before each P wave. 3. Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. 4. Spikes occur before all QRS complexes regardless of intrinsic ventricular activity.
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Answer: C When a pacemaker is operating in the VVI mode, pacemaker spikes will be observed before the QRS complex if the client does not have their own intrinsic beat; therefore options 1, 2, and 4 are incorrect.
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The nurse determines that a client requires further teaching after permanent pacemaker insertion if which statement is made? 1. "My pulse rate should be less than what my pacemaker is set at." 2. "I'll need to call my health care provider if I feel tired or dizzy." 3. "I'll have to avoid carrying the grocery bags into the house for the next 6 weeks." 4. "It's safe to use my microwave as long it is properly grounded and well shielded."
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Answer: A The client should call the health care provider if the pulse rate is less than what the pacemaker is set at because this could be a sign of pacemaker or battery failure. Option 1 indicates the client needs further teaching, whereas options 2, 3, and 4 are correct statements.
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Which locations is the correct position for the V1 lead when performing a 12-lead electrocardiogram? 1. Fourth intercostal space left sternal border 2. Fourth intercostal space right sternal border 3. Fifth intercostal space left midaxillary line 4. Fifth intercostal space left midclavicular line
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Answer: B The correct location for the V1 electrode is the fourth intercostal space right sternal border. Therefore, options 1, 3, and 4 are incorrect.
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After instruction on the application of antiembolism stockings, the nurse determines that the client requires further teaching if which of these actions is performed? 1. The client puts on the stockings before getting out of bed. 2. The client bunches up the stockings for easier application. 3. The client ensures that stockings are pulled all the way up. 4. The client makes sure the rough seams of the stockings are on the outside.
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Answer: B When applying antiembolism stockings the client should not bunch up the stockings. Instead the client should place the hand inside the stocking and pull the heel out. The foot of the stocking should then be placed over the client's foot and the rest of the stocking pulled up the leg. This will help to prevent wrinkling and twisting of the stocking. Options 1, 3, and 4 demonstrate correct application of the stockings.
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During assessment of a client newly diagnosed with hypertension, the nurse recognizes that which is a common occurrence? 1. Be asymptomatic 2. Be short of breath 3. Have visual disturbances 4. Have frequent nosebleeds
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Answer: A Hypertensive clients often have no symptoms until target organ involvement, which happens with very high blood pressure. This is why it is often noted as the "silent killer." Options 2, 3, and 4 are incorrect because those clinical manifestations occur with severely high hypertension.
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The nurse monitors the client for which condition as a complication of polycythemia vera? 1. Thrombosis 2. Hypotension 3. Cardiomyopathy 4. Pulmonary edema
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Answer: A Polycythemia vera is a disorder of the bone marrow. It results in excessive production of white blood cells, red blood cells, and platelets. Clients with polycythemia vera are also more likely to form blood clots that can cause thrombi, strokes, myocardial infarctions, and abnormal bleeding. Clients with polycythemia are hypertensive; therefore option 2 is incorrect. Options 3 and 4 are not concerns with this disorder.
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A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor. Which is the nurse's first action? 1. Check the blood pressure. 2. Call the health care provider. 3. Check the client and the chest leads. 4. Initiate cardiopulmonary resuscitation (CPR).
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Answer: C This type of pattern on the cardiac monitor indicates either ventricular fibrillation or lead displacement. The first action of the nurse is always to check the client and the chest leads. If the client is nonresponsive and the leads are not the problem, then option 4 would be the next choice, along with contacting the health care provider.
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Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? 1. Monitor oxygen saturation with pulse oximetry. 2. Assess activity tolerance before and after exercise. 3. Observe the client's cardiac rhythm with telemetry. 4. Assess peripheral pulses with an ultrasonic Doppler device.
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Answer: D Acute arterial insufficiency is associated with interruption of arterial blood flow to an organ, tissue, or extremity. It is associated with an acutely painful pasty-colored leg. The priority is for the nurse to perform a comprehensive assessment of peripheral circulation. When pulses are difficult to palpate, the Doppler device is useful to determine the presence of blood flow to the area. The Doppler directs sound waves toward the artery being examined, which emits an audible sound. The nurse must document that the pulse was present via Doppler and not palpation. Although options 1, 2, and 3 may be components of the assessment, they are not the priority.
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A client's electrocardiogram shows that the atrial and ventricular rhythms are irregular and there are no discernible P waves. The nurse recognizes that this pattern is associated with which condition? 1. Atrial flutter 2. Atrial fibrillation 3. Third-degree AV block 4. First-degree atrioventricular (AV) block
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Answer: B With atrial fibrillation, the atrial and ventricular rhythms are irregular and there are usually no discernible P waves. In atrial flutter, the QRS complexes may be either regular or irregular, and the P waves occur as flutter waves. A client in third-degree AV block (also known as complete heart block) has regular atrial and ventricular rhythms, but there is no connection between the P waves and the QRS complexes. In other words, the PR interval is variable and the QRS complexes are normal or widened, with no relationship with the P waves. With first-degree AV block the PR interval is longer than normal, and there is a connection between the occurrence of P waves and that of QRS complexes.
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The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which is in the client's hospital room as a priority item? 1. Over-bed trapeze 2. Dry sterile dressings 3. Surgical tourniquet 4. Incentive spirometer
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Answer: C Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items considering the surgical procedure that the client underwent.
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An emergency room nurse is performing a cardiovascular assessment on a client. During auscultation of the heart sounds, the nurse hears these abnormal sounds.
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The sound that the nurse hears is the fourth heart sound (S4). Diastolic filling sounds or gallops (S3, the third heart sound, and S4, the fourth heart sound) are produced when there is decreased compliance of either or both ventricles. S3 is termed ventricular gallop, and S4 is referred to as atrial gallop. The S4 sound occurs in the later stage of diastole, during atrial contraction and active filling of the ventricles. It is a soft, low-pitched sound and is heard immediately before S1. An atrial gallop is found most commonly in disorders involving increased stiffness of the ventricle, such as ventricular hypertrophy, ischemia, and fibrosis. S4 is never heard in the absence of atrial contraction (atrial fibrillation). S4 is best heard with the bell of the stethoscope at the apex, with the client in the supine, left lateral position. The presence of S4 may also result from myocardial infarction, hypertension, hypertrophy, fibrosis, cardiomyopathy, cor pulmonale, aortic stenosis, or pulmonic stenosis. Therefore options 1, 2, and 4 are incorrect.
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A nurse is caring for a postoperative client who has lost a significant amount of blood because of complications during a surgical procedure. Which assessment finding would be indicative of further fluid volume deficit? 1. +4 Edema noted in lower extremities 2. Crackles auscultated from lung bases to apices 3. Blood pressure rises from 116/68 to118/74 mm Hg 4. Pulse rate increases from 100 beats/min to 136 beats/min
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Answer: D The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. An increase in the pulse rate compensates for decreases in fluid volume. Options 1 and 2 may be noted in fluid overload. A low blood pressure is expected in a postoperative client who lost a significant amount of blood.
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A nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse to make which conclusion? 1. The cardiac output is above the normal range. 2. The cardiac output is below the normal range. 3. The cardiac output is in the low-normal range. 4. The cardiac output is in the high-normal range.
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Answer: B The normal cardiac output for the adult can range from 4 to 7 L/min. Therefore a cardiac output of 3.2 L/min is below normal range.
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A nurse is auscultating a 56 year old adult client's apical heart rate before giving digoxin (Lanoxin) and notes that the heart rate is 48 beats/minute. Which action should the nurse take? 1. Withhold the digoxin, and reevaluate the heart rate in 4 hours. 2. Administer half the prescribed dose to avoid a further decrease in heart rate. 3. Withhold the digoxin; assess for signs of decreased cardiac output and digoxin toxicity. 4. Administer the digoxin. The heart rate would be considered normal because of the client's age.
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Answer: C The normal heart rate is 60 to 100 beats/min in an adult. If the nurse notes a heart rate that is less than 60 beats/min, the nurse would not administer the digoxin and would further evaluate the client for signs and symptoms of digoxin toxicity. When clients are bradycardic, they may have symptoms of decreased cardiac output so this would also be assessed.
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A nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which vital signs? 1. Increased heart rate and increased blood pressure 2. Increased heart rate and decreased blood pressure 3. Decreased heart rate and increased blood pressure 4. Decreased heart rate and decreased blood pressure
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Answer: D he heart rate and blood pressure are decreased because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases. Therefore options 1, 2, and 3 are incorrect.
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A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? 1. Ascites 2. Pedal edema 3. Bilateral lung crackles 4. Jugular vein distention
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Answer: C The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Adventitious breath sounds, such as crackles, are an indicator of decreased left-sided heart function. Peripheral edema, jugular vein distention, and ascites all can be present because of insufficiency of the pumping action of the right side of the heart.
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A client with angina complains that the anginal pain is prolonged, severe, and occurs at the same time each day, most often in the morning. On further assessment, the nurse notes that the pain occurs in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? 1. Stable angina 2. Variant angina 3. Unstable angina 4. Nonanginal pain
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Answer: B Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, usually in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity than those that previously precipitated the angina. Unstable angina also occurs at rest, is less predictable, and is often a precursor of myocardial infarction.
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A client's total cholesterol level is 344 mg/dL, low-density lipoprotein cholesterol (LDL-C) level is 164 mg/dL, and high-density lipoprotein cholesterol (HDL-C) level is 30 mg/dL. Based on analysis of the data, how should the nurse direct client teaching? 1. The client should maintain the current dietary regimen but increase activity level. 2. Results are inconclusive unless the triglyceride level is also screened, so teaching is not indicated at this time. 3. The client is at high risk for cardiovascular disease, and measures to modify all identified risk factors should be taught. 4. The client is at low risk for cardiovascular disease, so the client should be encouraged to continue to follow the current regimen.
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In the absence of documented cardiovascular disease, the desired goal is to have the total cholesterol level lower than 200 mg/dL. A desired LDL-C level for all individuals is lower than 100 mg/dL, and a desirable HDL-C level is higher than 40 mg/dL. Because the client's levels are outside the range for all three values to a significant degree, the client is at high risk for developing cardiovascular disease and requires teaching on risk factor reduction.
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An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates the client needs additional education? 1. "It is important that I limit protein intake." 2. "I need to maintain a regular exercise program." 3. "I understand that I need to avoid adding salt to foods." 4. "It is important that I begin reducing and then maintaining weight."
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Answer: A Obesity and sodium intake are modifiable risk factors for hypertension. These are of the utmost importance because they can be changed or modified by the individual through a regular exercise program and careful monitoring of sodium intake. Protein intake has no relationship to hypertension.
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A nurse identifies that a client is having occasional premature ventricular contractions (PVCs) on the cardiac monitor. The nurse reviews the client's laboratory results and determines that which result would be consistent with the observation? 1. Serum sodium level of 145 mEq/L 2. Serum chloride level of 98 mEq/L 3. Serum calcium level of 10 mg/dL 4. Serum potassium level of 2.8 mEq/L
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Answer: D The nurse should check the client's serum laboratory study results for hypokalemia. The client may experience PVCs in the presence of hypokalemia, because this electrolyte imbalance increases the electrical instability of the heart. The values noted in the remaining options are normal.
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The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing
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Answer: C Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign.
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The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1. Immunoglobulin 2. Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer
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Answer: D Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay. Options 1, 2, and 3 would not help to confirm the diagnosis of rheumatic fever.
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On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin
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Answer: C Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.
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The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the need for further instructions? 1. "I will not mix the medication with food." 2. "I will take my child's pulse before administering the medication." 3. "If more than one dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."
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Answer: D Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered.
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The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula
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Answer: A The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?Rationale: Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the most appropriate method in an infant and places the infant at risk for infection.
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The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances
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Answer: C Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.
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The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instructions? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."
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Answer: B The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.
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A child with rheumatic fever will be arriving in the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"
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Answer: D Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A b-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever.
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A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing
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Answer: D Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.
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Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition. 1. Aortic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect
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Answer: C A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles.
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The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1. Prone position 2. Knee-chest position 3. High Fowler's position 4. Reverse Trendelenburg's position
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Answer: B The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position?
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The nurse is monitoring an infant with heart failure (HF). Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider (HCP)? a. Bradypnea 2. Diaphoresis 3. Decreased blood pressure 4. A weight gain of 1 lb in 1 day
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Answer: D HF is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. A weight gain of 0.5 kg (1 lb) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the HCP. Tachypnea and increased blood pressure occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and usually occurs with exertional activities.
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A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1. Anxiety 2. A temper tantrum 3. A hypercyanotic episode 4. The need for immediate health care provider (HCP) notification
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Answer: C Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate HCP notification is not required unless other appropriate nursing interventions are unsuccessful. Options 1 and 2 are unrelated to tetralogy of Fallot.
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The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1. "The child may return to school in 1 week." 2. "The child will not be able to return to school during this academic year." 3. "The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4. "The child may return to school in 3 weeks but needs to go half-days for the first few days."
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Answer: D After heart surgery, the child may return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months. Options 1, 2, and 3 are incorrect.
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A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? 1. Elevated antistreptolysin O (ASO) titer 2. Decreased erythrocyte sedimentation rate (ESR) 3. Negative result on antinuclear antibody (ANA) assay 4. Negative result on C-reactive protein (CRP) determination
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Answer: A In the presence of rheumatic fever, the child will exhibit an elevated ASO titer, an elevated ESR, leukocytosis, and a positive result on CRP determination. A positive result on ANA testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and also will be positive with rheumatic fever.
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A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever? a. Presence of Aschoff's bodies 2. Absence of C-reactive protein 3. Presence of Reed-Sternberg cells 4. Decreased antistreptolysin O titer
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Answer: A Rheumatic fever develops after a group A β-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptolysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.
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The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. a. Presence of Aschoff's bodies 2. Absence of C-reactive protein 3. Elevated antistreptolysin O titer 4. Presence of Reed-Sternberg cell 5. Elevated erythrocyte sedimentation rate
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Answer: A, C, E Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.
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Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? a. Prevents blue (tet) spells 2. Maintains adequate cardiac output 3. Maintains an adequate hormonal level 4. Maintains the position of the great arteries
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Answer: B A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output. The remaining options are incorrect. In addition, tet spells occur in tetralogy of Fallot, not in transposition of the great arteries
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A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin (Lanoxin). The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/min. Which action should the nurse take? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Withhold the medication and notify the health care provider.
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Answer: C The apical pulse rate for a 1-year-old infant is 90 to 130 beats/min. Because the apical rate is normal, options 1, 2, and 4 are incorrect.
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The nurse is assessing a newborn with heart failure before administering the prescribed digoxin (Lanoxin). In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 2.4 ng/mL and an apical heart rate of 98 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1. Retake the apical pulse. 2. Administer the medication. 3. Withhold the medication for 1 hour. 4. Withhold the medication and notify the health care provider.
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Answer: D The apical pulse rate for a newborn is 120 to 140 beats/min. The therapeutic digoxin level ranges from 0.5 to 2.0 ng/dL. Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider. Therefore options 1, 2, and 3 are incorrect.
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A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication.
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Answer: A Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider. Therefore, options 2, 3, and 4 are incorrect actions; it would be harmful to administer the medication.
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The nurse is developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include to monitor the child for signs of which condition? 1. Bleeding 2. Failure to thrive 3. Heart failure (HF) 4. Decreased tolerance to stimulation
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Answer: C Nursing care initially centers on observing for signs of HF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distention. Options 1, 2, and 4 are not conditions directly associated with this disorder.
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The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever (RF) who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action is most appropriate? 1. Administer the aspirin if the child's temperature is elevated. 2. Administer the aspirin if the child experiences any joint pain. 3. Consult with the health care provider to verify the prescription. 4. Administer acetaminophen (Tylenol) for temperature elevation.
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Answer: C Anti-inflammatory agents, including aspirin, may be prescribed for the child with RF. Aspirin should not be given to a child who has chickenpox or other viral infections. Therefore, the nurse should consult with the health care provider to verify the prescription. The nurse would not administer acetaminophen (Tylenol) without specific health care provider's prescriptions. Options 1 and 2 are not appropriate actions.
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A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the initial action by the nurse? 1. Place the infant in a prone position. 2. Call a code and notify the supervisor. 3. Place the infant in a knee-chest position. 4. Contact the respiratory therapy department.
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Answer: C If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia. Therefore, options 1, 2, and 4 are incorrect.
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A nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure (HF)? 1. Paleness of the skin 2. Strong sucking reflex 3. Diaphoresis during feeding 4. Slow and shallow breathing
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Answer: C The early symptoms of HF include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding. Paleness of the skin, pallor, may be noted in the infant with HF, but it is not an early symptom. A strong sucking reflex is unrelated to the development of HF.
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The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic findings 3. Bluish discoloration of the skin 4. Higher than normal body weight
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Answer: C The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Options 1 and 2 are inaccurate findings. Many children with a left-to-right shunt may remain asymptomatic. Option 4 is incorrect because these children usually have lower than normal body weight.
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The nurse is collecting data on a child with a diagnosis of rheumatic fever (RF). Which question should the nurse initially ask the mother of the child? 1. "Has the child been vomiting?" 2. "Has the child had any diarrhea?" 3. "Does the child complain of chest pain and numbness in the right arm?" 4. "Has the child complained of a sore throat within the past few months?"
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Answer: D RF characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child or any family members have had a sore throat or unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.
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A nurse is reviewing the health record of an infant with a diagnosis of congenital heart disease. The nurse notes documentation in the record that the infant has clubbing of the fingers. The nurse understands that this finding is caused by which problem? 1. Chronic fatigue 2. Poor oxygenation 3. Poor sucking ability 4. Consistent sucking on the fingers
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Answer: B The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. Options 1, 3, and 4 are unrelated to this occurrence.
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A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching? 1. "Quiet activities are allowed." 2. "The child should play inside for now." 3. "Visitors are not allowed for 1 month." 4. "The regular schedule for naps is resumed."
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Visitors without signs of any infection are allowed to visit the child. The mother should be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge. Options 1, 2, and 4 are accurate instructions regarding activity following heart surgery.
