NCLEX 3500: Cardiac

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Following a myocardial infarction, a client develops an arrhythmia and requires a continuous infusion of lidocaine. To monitor the effectiveness of the intervention, the nurse should focus primarily on the client’s:
1. electrocardiogram (ECG).
2. urine output.
3. creatine kinase (CK) and troponin levels.
4. blood pressure and heart rate.
Correct Answer: 1
RATIONALES: Lidocaine is an antiarrhythmic and is given for the treatment of cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is a reduction in or disappearance of ventricular arrhythmias as seen on an ECG. Urine output is an indicator of pump effectiveness; CK and troponin levels monitor myocardial damage. Blood pressure and heart rate measurements are too nonspecific to help determine the effectiveness of parenteral lidocaine.
A client is admitted to the emergency department after complaining of acute chest pain radiating down his left arm. Which laboratory studies would be indicated?
1. Hemoglobin and hematocrit
2. Serum glucose
3. Creatinine phosphokinase (CPK)
4. Troponin T and troponin I
5. Myoglobin
6. Blood urea nitrogen (BUN)
Correct Answer: 3,4,5
RATIONALES: Levels of CPK, troponin T, and troponin I elevate because of cellular damage. Myoglobin elevation is an early indicator of myocardial damage. Hemoglobin, hematocrit, serum glucose, and BUN levels don’t provide information related to myocardial ischemia.
A client is admitted to an acute care facility with pneumonia. When auscultating heart sounds, the nurse notes a fixed split of the second heart sound (S2) — a pathological split that doesn’t vary with respirations. A fixed S2 split is the hallmark of:
1. right bundle-branch block.
2. left bundle-branch block.
3. atrial septal defect.
4. aortic stenosis.
Correct Answer: 3
RATIONALES: A fixed S2 split is the hallmark of atrial septal defect. This split, which is continuous and doesn’t vary with respirations, results from prolonged emptying of the right ventricle. A right bundle-branch block causes a wide S2 split that is louder on inspiration than on expiration; this split results from delayed depolarization of the right ventricle and late pulmonic valve closure. Left bundle-branch block, aortic stenosis, and patent ductus arteriosus cause a paradoxical S2 split. Heard only on expiration, a paradoxical S2 split results from delayed aortic valve closure.

A client with an acute myocardial infarction is receiving nitroglycerin (Tridil) by continuous I.V. infusion. Which statement by the client indicates that this drug is producing its therapeutic effect?
1. “I have a bad headache.”
2. “My chest pain is decreasing.”
3. “I feel a tingling sensation around my mouth.”
4. “My blood pressure must be up because my vision is blurred.”
Correct Answer: 2
RATIONALES: Nitroglycerin, a vasodilator, increases the arterial supply of oxygen-rich blood to the myocardium, thus producing its intended effect: relief of chest pain. Headache is an adverse effect of nitroglycerin. The drug shouldn’t cause a tingling sensation around the mouth and should lower, not raise, blood pressure.
A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
1. negative history of tonic-clonic seizures.
2. ampule of naloxone (Narcan) at the bedside.
3. continuous electrocardiogram (ECG) monitoring.
4. up-to-date partial thromboplastin time (PTT) result in his record.
Correct Answer: 4
RATIONALES: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation and, thereby, reduces cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date PTT result available. The drug isn’t contraindicated in clients with a seizure history. Abciximab isn’t an opioid; therefore, an opioid antagonist doesn’t need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn’t a requirement for administering abciximab.
The telemetry unit nurse is caring for a client who was just transferred from the coronary care unit (CCU). The client is anxious because he fears he won’t be monitored as closely as he was in the CCU. How can the nurse allay his fears?
1. Assign the same nurse to the client when possible.
2. Allow the client uninterrupted periods of rest as much as possible.
3. Limit the client’s visitors to coincide with CCU visiting policy.
4. Move the client to a room far from the nurses’ station to reduce his exposure to noise.
Correct Answer: 1
RATIONALES: Assigning the same nurse to the client when possible provides continuity of care and stability, thereby reducing his anxiety. The client needs uninterrupted periods of rest; however, providing as much rest as possible may leave the client feeling isolated. Feelings of isolation can increase the client’s anxiety, and having visitors can help distract the client. A room close to nurses’ station would provide this client with a sense of security because the nurses are close by in the event of an emergency.
Before administering digoxin (Lanoxin), a nurse reviews information about the drug. She learns that after digoxin is metabolized, the body eliminates remaining digoxin as unchanged drug by way of the:
1. lungs.
2. kidneys.
3. feces.
4. skin.
Correct Answer: 2
RATIONALES: After digoxin is metabolized, the kidneys eliminate remaining digoxin as unchanged drug. Therefore, a
client with renal dysfunction will require a decreased digoxin dosage. Although some drugs may be eliminated by other routes, digoxin isn’t known to be eliminated by way of the lungs, feces, or skin.
The nurse determines that a hockey player hospitalized with bilateral leg fractures is hemodynamically stable and observes the following pattern on the electrocardiogram (ECG) monitor. Which nursing intervention is most appropriate at this time?
1. None; this arrhythmia is benign
2. Administering atropine sulfate, 0.5 mg, as prescribed, to increase the heart rate
3. Continuing to monitor for lengthening PR intervals
4. Evaluating the client’s recent serum electrolyte studies
Correct Answer: 1
RATIONALES: This ECG shows sinus arrhythmia with a rate of 70 beats/minute. In this benign arrhythmia, the rhythm is irregular; the impulse originates in the sinoatrial node and travels down the conduction system normally. The P-P interval is irregular; a P wave precedes every QRS complex; and the R-R interval is irregular, increasing with inspiration and decreasing with expiration. Sinus arrhythmia commonly is associated with vagal inhibition caused by respiration. It seldom causes symptoms and doesn’t call for atropine or other treatment. Continuing to monitor for lengthening PR intervals isn’t necessary because the PR interval doesn’t increase with sinus arrhythmia. Because this arrhythmia isn’t caused by an electrolyte imbalance, evaluating serum electrolyte studies isn’t warranted.
The nurse would advise the client with an axillofemoral bypass graft to avoid:
1. standing for prolonged periods.
2. tight belts.
3. reclining and instead sit in a chair for prolonged periods.
4. upper-extremity exercises.
Correct Answer: 2
RATIONALES: Tight belts around the waist can occlude the axillofemoral bypass; the client should use suspenders instead. Prolonged sitting can kink the femoral portion of the graft. Prolonged standing and upper-extremity exercises need not be avoided.
The nurse administers basic cardiac life support to a client in cardiac arrest. Which action does the nurse perform?
1. Assessing the patency of the airway
2. Administering I.V. medications
3. Administering a countershock of 200 joules
4. Breathing for the client after inserting an endotracheal (ET) tube
Correct Answer: 1
RATIONALES: A nurse certified in basic cardiac life support can assess airway patency. I.V. medications given to maintain blood pressure, correct acidosis, or restore a cardiac rhythm are administered by a provider of advanced cardiac life support. Administering a countershock of 200 joules and breathing for the client after inserting an ET tube are measures carried out during advanced life support.
The nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client’s blood pressure, which is 84/50 mm Hg. It’s time for the nurse to administer the client’s medications: nitroglycerin, metoprolol (Lopressor), and furosemide (Lasix). Which action is best taken by the nurse?
1. Withhold the medications and notify the physician.
2. Administer the medications immediately.
3. Encourage the client to sit up and eat breakfast.
4. Administer the nitroglycerin and metoprolol and withhold the furosemide.
Correct Answer: 1
RATIONALES: The nurse should withhold the three medications and notify the physician. Each of these medications has the potential to lower the client’s blood pressure. Administering them together when the client is already hypotensive may severely lower the client’s blood pressure. The client may continue to experience dizziness when sitting up so breakfast should be held until his blood pressure stabilizes.
A client with a permanent pacemaker and a long history of cardiac disease is admitted to the coronary care unit for evaluation for heart failure. The nurse observes the following electrocardiogram (ECG) pattern. What does this pattern indicate?
1. Use of a DDD pacemaker with a rate of 78 beats/minute
2. Use of a VVI pacemaker with a rate of 72 beats/minute
3. Use of an AVI pacemaker with a rate of 76 beats/minute
4. Use of an AAI pacemaker with a rate of 80 beats/minute
Correct Answer: 2
RATIONALES: In the pacemaker identification code, the first letter stands for the heart chamber being paced (atrium, ventricle, or both [D]); the second letter stands for the chamber being sensed (atrium, ventricle, both, or none [O]); and the third letter stands for the pacemaker’s response to the sensed event (inhibited, triggered, both, or none). This ECG indicates use of a VVI pacemaker, which paces and senses the ventricle and is inhibited by a sensed event (a spontaneous QRS complex). A spike precedes every QRS complex stimulated by the pacemaker. Sensing that the client’s intrinsic rate is below 72 beats/minute, the pacemaker triggers a ventricular impulse. The other options give incorrect rates; also, if the atrium were being paced, a spike would precede each P wave, indicating atrial contraction.
During digoxin (Lanoxin) therapy, the nurse should closely monitor the client’s:
1. serum potassium and magnesium levels.
2. urine glucose and ketones.
3. serum potassium and creatine kinase (CK) levels.
4. urine potassium and CK levels.
Correct Answer: 1
RATIONALES: During digoxin therapy, the nurse should closely monitor the client’s serum potassium and magnesium levels. This is because hypokalemia or hypomagnesemia can predispose the client to digitalis toxicity. Glucose and ketones aren’t usually in the urine except in a client with uncontrolled diabetes, and digoxin isn’t known to affect these levels in the diabetic. CK levels may be elevated if digoxin is administered I.M., but this route of administration isn’t recommended.
A client is participating in a cardiac research study in which his physician is directly involved. Which statement by the client indicates a lack of understanding about his rights as a research study participant?
1. `I can withdraw from the study at anytime.`
2. `My confidentiality will not be compromised by this study.`
3. `I will have to find a new physician if I do not complete this study.`
4. `I understand the risks associated with this study.`
Correct Answer: 3
RATIONALE: The client’s participation in this study should not influence the relationship with his physician. The client has the right to withdraw from a study at any time without penalty. All information provided by the client will be kept confidential and used only by members of the study team for scientific purposes. The client must be informed of all risks associated with study participation.
A client with chest pain receives nitroglycerin on the way to the acute care facility. Based on an electrocardiogram obtained on admission, the physician suspects a myocardial infarction (MI) and prescribes I.V. morphine to relieve continuing pain. A primary goal of nursing care for this client is to recognize life-threatening complications of an MI. The major cause of death after an MI is:
1. cardiogenic shock.
2. cardiac arrhythmia.
3. heart failure.
4. pulmonary embolism.
Correct Answer: 2
RATIONALES: Cardiac arrhythmias cause roughly 40% to 50% of deaths after MI. Heart failure, in contrast, accounts for 33% and cardiogenic shock for 9% of post-MI deaths. Pulmonary embolism, another potential complication of an MI, is less common.
The home care nurse visits a client diagnosed with atrial fibrillation who is prescribed warfarin (Coumadin). The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? 1. “I will watch my gums for bleeding when I brush my teeth.”
2. “I will use an electric razor to shave.”
3. “I will eat four servings of fresh, dark greens vegetables every day.”
4. “I will report any unexplained or severe bruising to my doctor right away.”
Correct Answer: 3
RATIONALES: Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and any severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.
A client, age 59, complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks ago. The client’s history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental), 400 mg three times daily with meals. The nurse should provide which instruction concerning long-term care?
1. `Practice meticulous foot care.`
2. `Consider cutting down on your smoking.`
3. `Reduce your level of exercise.`
4. `See the physician if complications occur.`
Correct Answer: 1
RATIONALES: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe the feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications unless the physician approves. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. The client must see the physician regularly to evaluate the effectiveness of the therapeutic regimen, not just when complications occur.
A postoperative client is receiving heparin (Heparin sodium injection) after developing thrombophlebitis. The nurse monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
1. phytonadione (vitamin K)
2. protamine sulfate
3. thrombin
4. plasma protein fraction
Correct Answer: 2
RATIONALES: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn’t given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it’s used to treat clients in shock.
The nurse is evaluating the 12-lead electrocardiogram (ECG) of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the team, she correctly identifies which ECG changes associated with an evolving MI?
1. Notched T-wave
2. Presence of a U-wave
3. T-wave inversion
4. Prolonged PR-interval
5. ST-segment elevation
6. Pathologic Q-wave
Correct Answer: 3,4,5
RATIONALES: T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue hypoxia which occur during an MI. Ischemia results from inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion. Injury results from prolonged ischemia and is reflected by ST-segment elevation. Q-waves may become evident when the injury progresses to infarction. A notched T-wave may indicate pericarditis in an adult client. The presence of a U-wave may or may not be apparent on a normal ECG; it represents repolarization of the Purkinje fibers. A prolonged PR-interval is associated with first-degree atrioventricular block.
A client with severe angina and ST-segment elevation on the electrocardiogram is being seen in the emergency department. In terms of diagnostic laboratory testing, it’s most important for the nurse to advocate ordering a:
1. creatine kinase level.
2. hemoglobin (Hb) level.
3. troponin level.
4. liver panel.
Correct Answer: 3
RATIONALES: Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction (MI). It’s the best serum indicator of MI and is more indicative of cardiac damage than creatine kinase. Hb values and liver panel components aren’t as useful in the diagnosis of MI as a troponin level.
The nurse on the telemetry unit is faced with various situations. Which situation takes priority?
1. A client’s cardiac monitor suddenly reveals sinus tachycardia with isolated premature ventricular contractions.
2. A client’s cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation.
3. A client is requesting help to go to the bathroom.
4. The cardiologist is asking the nurse to make rounds with him to his clients.
Correct Answer: 2RATIONALES: The client whose cardiac rhythm suddenly changes from normal sinus rhythm to uncontrolled atrial fibrillation takes priority. This cardiac rhythm change may cause clots to shower from the atria placing the client at risk for a stroke. The client whose cardiac monitor reveals sinus tachycardia with isolated premature ventricular contractions isn’t experiencing a life-threatening situation; therefore, he doesn’t take priority. The nurse can ask her ancillary staff member to assist the client to the bathroom. Making rounds with the physician can wait until the nurse addresses the needs of the client in atrial fibrillation.
After having several Stokes-Adams attacks over 4 months, a client reluctantly agrees to implantation of a permanent pacemaker. Before discharge, the nurse reviews pacemaker care and safety guidelines with the client and spouse. Which safety precaution is appropriate for a client with a pacemaker?
1. Stay at least 2? away from microwave ovens.
2. Never engage in activities that require vigorous arm and shoulder movement.
3. Avoid going through airport metal detectors.
4. Avoid having magnetic resonance imaging (MRI).
Correct Answer: 4
RATIONALES: A client with a pacemaker should avoid having an MRI because the magnet may disrupt pacemaker function and cause injury to the client. Disruption is less likely to occur with newer microwave ovens; nonetheless, the client should stay at least 5? away from microwaves, not 2?. The client must avoid vigorous arm and shoulder movement only for the first 6 weeks after pacemaker implantation. Airport metal detectors don’t harm pacemakers; however, the client should notify airport security guards of the pacemaker because its metal casing and programming magnet may trigger the metal detector.
A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse’s priority would be to assess her:
1. neuromuscular function.
2. bowel sounds.
3. respiratory rate.
4. electrocardiogram (ECG) results.
Correct Answer: 4
RATIONALES: Although changes in all these findings are seen in hyperkalemia, ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn’t be appropriate to assess the client’s neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time?
1. Decreased cardiac output related to depressed myocardial function, fluid volume deficit, or impaired electrical conduction
2. Anxiety related to an actual threat to health status, invasive procedures, and pain
3. Disabled family coping related to knowledge deficit and a temporary change in family dynamics
4. Hypothermia related to exposure to cold temperatures and a long cardiopulmonary bypass time
Correct Answer: 1
RATIONALES: For a client recovering from CABG surgery, Decreased cardiac output is the most important nursing diagnosis because myocardial function may be depressed from anesthetics or a long cardiopulmonary bypass time, leading to decreased cardiac output. Other possible causes of decreased cardiac output in this client include fluid volume deficit and impaired electrical conduction. The other options may be relevant but take lower priority at this time because maintaining cardiac output is essential to sustaining the client’s life.
Before discharge, which instruction should the nurse give to a client receiving flecainide (Tambocor) to reduce the risk of heart failure?
1. `Limit your fluid intake.`
2. `Take a diuretic before going to bed.`
3. `Limit your potassium intake.`
4. `Have your serum electrolyte levels measured weekly.`
Correct Answer: 1
RATIONALES: The nurse should tell the client receiving flecainide to limit fluid intake. The client shouldn’t take a diuretic unless prescribed by the physician; if prescribed, the diuretic should be taken early in the day to prevent nocturia. Sodium (not potassium) should be limited because excessive sodium intake causes water retention. The client’s electrolyte levels don’t need to be measured weekly.
The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:
1. encouraging ambulation to prevent pooling of blood.
2. providing warmth to the extremity.
3. elevating the extremity to prevent pooling of blood.
4. forcing blood into the deep venous system.
Correct Answer: 4
RATIONALES: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn’t a function of the stockings. Antiembolism stockings could possibly provide warmth, but this isn’t how they prevent DVT. Elevating the extremity will decrease edema but won’t prevent DVT.
A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah’s Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
1. realize the surgeon has the right to refuse to care for the client.
2. advise the surgeon to arrange for an alternate cardiac surgeon.
3. tell the client that she can donate her own blood for the procedure.
4. inform the client that her decision could shorten her life.
Correct Answer: 1
RATIONALES: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn’t acceptable to the client. It isn’t the responsibility of the surgeon to find an alternate. Jehovah’s Witnesses don’t believe in receiving blood transfusions. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client’s right of autonomy.
The nurse should be prepared to manage complications after abdominal aortic aneurysm resection. Which complication is most common postoperatively?
1. Renal failure
2. Hemorrhage and shock
3. Graft occlusion
4. Enteric fistula
Correct Answer: 1
RATIONALES: Renal failure commonly occurs if clamping time is prolonged, cutting off the blood supply to the kidneys. Hemorrhage and shock are the most common complications before abdominal aortic aneurysm resection, and they occur if the aneurysm leaks or ruptures. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.
A client has a history of atrial fibrillation. To prevent a recurrence, the physician prescribes sustained-release procainamide hydrochloride (Procan SR), 500 mg P.O. every 6 hours. How soon after administering procainamide can the nurse expect the drug to reach its peak concentration?
1. 15 to 60 minutes
2. 45 to 60 minutes
3. 1? to 2 hours
4. 3 to 4 hours
RATIONALES: Sustained-release procainamide preparations reach peak concentrations in 1? to 2 hours. On the other hand, I.M. procainamide reaches peak concentrations in 15 to 60 minutes. The sustained-release form of quinidine (not procainamide) reaches a peak concentration level in 3 to 4 hours.
The nurse is counseling a 52-year-old client about risk factors for hypertension. Which risk factors should the nurse list for primary hypertension?
1. Obesity
2. Diabetes mellitus
3. Head injury
4. Stress
5. Hormonal contraceptives
6. High intake of sodium or saturated fat
Correct Answer: 1,4,6
RATIONALES: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes mellitus, head injury, and hormonal contraceptives are risk factors for secondary hypertension.
To avoid a falsely elevated serum digoxin level, the nurse should wait how long after administering oral digoxin (Lanoxin) to draw a blood sample?
1. At least 1 hour
2. At least 4 hours
3. At least 6 hours
4. At least 8 hours
Correct Answer: 4
RATIONALES: To avoid a falsely elevated serum digoxin level, the nurse should wait at least 8 hours after administering oral digoxin and at least 6 hours after administering I.V. digoxin to draw a blood sample. In most cases, a serum sample is taken immediately before administering the daily maintenance dose, about 24 hours after the last dose.
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. When exploring the chief complaint, the nurse should find out if the client has any other common cardiovascular symptoms, such as:
1. shortness of breath.
2. insomnia.
3. irritability.
4. lower substernal abdominal pain.
Correct Answer: 1
RATIONALES: Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, dyspnea, palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders
A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which nursing diagnosis may be appropriate?
1. Risk for injury
2. Risk for deficient fluid volume
3. Ineffective thermoregulation
4. Risk for peripheral neurovascular dysfunction
Correct Answer: 1
RATIONALES: Risk for injury is an appropriate nursing diagnosis for a client with HCM because physical exertion may cause syncope or sudden death. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis of Risk for deficient fluid volume isn’t applicable. Ineffective thermoregulation and Risk for peripheral neurovascular dysfunction are inappropriate because HCM doesn’t cause these problems.
A client is admitted to the acute care facility for treatment of heart failure. The nurse expects the physician to prescribe which drug?
1. prednisone (Orasone)
2. hydroxychloroquine sulfate (Plaquenil Sulfate)
3. lidocaine (Xylocaine)
4. furosemide (Lasix)
Correct Answer: 4
RATIONALES: To maintain fluid balance — crucial for a client with heart failure — the physician typically prescribes a diuretic, such as furosemide; vasodilating agents; and drugs that increase contractility, such as digitalis glycosides. Prednisone, a corticosteroid, and hydroxychloroquine, an antimalarial agent, aren’t indicated for heart failure. Lidocaine would be used only if the client also had ventricular ectopy.
A client develops heart failure. The physician prescribes inamrinone lactate (Inocor), 0.75 mg/kg I.V. over 3 minutes followed by 5 mcg/kg/minute with continuous I.V. infusion. Which laboratory test results should the nurse obtain before starting inamrinone therapy?
1. Platelet count and liver enzyme levels
2. Hemoglobin levels and hematocrit
3. Creatine kinase (CK) level
4. White blood cell (WBC) count
Correct Answer: 1
RATIONALES: Before starting inamrinone therapy, the nurse should determine the client’s baseline platelet count and liver enzyme levels because inamrinone may cause thrombocytopenia and liver enzyme alterations. The drug isn’t known to cause anemia or affect the CK level or WBC count.
A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:
1. place a heating pad around the affected calf.
2. elevate the affected leg as high as possible.
3. keep the affected leg level or slightly dependent.
4. shave the affected leg in anticipation of surgery.
Correct Answer: 3
RATIONALES: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg may cause accidental trauma from cuts or nicks.
When a client is started on oral or I.V. diltiazem (Cardizem), the nurse should monitor for which potential complication?
1. Flushing
2. Heart failure
3. Renal failure
4. Hypertension
Correct Answer: 2
RATIONALES: The chief adverse effects of diltiazem are hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. Other reactions that have been reported include flushing, nocturia, and polyuria, but not renal failure. Although flushing may occur, it’s an adverse reaction, not a potential complication. Heart failure is a lifethreatening reaction.
A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will require long-term administration of:
1. aspirin or acetaminophen (Tylenol).
2. pentoxifylline (Trental) or acetaminophen (Tylenol).
3. aspirin or dipyridamole (Persantine).
4. penicillin V potassium (Pen-Vee K) or erythromycin (E-Mycin).
Correct Answer: 3
RATIONALES: After PTCA, the client begins long-term aspirin or dipyridamole therapy to prevent thromboembolism. Heparin is given for anticoagulation during this procedure; some physicians discharge clients with a prescription for longterm warfarin (Coumadin) or low-molecular-weight heparin therapy. Pentoxifylline, a vasodilator used to treat chronic arterial occlusion, isn’t required after PTCA because the procedure itself opens the vessel. The physician may prescribe short-term acetaminophen therapy to manage fever or discomfort, but prolonged therapy isn’t warranted. After the procedure, the client may need an antibiotic, such as penicillin or erythromycin, for a brief period to prevent infection associated with an invasive procedure; long-term therapy isn’t necessary.
A client with chronic heart failure is examined in the outpatient department to investigate recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
1. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
2. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
3. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
4. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
Correct Answer: 1
RATIONALES: Pitting edema is documented as a +1 when a depression is barely detectable on release of thumb pressure and when foot and leg contours are normal. A detectable depression of less than 5 mm accompanied by normal leg and foot contours warrants a +2 rating. A deeper depression (5 to 10 mm) accompanied by foot and leg swelling is evaluated as +3. An even deeper depression (more than 1 cm) accompanied by severe foot and leg swelling rates a +4.
A 32-year-old female with systemic lupus erythematosus (SLE) complains that her hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these sign and symptoms?
1. Peripheral vascular disease
2. Raynaud’s disease
3. Arterial occlusive diseases
4. Buerger’s disease
Correct Answer: 2
RATIONALES: Raynaud’s disease results from reduced blood flow to the extremities when exposed to cold or stress. It’s commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger’s disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.
On a routine visit to the physician, a client with chronic arterial occlusive disease reports stopping smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, the nurse should recommend which additional measure?
1. Taking daily walks
2. Engaging in anaerobic exercise
3. Reducing daily fat intake to less than 45% of total calories
4. Avoiding foods that increase levels of high-density lipoproteins (HDLs)
Correct Answer: 1
RATIONALES: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not avoid, foods that raise HDL levels.
During a routine checkup, the nurse performs a physical examination on a client with aortic insufficiency. The client’s history reveals an Austin Flint murmur. To best hear this murmur, the nurse should place the stethoscope:
1. over the carotid artery.
2. at the base of the heart.
3. at the apex of the heart.
4. at the left fifth intercostal space.
Correct Answer: 3
RATIONALES: To best hear an Austin Flint murmur, the nurse should place the stethoscope at the apex of the heart. An Austin Flint murmur produces a soft, low-pitched, rumbling, middiastolic or presystolic bruit. Placing the stethoscope over the carotid artery, at the base of the heart, or at the left fifth intercostal space would make this murmur more difficult to hear.
The staff nurse is caring for a client who is a potential heart donor. The client’s family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process?
1. `I will have the transplant coordinator speak with you to answer your questions.`
2. `There is never contact between the donor’s family and the recipient.`
3. `The recipient is allowed to ask questions about the donor and have them answered.`
4. `It is important that the recipient know where to send Thank-You cards.`
Correct Answer: 1
RATIONALES: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members and answers their questions. Contact is permitted after the procedure with consent from the donor’s family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.
The physician prescribes digoxin (Lanoxin) for a client with heart failure. During digoxin therapy, which electrolyte imbalance may predispose the client to digitalis toxicity?
1. Hypermagnesemia
2. Hypercalcemia
3. Hypernatremia
4. Hypokalemia
Correct Answer: 4
RATIONALES: During digoxin therapy, conditions that may predispose a client to digitalis toxicity include hypokalemia, hypomagnesemia, hypothyroidism, hypoxemia, advanced myocardial disease, active myocardial ischemia, and altered autonomic tone. Hypermagnesemia, hypercalcemia, and hypernatremia aren’t associated with a risk for digitalis toxicity.
A client is prescribed lisinopril (Zestril) for treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should teach him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?
1. Constipation
2. Dizziness
3. Headache
4. Hyperglycemia
5. Hypotension
6. Impotence
Correct Answer: 2,3,5
RATIONALES: Dizziness, headache, and hypotension are all common adverse effects of lisinopril and other ACE inhibitors. Lisinopril may cause diarrhea, not constipation. Lisinopril isn’t known to cause hyperglycemia or impotence.
The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
1. Straw-colored urine
2. Reduced hematocrit
3. Clay-colored stools
4. Elevated urobilinogen in the urine
Correct Answer: 3
RATIONALES: Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren’t affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it’s converted to urobilinogen), the urine contains no urobilinogen.
The nurse is caring for a client who’s experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he complains of dizziness. Which medication would be used to treat his bradycardia? 1. Atropine
2. Dobutamine (Dobutrex)
3. Amiodarone (Cordarone)
4. Lidocaine (Xylocaine)
Correct Answer: 1
RATIONALES: I.V. push atropine is used to treat symptomatic bradycardia. Dobutamine is used to treat heart failure and low cardiac output. Amiodarone is used to treat ventricular fibrillation and unstable ventricular tachycardia. Lidocaine is used to treat ventricular ectopy, ventricular tachycardia, and ventricular fibrillation.
Which signs and symptoms are present with a diagnosis of pericarditis?
1. Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
2. Low urine output secondary to left ventricular dysfunction
3. Lethargy, anorexia, and heart failure
4. Pitting edema, chest discomfort, and nonspecific ST-segment elevation
Correct Answer: 1
RATIONALES: The classic signs and symptoms of pericarditis include fever, positional chest discomfort, nonspecific STsegment elevation, elevated ESR, and pericardial friction rub. All other symptoms may result from acute renal failure.
A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?
1. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to lower the secretion of aldosterone and antidiuretic hormone.
2. Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.
3. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to raise aldosterone secretion.
4. Low blood pressure triggers the baroreceptors to decrease sympathetic nervous system stimulation.
Correct Answer: 2
RATIONALES: In the early stage of heart failure, low blood pressure triggers baroreceptors in the carotid sinus and aortic arch to increase sympathetic nervous system stimulation, causing a faster heart rate, vasoconstriction, and increased myocardial oxygen consumption. Decreased renal blood flow causes the renin-angiotensin-aldosterone system to increase, not reduce, secretion of aldosterone and antidiuretic hormone, in turn causing sodium and water retention and arterial vasoconstriction.
After a myocardial infarction, a client develops a complication requiring a continuous infusion of lidocaine. To monitor the effectiveness of this infusion, the nurse should focus primarily on:
1. electrocardiogram (ECG).
2. urine output.
3. creatine kinase (CK) and troponin levels.
4. blood pressure and heart rate.
Correct Answer: 1
RATIONALES: Lidocaine is an antiarrhythmic given to treat cardiac irritability and ventricular arrhythmias. The best indicator of its effectiveness is the reduction or disappearance of ventricular arrhythmias as seen on the ECG. Urine output is an indicator of pump effectiveness. CK and troponin levels monitor myocardial damage. Blood pressure and heart rate are too nonspecific to be indicators of lidocaine’s effectiveness.
The nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:
1. elevate the client’s head to 90 degrees.
2. press the right upper abdomen.
3. press the left upper abdomen.
4. lie the client flat in bed.
Correct Answer: 2
RATIONALES: Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux.
A client with supraventricular tachycardia, is prescribed esmolol (Brevibloc). During esmolol therapy, the nurse should monitor the client’s:
1. body temperature.
2. heart rate and blood pressure.
3. ocular pressure.
4. cerebral perfusion pressure.
Correct Answer: 2
RATIONALES: Because class II antiarrhythmics such as esmolol inhibit sinus node stimulation, they may produce bradycardia. Hypotension with peripheral vascular insufficiency also may occur, especially with esmolol. Class II antiarrhythmics don’t alter body temperature, ocular pressure, or cerebral perfusion pressure.
A client is in hemorrhagic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client’s:
1. blood pressure.
2. hemoglobin level.
3. temperature.
4. heart rate.
Correct Answer: 1
RATIONALES: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client’s blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren’t directly related to fluid status.
The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant?
1. Croup
2. Rheumatic fever
3. Severe staphylococcal infection
4. Medullary sponge kidney
Correct Answer: 2
RATIONALES: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup — a severe upper airway inflammation and obstruction that typically strikes children ages 3 months to 3 years — may cause latent complications, such as ear infection and pneumonia. However, it doesn’t affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn’t damage heart structures.
When administering low doses of dopamine (Intropin), the nurse knows that dopamine activates which receptors?
1. Alpha
2. Beta1
3. Dopaminergic
4. Beta2
Correct Answer: 3
RATIONALES: Dopamine activates dopaminergic receptor sites only at low doses. At normal or high doses, dopamine activates alpha and beta1 receptor sites. Dopamine doesn’t activate beta2 receptor sites.
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
1. Pulmonary embolism
2. Heart failure
3. Cardiac tamponade
4. Tension pneumothorax
Correct Answer: 2
RATIONALES: A client with heart failure has decreased cardiac output caused by the heart’s decreased pumping ability. A
buildup of fluid occurs, causing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. A client with pulmonary embolism experiences acute shortness of breath, pleuritic chest pain, hemoptysis, and fever. A client with cardiac tamponade experiences muffled heart sounds, hypotension, and elevated central venous pressure. A client with tension pneumothorax has a deviated trachea and absent breath sounds on the affected side as well as dyspnea and jugular vein distention.
The nurse is teaching a client about maintaining a healthy heart. The nurse should include which point in her teaching?
1. Smoke in moderation.
2. Use alcohol in moderation.
3. Consume a diet high in saturated fats and low in cholesterol.
4. Exercise one or two times per week.
Correct Answer: 2
RATIONALES: Alcohol may be used in moderation as long as there are no other contraindications for its use. Smoking, a diet high in cholesterol and saturated fat, and a sedentary lifestyle are all known risk factors for cardiac disease. The client should be encouraged to quit smoking, exercise three to four times per week, and consume a diet low in cholesterol and saturated fat.
A client has a heart rate of 170 beats/minute. The physician diagnoses ventricular tachycardia and orders lidocaine hydrochloride (Xylocaine), an initial I.V. bolus of 50 mg followed in 5 minutes by a second 50-mg bolus, then continuous I.V. infusion at 2 mg/minute. The nurse can expect the client to begin experiencing an antiarrhythmic effect within:
1. 1 to 2 minutes after I.V. bolus administration.
2. 1 to 2 minutes after continuous I.V. infusion.
3. 10 to 15 minutes after I.V. bolus administration.
4. 10 to 15 minutes after continuous I.V. infusion.
Correct Answer: 1
RATIONALES: Lidocaine exerts its antiarrhythmic effect in 1 to 2 minutes after I.V. bolus administration. A continuous I.V. infusion will maintain lidocaine’s antiarrhythmic effect for as long as the drip is used. Lidocaine provides antiarrhythmic effects for only 15 minutes after the I.V. infusion is stopped.
In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most often related to:
1. vestibular dysfunction.
2. sudden vascular fluid shifting.
3. postural hypotension.
4. bradyrhythmia.
Correct Answer: 4
RATIONALES: Parasympathetic hyperactivity leading to sudden hypotension secondary to bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope. Vasovagal syncope isn’t caused by vestibular (inner ear) dysfunction, postural hypotension, or vascular fluid shifting.
A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pinktinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
1. right-sided heart failure.
2. acute pulmonary edema.
3. pneumonia.
4. cardiogenic shock.
Correct Answer: 2
RATIONALES: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. In right-sided heart failure, the client would exhibit hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia, the client would have a temperature spike and sputum that varies in color. Cardiogenic shock would show signs of hypotension and tachycardia.
Within hours after suffering a massive myocardial infarction, a client experiences cardiogenic shock. All vital functions are being monitored closely; an intra-arterial catheter has been inserted to detect changes in arterial blood pressure.
Which statement comparing intra-arterial and cuff blood pressure readings is accurate?
1. Intra-arterial readings should be at least 10 mm Hg higher than cuff readings.
2. Intra-arterial readings should be at least 10 mm Hg lower than cuff readings.
3. Cuff readings are easier to obtain than intra-arterial readings.
4. Cuff readings detect excessive peripheral vasoconstriction more accurately than intra-arterial readings.
Correct Answer: 1
RATIONALES: Intra-arterial blood pressure readings should be at least 10 mm Hg higher than cuff readings. Placement of an indwelling catheter for intra-arterial monitoring allows continuous recording of arterial pressure, eliminating the need to locate the client’s brachial pulse and place a stethoscope on the arm for each reading. This makes intra-arterial readings easier, not harder, to obtain than cuff readings. Intra-arterial pressure monitoring can detect blood pressure in clients with excessive peripheral vasoconstriction, low cardiac output, and fluctuating hemodynamic status — even when cuff measurements can’t.
Within hours after suffering a massive myocardial infarction, a client experiences cardiogenic shock. All vital functions are being monitored closely; an intra-arterial catheter has been inserted to detect changes in arterial blood pressure.
Which statement comparing intra-arterial and cuff blood pressure readings is accurate?
1. Intra-arterial readings should be at least 10 mm Hg higher than cuff readings.
2. Intra-arterial readings should be at least 10 mm Hg lower than cuff readings.
3. Cuff readings are easier to obtain than intra-arterial readings.
4. Cuff readings detect excessive peripheral vasoconstriction more accurately than intra-arterial readings.
Correct Answer: 1
RATIONALES: Intra-arterial blood pressure readings should be at least 10 mm Hg higher than cuff readings. Placement of an indwelling catheter for intra-arterial monitoring allows continuous recording of arterial pressure, eliminating the need to locate the client’s brachial pulse and place a stethoscope on the arm for each reading. This makes intra-arterial readings easier, not harder, to obtain than cuff readings. Intra-arterial pressure monitoring can detect blood pressure in clients with excessive peripheral vasoconstriction, low cardiac output, and fluctuating hemodynamic status — even when cuff measurements can’t.
A client requested a do-not-resuscitate (DNR) order upon admission to the hospital. He now tells the nurse that he wants the medical team to do everything possible to help him get better and is concerned about the DNR order. Which response by the nurse is best?
1. “It is too late to change your mind now.”
2. “We will have to ask your physician if this is possible.”
3. “Why do you want to do this?”
4. “It’s not a problem to rescind your DNR order; I’ll let your physician know your wishes right away.”
Correct Answer: 4
RATIONALES: The client is allowed to rescind a DNR order at any time. The client makes the decision about a DNR order with input from the physician. Questioning a client’s motives can make the client feel defensive and shut down communication with the nurse.
When caring for a client with rheumatic fever, the nurse formulates a nursing diagnosis of Activity intolerance related to reduced cardiac reserve and enforced bed rest. Before the nurse can eliminate this nursing diagnosis, the client must meet which outcome measurement criterion?
1. `Erythrocyte sedimentation rate returns to normal.`
2. `Pulse doesn’t rise above 150 beats/minute with activity.`
3. `Temperature remains normal with salicylate administration.`
4. `Pericardial friction rub is diminishing in intensity.`
Correct Answer: 1
RATIONALES: Bed rest must continue until the client’s erythrocyte sedimentation rate returns to normal, indicating resolution of rheumatic fever; the resting pulse is under 100 beats/minute; the client can maintain a normal temperature without salicylates; and a pericardial friction rub disappears completely. If the client needs salicylates to maintain a normal temperature, inflammation still is present and activity may cause serious myocardial damage. Resuming activity before a pericardial friction rub disappears completely may impair cardiac function.
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client’s care plan, the nurse should include which expected outcome?
1. `Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours.`
2. `Client will verbalize the intention to avoid exercise.`
3. `Client will verbalize the intention to stop smoking.`
4. `Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol.`
Correct Answer: 3
RATIONALES: The client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level; this, in turn, reduces the heart’s oxygen supply and may induce angina. The client must seek immediate medical attention if chest pain doesn’t subside after three nitroglycerin doses taken 10 to 15 minutes apart; serious myocardial damage or even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a role in angina).
A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because:
1. the client is experiencing heart failure.
2. the client is going into cardiogenic shock.
3. the client shows signs of aneurysm rupture.
4. the client is in the early stage of right-sided heart failure.
Correct Answer: 2
RATIONALES: This client’s findings indicate cardiogenic shock, which occurs when the heart fails to pump properly, impeding blood supply and oxygen flow to vital organs. Cardiogenic shock also may cause cold, clammy skin and generalized weakness, fatigue, and muscle pain as lactic acid accumulates from poor blood flow, preventing waste removal. Left-sided and right-sided heart failure eventually cause venous congestion with jugular vein distention and edema as the heart fails to pump blood forward. A ruptured aneurysm causes severe hypotension and a quickly deteriorating clinical status from blood loss and circulatory collapse; this client has low but not severely decreased blood pressure. Also, in ruptured aneurysm, deterioration is more rapid and full cardiac arrest is common.
The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
1. administer oxygen.
2. have the client take deep breaths and cough.
3. place the client in high Fowler’s position.
4. perform chest physiotherapy.
Correct Answer: 3
RATIONALES: The high Fowler’s position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn’t the primary problem in pulmonary edema.
An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by:
1. cerebral bleeding.
2. I.M. injection.
3. myocardial necrosis.
4. skeletal muscle damage due to a recent fall.
Correct Answer: 3
RATIONALES: An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including brain injury, such as cerebral bleeding; skeletal muscle damage, which can be caused by I.M.
injections or falls; muscular or neuromuscular disease; vigorous exercise; trauma; or surgery.
The nurse suspects that her client is in cardiac arrest. According to the American Heart Association, the nurse should perform the actions listed below. Order these actions in the sequence that the nurse should perform them.
1. Activate the emergency medical system.
2. Assess responsiveness.
3. Call for a defibrillator.
4. Provide two slow breaths.
5. Assess pulse.
6. Assess breathing.
Correct Answer: 213645
RATIONALES: According to the American Heart Association, the nurse should first assess responsiveness. If the client is unresponsive, the nurse should activate the emergency medical system, and then call for a defibrillator. Next, the nurse should assess breathing by opening the airway and then looking, listening, and feeling for respirations. If respirations aren’t present, the nurse should administer two slow breaths, then assess the pulse. If no pulse is present, the nurse should start chest compressions.
A client with substernal chest pain that radiates to the jaw is admitted to the coronary care unit. The client subsequently develops hypotension and suffers cardiac arrest. Which calcium preparation is injected into the ventricle during cardiac arrest?
1. calcium carbonate (BioCal)
2. calcium chloride
3. calcium glubionate (Neo-Calglucon)
4. calcium lactate
Correct Answer: 2
RATIONALES: Calcium chloride is the only calcium preparation that should be injected into the ventricle during cardiac arrest, if appropriate.
The home care nurse is visiting a left-handed client who has an automated implantable cardioverter-defibrillator implanted in his left chest. The client tells the nurse how excited he is because he’s planning to go rifle hunting with his grandson. How should the nurse respond?
1. `Be sure to enjoy your time with your grandson.`
2. `You cannot shoot a rifle left-handed because the rifle’s recoil will traumatize the AICD site.`
3. `Being that close to a rifle might make your AICD fire.`
4. `You will need to take an extra dose of your antiarrhythmic before you shoot.`
Correct Answer: 2
RATIONALES: The recoil from the rifle can damage the AICD so the client should be warned against shooting a rifle with his left hand. Close proximity to a rifle won’t cause the AICD to fire inadvertently. The client shouldn’t take an extra dose of his antiarrhythmic.
The nurse is teaching a client who receives nitrates for the relief of chest pain. Which instruction should the nurse emphasize?
1. Repeat the dose of sublingual nitroglycerin every 15 minutes for three doses.
2. Store the drug in a cool, well-lit place.
3. Lie down or sit in a chair for 5 to 10 minutes after taking the drug.
4. Restrict alcohol intake to two drinks per day.
Correct Answer: 3
RATIONALES: Nitrates act primarily to relax coronary smooth muscle and produce vasodilation. They can cause hypotension, which makes the client dizzy and weak. Nitrates are taken at the first sign of chest pain and before activities that might induce chest pain. Sublingual nitroglycerin is taken every 5 minutes for three doses. If the pain persists, the client should seek medical assistance immediately. Nitrates must be stored in a dark place in a closed container. Sunlight causes the medication to lose its effectiveness. Alcohol is prohibited because nitrates may enhance the effects of the alcohol.
After receiving nitroglycerin (Nitrostat), a client verbalizes relief of chest pain. The physician prescribes transdermal nitroglycerin (Nitro-Dur), 5-mg patch daily, as prophylaxis for angina pectoris. When teaching the client how to apply the transdermal system, the nurse should provide which instruction?
1. `Use the same clean, hairless application site each day.`
2. `You may touch the medication pad after washing your hands.`
3. `Be sure to report skin irritation or other adverse reactions.`
4. `Store your supply of transdermal pads in the refrigerator.`
Correct Answer: 3
RATIONALES: This is the only correct instruction because transdermal nitroglycerin may cause skin irritation. The other options reflect incorrect teaching regarding transdermal nitroglycerin. The client should rotate the patch application site daily to prevent sensitization and tolerance; should avoid touching the medication-impregnated pad because this may cause drug absorption; and should store pads away from temperature and humidity extremes, which may inactivate the drug.
An obese white male client, age 49, is diagnosed with hypercholesterolemia. The physician prescribes a low-fat, low cholesterol, low-calorie diet to reduce blood lipid levels and promote weight loss. This diet is crucial to the client’s wellbeing because his race, sex, and age increase his risk for coronary artery disease (CAD). To determine if the client has other major risk factors for CAD, the nurse should assess for:
1. a history of diabetes mellitus.
2. elevated high-density lipoprotein (HDL) levels.
3. a history of ischemic heart disease.
4. alcoholism.
Correct Answer: 1
RATIONALES: Diabetes mellitus, smoking, and hypertension are other major risk factors for CAD. Elevated HDL levels aren’t a risk factor for CAD; in fact, increased HDL levels seem to protect against CAD. Ischemic heart disease is another term for CAD, not a risk factor. Alcoholism hasn’t been identified as a major risk factor for CAD.
A client hospitalized for treatment of hypertension is being prepared for discharge. The nurse should be sure to cover which teaching topic?
1. Maintaining a low-potassium diet
2. Skipping a medication dose if dizziness occurs
3. Maintaining a low-sodium diet
4. Receiving I.V. antihypertensive medications
Correct Answer: 3
RATIONALES: The nurse must teach the hypertensive client how to modify the diet to restrict sodium and saturated fats. In addition to teaching about adverse effects of prescribed antihypertensives, the nurse must discuss the actions and dosages of these drugs. Option 1 is incorrect because a client receiving antihypertensives also may take a diuretic as part of the drug regimen and thus may require dietary potassium supplements and high-potassium foods to avoid electrolyte disturbances. Instead of skipping medication if dizziness occurs (option 2), the client should notify the physician of this symptom. The client receiving antihypertensives at home takes them by mouth, not I.V., making option 4 incorrect.
A client with mitral stenosis comes to the physician’s office for a routine checkup. When listening to the client’s heart, the nurse expects to hear which type of murmur?
1. Pansystolic, blowing, high-pitched
2. Systolic, harsh, crescendo-decrescendo
3. Diastolic, blowing, decrescendo
4. Diastolic, rumbling, low-pitched
Correct Answer: 4
RATIONALES: Mitral stenosis causes a diastolic, rumbling, low-pitched murmur heard at the apex. A pansystolic, blowing, high-pitched murmur characterizes mitral insufficiency. A systolic, harsh, crescendo-decrescendo murmur occurs with aortic insufficiency. A diastolic, blowing, decrescendo murmur accompanies aortic insufficiency.
The nurse is teaching a client who will be discharged soon with a prescription for warfarin (Coumadin). The nurse should include which statement in discharge teaching?
1. “Increase your intake of yogurt and broccoli.”
2. “This drug will dissolve any clots you may still have.”
3. “If you miss a dose, double the next dose.”
4. “Avoid aspirin while taking warfarin.”
Correct Answer: 4
RATIONALES: Because aspirin decreases platelet agglutination and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects — and bleeding. Warfarin therapy doesn’t necessitate dietary changes. Although warfarin interrupts the normal clotting cycle, it doesn’t dissolve clots that have already formed. The client should take warfarin exactly as prescribed to maintain the desired level of anticoagulation. Doubling a dose could lead to bleeding.
The physician is treating a client in the cardiac care unit for atrial arrhythmia and prescribes propranolol (Inderal), 10 mg P.O. three times a day. Propranolol inhibits the action of sympathomimetics at beta1-receptor sites. Where these sites are mainly located?
1. Uterus
2. Blood vessels
3. Bronchi
4. Heart
Correct Answer: 4
RATIONALES: Beta1-receptor sites are mainly located in the heart. Beta2-receptor sites are located in the uterus, blood vessels, and bronchi.
In presenting a workshop on parameters of cardiac function, which conditions should the nurse list as those most likely to lead to a decrease in preload?
1. Hemorrhage, sepsis, and anaphylaxis
2. Myocardial infarction, fluid overload, and diuresis
3. Fluid overload, sepsis, and vasodilation
4. Third spacing, heart failure, and diuresis
Correct Answer: 1
RATIONALES: Preload is the volume in the left ventricle at the end of diastole. It’s also referred to as end-diastolic volume. Preload is reduced by any condition that reduces circulating volume, such as hemorrhage, sepsis, and anaphylaxis. Hemorrhage reduces circulating volume by loss of volume from the intravascular space. Sepsis and anaphylaxis reduce circulating volume by increased capillary permeability. Diuresis, vasodilation, and third spacing also reduce preload. Preload would increase with fluid overload and heart failure.
A client is admitted for treatment of Prinzmetal’s angina. When developing the care plan, the nurse keeps in mind that this type of angina is triggered by:
1. activities that increase myocardial oxygen demand.
2. an unpredictable amount of activity.
3. coronary artery spasm.
4. the same type of activity that caused previous angina episodes.
Correct Answer: 3
RATIONALES: Prinzmetal’s angina results from coronary artery spasm. Activities that increase myocardial oxygen demand may trigger angina of effort. An unpredictable amount of activity may precipitate unstable angina. Worsening angina is brought on by the same type or level of activity that caused previous angina episodes; however, anginal pain is increasingly severe.
The nurse is caring for a cardiac client who requires various cardiac medications. When the nurse helps the client out of bed for breakfast, the client becomes dizzy and asks to lie down. The nurse helps the client lie down, puts up the side rails, and obtains the client’s blood pressure, which is 84/50 mm Hg. It’s time for the nurse to administer the client’s medications: nitroglycerin, metoprolol (Lopressor), and furosemide (Lasix). Which action is best taken by the nurse?
1. Withhold the medications and notify the physician.
2. Administer the medications immediately.
3. Encourage the client to sit up and eat breakfast.
4. Administer the nitroglycerin and metoprolol and withhold the furosemide.
Correct Answer: 1
RATIONALES: The nurse should withhold the three medications and notify the physician. Each of these medications has the potential to lower the client’s blood pressure. Administering them together when the client is already hypotensive may severely lower the client’s blood pressure. The client may continue to experience dizziness when sitting up so breakfast should be held until his blood pressure stabilizes.
The physician orders blood coagulation tests to evaluate a client’s blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test is used to determine a client’s response to oral anticoagulant drugs? 1. Bleeding time
2. Platelet count
3. Prothrombin time (PT)
4. Partial thromboplastin time (PTT)
Correct Answer: 3
RATIONALES: PT determines a client’s response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample after calcium ions and tissue thromboplastin are added and compares this time with the fibrin clotting time in a control sample. Anticoagulant dosages should be adjusted, as needed, to maintain PT at 1.5 to 2.5 times the control value. PTT determines the effectiveness of heparin therapy and helps evaluate bleeding tendencies. Roughly 99% of bleeding disorders are diagnosed from PT and PTT values. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reveals the number of circulating platelets in venous or arterial blood.
A client with a history of I.V. drug abuse is admitted to the medical-surgical unit for evaluation for infective endocarditis.
Nursing assessment is most likely to reveal that this client has:
1. retrosternal pain that worsens during supine positioning.
2. pulsus paradoxus.
3. a scratchy pericardial friction rub.
4. Osler’s nodes and splinter hemorrhages.
Correct Answer: 4
RATIONALES: Infective endocarditis occurs when an infectious agent enters the bloodstream, such as from I.V. drug abuse or during an invasive procedure or dental work. Typical assessment findings in clients with this disease include Osler’s nodes (red, painful nodules on the fingers and toes), splinter hemorrhages, fever, diaphoresis, joint pain, weakness, abdominal pain, a new or altered heart murmur, and Janeway’s lesions (small, hemorrhagic areas on the fingers, toes, ears, and nose). The other options are common findings in clients with pericarditis, not infective endocarditis.
A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and family to expect which common symptom that typically resolves spontaneously?
1. Depression
2. Ankle edema
3. Memory lapses
4. Dizziness
Correct Answer: 1
RATIONALES: For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves on its own and doesn’t require medical intervention; however, family members should be aware that symptoms don’t always resolve on their own. They should also be instructed about worsening symptoms of depression and when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure; because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition after CABG surgery that warrants immediate physician notification.
A client with severe angina and electrocardiogram changes is seen by a nurse practitioner in the emergency department.
In terms of serum testing, it’s most important for the nurse to order cardiac:
1. creatine kinase.
2. lactate dehydrogenase.
3. myoglobin.
4. troponin.
Correct Answer: 4
RATIONALES: The client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of MI is troponin level. The other tests can show evidence of muscle injury but they’re a less specific indicator of myocardial damage than troponin.
The home care nurse visits a client diagnosed with atrial fibrillation who is prescribed warfarin (Coumadin). The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?
1. “I will watch my gums for bleeding when I brush my teeth.”
2. “I will use an electric razor to shave.”
3. “I will eat four servings of fresh, dark greens vegetables every day.”
4. “I will report any unexplained or severe bruising to my doctor right away.”
Correct Answer: 3
RATIONALES: Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and any severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.
A client with deep vein thrombosis has an I.V. infusion of heparin sodium infusing at 1,500 U/hour. The concentration in the bag is 25,000 U/500 ml. How many milliliters of solution should the nurse document as intake from this infusion for an 8-hour shift?Correct Answer: 240
RATIONALES: First, calculate how many units are in each milliliter of the medication:
25,000 U/500 ml = 50 U/ml
Next, calculate how many milliliters the client receives each hour: 1 ml/50 U ? 1,500 U/hour = 30 ml/hour Lastly, multiply by 8 hours:
30 ml/hour ? 8 hours = 240 ml
An electrocardiogram (ECG) taken during a routine checkup reveals that a client has had a silent myocardial infarction. On a 12-lead ECG, which leads record electrical events in the septal region of the left ventricle?
1. Leads I, aVL, V5, and V6
2. Leads II, III, and aVF
3. Leads V1 and V2
4. Leads V3 and V4
Correct Answer: 4
RATIONALES: Leads V3 and V4 record electrical events in the septal region of the left ventricle. Leads I, aVL, V5, and V6 record electrical events on the lateral surface of the left ventricle. Leads II, III, and aVF record electrical events on the inferior surface of the left ventricle. Leads V1 and V2 record electrical events on the anterior surface of the right ventricle and the anterior surface of the left ventricle.
A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue and dizziness, especially on rising. When developing a client teaching plan to minimize orthostatic hypotension, the nurse should include which instruction?
1. “Avoid drinking alcohol and straining at stool, and eat a low-protein snack at night.”
2. “Wear elastic stockings, change positions quickly, and hold onto a stationary object when rising.”
3. “Flex your calf muscles, avoid alcohol, and change positions slowly.”
4. “Rest between demanding activities, eat plenty of fruits and vegetables, and drink 6 to 8 cups of fluid daily.”
Correct Answer: 3
RATIONALES: Measures that minimize orthostatic hypotension include flexing the calf muscles to boost blood return to the heart, avoiding alcohol and straining at stool, changing positions slowly, eating a high-protein snack at night, wearing elastic stockings, and holding onto a stationary object when rising. Although the client should rest between demanding activities and consume plenty of fluids and fiber (contained in fruits and vegetables) to maintain a balanced diet, these measures don’t directly relieve orthostatic hypotension.
A client comes to the emergency department complaining of visual changes and a severe headache. The nurse measures the client’s blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder.
After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?
1. Pyelonephritis
2. Dissecting aortic aneurysm
3. Pheochromocytoma
4. Untreated hypertension
Correct Answer: 4
RATIONALES: Untreated hypertension is the most common cause of malignant hypertension. Pyelonephritis, dissecting aortic aneurysm, and excessive catecholamine release (an effect of pheochromocytoma) are less common causes. Rarely, malignant hypertension results from eclampsia, ingestion of or exposure to drugs or toxic substances, and food and drug interactions (such as monoamine oxidase inhibitors with aged cheeses).
A client, age 59, complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks ago. The client’s history includes diabetes mellitus and a two-pack-a-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and prescribes pentoxifylline (Trental), 400 mg three times daily with meals. The nurse should provide which instruction concerning long-term care?
1. `Practice meticulous foot care.`
2. `Consider cutting down on your smoking.`
3. `Reduce your level of exercise.`
4. `See the physician if complications occur.`
Correct Answer: 1
RATIONALES: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe the feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications unless the physician approves. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. The client must see the physician regularly to evaluate the effectiveness of the therapeutic regimen, not just when complications occur.
The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the client is responding favorably to therapy?
1. The client demonstrates the ability to tolerate increasing activity without chest pain.
2. The client exhibits a heart rate above 100 beats/minute.
3. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking.
4. The client states that sublingual nitroglycerin usually relieves chest pain.
Correct Answer: 1
RATIONALES: The ability to tolerate increasing activity without chest pain indicates a favorable response to therapy in a client who is recovering from an MI or who has a history of coronary artery disease. The client should have a normal electrocardiogram with no arrhythmias and a regular heart rate of 60 to 100 beats/minute. Smoking is a cardiovascular risk factor that the client must be willing to eliminate. A client who responds favorably to therapy shouldn’t have chest pain.
The nurse is caring for a client who is recovering from a myocardial infarction (MI). The cardiologist refers him to cardiac rehabilitation. Which statement by the client indicates an understanding of cardiac rehabilitation?
1. “When I finish the rehabilitation program I’ll never have to worry about heart trouble again.`
2. `I won’t be able to jog again even with rehabilitation.”
3. “Rehabilitation will help me function as well as I physically can.”
4. “I’ll get rest during these rehabilitation classes. All I have to do is sit and listen to the instructor.`
Correct Answer: 3
RATIONALES: Cardiac rehabilitation helps the client reach his activity potential. Coronary artery disease, which typically causes an acute MI, is a chronic condition that isn’t cured. Many clients who suffer an acute MI can eventually return to such activities as jogging, depending on the extent of cardiac damage. Cardiac rehabilitation involves physical activity as well as classroom education.
A client with chest pain doesn’t respond to nitroglycerin. On admission to the emergency department, the health care team obtains an electrocardiogram and begins infusing I.V. morphine. The physician also considers administering alteplase (Activase). This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?
1. Within 12 hours
2. Within 24 hours
3. Within 24 to 48 hours
4. Within 5 to 7 days
Correct Answer: 1
RATIONALES: For the best chance of salvaging the client’s myocardium, a thrombolytic agent must be administered within 12 hours after onset of chest pain or other signs or symptoms of MI. Within the first 24 hours after an MI, sudden death is most likely to occur. I.V. heparin therapy begins after administration of a thrombolytic agent and usually continues for 5 to 7 days.
The nurse is educating a client who’s at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include:
1. gender, obesity, family history, and smoking.
2. inactivity, stress, gender, and smoking.
3. obesity, inactivity, diet, and smoking.
4. stress, family history, and obesity.
Correct Answer: 3
RATIONALES: The risk factors for coronary artery disease that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that can’t be controlled.
When assessing a client who reports recent chest pain, the nurse obtains a thorough history. Which statement by the client most strongly suggests angina pectoris?
1. `The pain lasted about 45 minutes.`
2. `The pain resolved after I ate a sandwich.`
3. `The pain got worse when I took a deep breath.`
4. `The pain occurred while I was mowing the lawn.`
Correct Answer: 4
RATIONALES: Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload; this, in turn, increases the heart’s need for oxygen and may precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn’t reduce this pain, although it may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
A client comes to the physician’s office for a complete physical examination required for employment. The physician assesses the client’s arms and legs for evidence of peripheral vascular disease. What is the most commonly used overall indicator of arm and leg circulation?
1. Exercise testing
2. Ankle-brachial index
3. Limb blood pressure
4. Allen’s test
Correct Answer: 2
RATIONALES: The ankle-brachial index is the most commonly used overall indicator of arm and leg circulation. Exercise testing reveals the severity of intermittent claudication and suggests how extensively this condition affects the client’s lifestyle. Limb blood pressure is the single best indicator of arm or leg perfusion, but its significance is limited to the limb being examined; limb blood pressures may vary greatly if peripheral vascular disease is present in one limb but not the other. Allen’s test is used to evaluate blood flow in the arm.
An 84-year-old male is returning from the operating room (OR) after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates leftsided heart failure?
1. Jugular vein distention
2. Right upper quadrant pain
3. Bibasilar fine crackles
4. Dependent edema
Correct Answer: 3
RATIONALES: Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.
The nurse is awaiting the arrival of a client from the emergency department. The client has a left ventricular myocardial infarction and is being admitted. In caring for this client, the nurse should be alert for which signs and symptoms of leftsided heart failure?
1. Jugular vein distention
2. Hepatomegaly
3. Dyspnea
4. Crackles
5. Tachycardia
6. Right upper quadrant pain
Correct Answer: 3,4,5
RATIONALES: Signs and symptoms of left-sided heart failure include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea; fatigue; nonproductive cough and crackles; hemoptysis; point of maximal impulse displaced toward the left anterior axillary line; tachycardia and S3 and S4 heart sounds; and cool, pale skin. Jugular vein distention, hepatomegaly, and right upper quadrant pain are all signs of right-sided heart failure.
A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah’s Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
1. realize the surgeon has the right to refuse to care for the client.
2. advise the surgeon to arrange for an alternate cardiac surgeon.
3. tell the client that she can donate her own blood for the procedure.
4. inform the client that her decision could shorten her life.
Correct Answer: 1
RATIONALES: Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn’t acceptable to the client. It isn’t the responsibility of the surgeon to find an alternate. Jehovah’s Witnesses don’t believe in receiving blood transfusions. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client’s right of autonomy.
The nurse is preparing a client with Crohn’s disease for a barium enema. What should the nurse do the day before the test?
1. Serve the client his usual diet.
2. Order a high-fiber diet.
3. Encourage plenty of fluids.
4. Serve dairy products.
Correct Answer: 3
RATIONALES: Adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren’t allowed the evening before the test. Clear liquids only are allowed the evening before the test.
A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition contraindicates use of the IABP?
1. Unstable angina pectoris
2. Aortic insufficiency
3. Hypertension
4. Diabetes mellitus
Correct Answer: 2
RATIONALES: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn’t respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren’t contraindications for IABP.
The nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques:
1. are helpful only because they assist in smoking cessation.
2. are helpful because stress stimulates the release of vasoconstricting catecholamines.
3. are helpful because they distract the client from focusing on claudication pain.
4. haven’t proved useful in clients with peripheral vascular disease.
Correct Answer: 2
RATIONALES: The stress-induced release of vasoactive catecholamines, such as epinephrine, causes vasoconstriction, which directly aggravates peripheral vascular disease by intensifying the ischemic burden of the affected tissues. Vasoconstriction also indirectly aggravates atherogenesis by inducing hypertension. Stress-reduction techniques make it easier for clients to avoid bad habits, such as smoking; however, this isn’t the only reason why they’re useful. Claudication is a signal of muscle ischemia and shouldn’t be ignored
A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which abnormal heart sound?
1. Opening snap
2. Graham Steell’s murmur
3. Ejection click
4. Pericardial friction rub
Correct Answer: 4
RATIONALES: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week after an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell’s murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as:
1. a first heart sound (S1).
2. a third heart sound (S3).
3. a fourth heart sound (S4).
4. a murmur.
correct Answer: 2
RATIONALES: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
Before discharge, which instruction should the nurse give to a client receiving digoxin (Lanoxin)?
1. `Take an extra dose of digoxin if you miss one dose.`
2. `Call the physician if your heart rate is above 90 beats/minute.`
3. `Call the physician if your pulse drops below 80 beats/minute.`
4. `Take digoxin with meals.`
Correct Answer: 2
RATIONALES: The nurse should instruct the client to notify the physician if his heart rate is greater than 90 beats/minute because cardiac arrhythmias may occur with digitalis toxicity. To prevent toxicity, the client should be instructed never to take an extra dose of digoxin if a dose is missed. The nurse should show the client how to take her pulse and to call the physician if her pulse rate drops below 60 beats/minute — not 80 beats/minute, which is a normal pulse rate and doesn’t warrant action. Digoxin shouldn’t be administered with meals because this slows the absorption rate.
A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?
1. Semi-Fowler’s
2. Leaning forward while sitting
3. Supine
4. Prone
Correct Answer: 2
RATIONALES: When the client leans forward, the heart pulls away from the diaphragmatic pleurae of the lungs, helping relieve chest pain caused by pericarditis. The semi-Fowler, supine, and prone positions don’t cause this pulling-away action and therefore don’t relieve chest pain associated with pericarditis.
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
1. Cyanosis of the lips
2. Bilateral crackles
3. Productive cough
4. Leg edema
Correct Answer: 4
RATIONALES: Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, neck vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.
The nurse is preparing a client for cardiac catheterization. The nurse knows that she must provide which nursing intervention when the client returns to his room after the procedure?
1. Withhold analgesics for at least 6 hours after the procedure.
2. Assess the puncture site frequently for hematoma formation or bleeding.
3. Inform the client that he may experience numbness or pain in his leg.
4. Restrict fluids for 6 hours after the procedure.
Correct Answer: 2
RATIONALES: Because the diameter of the catheter used for cardiac catheterization is large, the puncture site must be checked frequently for hematoma formation and bleeding. The nurse should administer analgesics as prescribed and needed. If the femoral artery was accessed during the procedure, the client should be instructed to report any leg pain or numbness, which may indicate arterial insufficiency. Fluids should be encouraged to eliminate dye from the client’s system.
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?
1. Varicose veins are more common in men than in women.
2. Primary varicose veins are caused by deep vein thrombosis and inflammation.
3. Sclerotherapy is used to cure varicose veins.
4. The severity of discomfort isn’t related to the size of varicosities.
Correct Answer: 4
RATIONALES: Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, deep vein thrombosis, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat varicose veins; it doesn’t cure them.
When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are found in the carotid sinus and aorta. Which other area should the nurse mention as the site of arterial baroreceptors?
1. Brachial artery
2. Radial artery
3. Left ventricular wall
4. Right ventricular wall
Correct Answer: 3
RATIONALES: Arterial baroreceptors are found in the left ventricular wall as well as the carotid sinus and aorta. None exist in the brachial artery, radial artery, or right ventricular wall.
A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
1. negative history of tonic-clonic seizures.
2. ampule of naloxone (Narcan) at the bedside.
3. continuous electrocardiogram (ECG) monitoring.
4. up-to-date partial thromboplastin time (PTT) result in his record.
Correct Answer: 4
RATIONALES: Clients undergoing PTCA receive abciximab because it inhibits platelet aggregation and, thereby, reduces cardiac ischemic complications. Before abciximab is administered, the client should have an up-to-date PTT result available. The drug isn’t contraindicated in clients with a seizure history. Abciximab isn’t an opioid; therefore, an opioid antagonist doesn’t need to be at the bedside. Any client with refractory angina should be on continuous ECG monitoring; however, monitoring isn’t a requirement for administering abciximab.
For a client with cardiomyopathy, the most important nursing diagnosis is:
1. Decreased cardiac output related to reduced myocardial contractility.
2. Excess fluid volume related to fluid retention and altered compensatory mechanisms.
3. Ineffective coping related to fear of debilitating illness.
4. Anxiety related to actual threat to health status.
Correct Answer: 1
RATIONALES: Decreased cardiac output related to reduced myocardial contractility is the greatest threat to the survival of a client with cardiomyopathy. Although the other options are important nursing diagnoses, they can be addressed when cardiac output and myocardial contractility have been restored.
A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is appropriate at this time?
1. Deficient knowledge (disease process) related to interventions used to treat acute illness
2. Impaired physical mobility related to complete bed rest
3. Social isolation related to restricted visiting hours in the ICU
4. Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia
Correct Answer: 4
RATIONALES: The client suffered a lethal arrhythmia, requiring immediate resuscitation. This arrhythmia was caused by ineffective perfusion to the heart. Therefore, the client should have the nursing diagnosis Ineffective tissue perfusion (cardiopulmonary). Client teaching should be limited to clear, concise explanations that reduce anxiety and promote cooperation. An anxious client has difficulty learning, so the knowledge deficit would continue despite attempts at teaching. Impaired physical mobility and Social isolation are necessitated by the client’s critical condition; therefore, they are considered therapeutic, not problems warranting nursing diagnoses.
A client with known coronary artery disease reports intermittent chest pain, usually on exertion. The physician diagnoses angina pectoris and prescribes sublingual nitroglycerin to treat acute angina episodes. When teaching the client about nitroglycerin administration, the nurse should provide which instruction?
1. `Be sure to take safety precautions because nitroglycerin may cause orthostatic hypotension.`
2. `Replace leftover sublingual nitroglycerin tablets every 6 months to make sure they’re fresh.”
3. “A burning sensation after administration indicates that the nitroglycerin tablets are potent.”
4. “You may take a sublingual nitroglycerin tablet every 30 minutes, if needed, to a maximum of four doses.”
Correct Answer: 1
RATIONALES: Nitroglycerin commonly causes orthostatic hypotension and dizziness. To minimize these problems, the nurse should teach the client to take safety precautions, such as changing to an upright position slowly, climbing up and down stairs carefully, and lying down at the first sign of dizziness. To ensure the freshness of sublingual nitroglycerin, the client should replace tablets every 3 months, not every 6 months, and store them in a tightly closed container in a cool, dark place. Many brands of sublingual nitroglycerin no longer produce a burning sensation. The client should take a sublingual nitroglycerin tablet at the first sign of angina and may repeat the dose every 10 to 15 minutes for up to three doses; if this doesn’t bring relief, the client should seek immediate medical attention
The physician prescribes pentoxifylline (Trental), 400 mg three times daily with meals, for a client with intermittent claudication and a history of adult-onset diabetes mellitus. The nurse knows that pentoxifylline is a:
1. hemostatic agent.
2. tissue plasminogen activator.
3. thrombolytic agent.
4. blood viscosity-reducing agent.
Correct Answer: 4
RATIONALES: Pentoxifylline is a hemorheologic agent that improves blood flow by decreasing blood viscosity and is used to treat intermittent claudication. A hemostatic agent is used to stop excessive bleeding. A tissue plasminogen activator is used in early management of acute myocardial infarction. A thrombolytic agent is prescribed to dissolve clots and other substances in thrombi and emboli.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
1. Take a mild laxative such as magnesium citrate when necessary.
2. Take a stool softener such as docusate sodium (Colace) daily.
3. Administer a tap-water enema weekly.
4. Administer a phospho-soda (Fleet) enema when necessary.
Correct Answer: 2
RATIONALES: Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.
The nurse is teaching a client how to take nitroglycerin to treat angina pectoris. The client verbalizes an understanding of the need to take up to three sublingual nitroglycerin (Nitrostat) tablets at 5-minute intervals, if necessary, and to notify the physician immediately if chest pain doesn’t subside within 15 minutes. The nurse knows that nitroglycerin may cause:
1. nausea, vomiting, depression, fatigue, and impotence.
2. sedation, nausea, vomiting, constipation, and respiratory depression.
3. headache, hypotension, dizziness, and flushing.
4. flushing, dizziness, headache, and pedal edema.
Correct Answer: 3
RATIONALES: Headache, hypotension, dizziness, and flushing are classic adverse effects of nitroglycerin, a vasodilator. Vasodilators, beta-adrenergic blockers, and calcium channel blockers are three major classes of drugs used to treat angina pectoris. Nausea, vomiting, depression, fatigue, and impotence are adverse effects of propranolol, a betaadrenergic blocker. Sedation, nausea, vomiting, constipation, and respiratory depression are common adverse effects of morphine, an opioid analgesic used to relieve pain associated with acute myocardial infarction. Flushing, dizziness, headache, and pedal edema are common adverse effects of nifedipine, a calcium channel blocker.
A client with a suspected diagnosis of acute myocardial infarction is admitted to the coronary care unit. To help confirm the diagnosis, the physician orders serial enzyme tests. Increased serum levels of the isoenzyme creatinine kinase of myocardial muscle (CK-MB), found only in cardiac muscle, can be detected how soon after the onset of chest pain?
1. 30 minutes to 1 hour
2. 2 to 3 hours
3. 4 to 6 hours
4. 12 to 18 hours
Correct Answer: 3
RATIONALES: Serum CK-MB levels can be detected 4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.
Which sign or symptom suggest that a client’s abdominal aortic aneurysm is extending?
1. Increased abdominal and back pain
2. Decreased pulse rate and blood pressure
3. Retrosternal back pain radiating to the left arm
4. Elevated blood pressure and rapid respirations
Correct Answer: 1
RATIONALES: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.
A septic client with hypotension is being treated with dopamine hydrochloride (Inotropin). The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine hydrochloride in 250 ml, the infusion pump is running at 23 ml/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving?Correct Answer: 7.71
RATIONALES: First, calculate how many micrograms per milliliter of dopamine hydrochloride are in the bag: 400 mg/250 ml = 1.6 mg/ml
Next, convert milligrams to micrograms:
1.6 mg/ml ? 1,000 mcg/mg = 1,600 mcg/ml Lastly, calculate the dose:
1,600 mcg/ml ? 23 ml/hour/79.5 kg
79.5 kg/60 minutes/hour = 7.71 mcg/kg/minute
When administering dobutamine (Dobutrex), the nurse knows that its major clinical use is to:
1. increase cardiac output.
2. prevent sinus bradycardia.
3. treat hypotension.
4. treat hypertension.
Correct Answer: 1
RATIONALES: Dobutamine increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Epinephrine hydrochloride, another catecholamine agent, may be used to treat sinus bradycardia. Many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, may be used to treat acute hypotension. None of the catecholamine agents are used to treat hypertension because many of them raise blood pressure as part of their action.
The nurse is assessing a client’s right lower leg, which is wrapped with an elastic (Ace) bandage. Which signs and symptoms suggest circulatory impairment?
1. Numbness, cool skin temperature, and pallor
2. Swelling, warm skin temperature, and drainage
3. Numbness, warm skin temperature, and redness
4. Redness, cool skin temperature, and swelling
Correct Answer: 1
RATIONALES: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include warm skin with normal return of skin color after blanching and normal sensation.
The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first:
1. establish unresponsiveness.
2. call for help.
3. open the airway.
4. assess the client for a carotid pulse.
Correct Answer: 1
RATIONALES: The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse.
Which measurement can best be used to monitor the respiratory status of a client with pulmonary edema?
1. Arterial blood gas (ABG) analysis
2. Pulse oximetry
3. Skin color assessment
4. Lung sounds
Correct Answer: 1
RATIONALES: ABG analysis is the best measure for determining the extent of hypoxia caused by pulmonary edema and for monitoring the effects of therapy. Although any of the options can be used to detect pulmonary changes, assessment of skin color and assessment of lung fields often are subject to interpretation by practitioners. The use of pulse oximetry is unreliable, especially in the case of severe vasoconstriction as is present in pulmonary edema.
Following a percutaneous transluminal coronary angioplasty (PTCA), a client is monitored in the postprocedure unit. The client’s heparin infusion was stopped 2 hours earlier. There is no evidence of bleeding or hematoma at the insertion site, and the pressure device is removed. The nurse should plan to remove the femoral sheath when the partial thromboplastin time (PTT) is:
1. 25 seconds or less.
2. 50 seconds or less.
3. 75 seconds or less.
4. 100 seconds or less.
Correct Answer: 2
RATIONALES: Heparin causes an elevation of the PTT and, thereby, increases the risk for bleeding. With a large cannulation such as a sheath used for angioplasty, the PTT should be 40 seconds or less before the sheath is removed. Removing the sheath prematurely can cause bleeding at the insertion site. The other PTT results are incorrect for determining when to remove the sheath.
A hospitalized client experiences digoxin- (Lanoxin-) induced premature ventricular contractions (PVCs). Which type of effect do such contractions represent?
1. Toxic
2. Secondary
3. Iatrogenic
4. Idiosyncratic
Correct Answer: 3
RATIONALES: Digoxin-induced PVCs are iatrogenic because the drug is mimicking a cardiac disorder. Because the client is experiencing an apparent pathological disorder, this effect isn’t considered toxic, secondary, or idiosyncratic.
Considering a client’s atrial fibrillation, the nurse must administer digoxin (Lanoxin) with caution because it:
1. affects the sympathetic division of the autonomic nervous system, decreasing vagal tone.
2. stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone.
3. can induce hypertensive crisis by constricting arteries.
4. can trigger proarrhythmia by increasing stroke volume.
Correct Answer: 2
RATIONALES: The nurse must administer digoxin with caution in a client with atrial fibrillation because digoxin stimulates the parasympathetic division of the autonomic nervous system, increasing vagal tone. The vagal effect slows the heart rate, increases the refractory period, and slows conduction through the atrioventricular node and junctional tissue, thus increasing the potential for new arrhythmias to develop. Digoxin doesn’t constrict arteries. Although it can trigger proarrhythmias, it does so by increasing vagal tone (not stroke volume).
A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, “His pulmonary artery wedge pressures have been in the high normal range.” The CSU nurse should be especially observant for:
1. hypertension.
2. high urine output.
3. dry mucous membranes.
4. pulmonary crackles.
Correct Answer: 4
RATIONALES: High pulmonary artery wedge pressures are diagnostic for left-sided heart failure. With left-sided heart failure, pulmonary edema can develop causing pulmonary crackles. In left-sided heart failure, hypotension may result and urine output will decline. Dry mucous membranes aren’t directly associated with elevated pulmonary artery wedge pressures
The nurse records a client’s history and discovers several risk factors for coronary artery disease. Which cardiac risk factors are considered controllable?
1. Diabetes, hypercholesterolemia, and heredity
2. Diabetes, age, and gender
3. Age, gender, and heredity
4. Diabetes, hypercholesterolemia, and hypertension
Correct Answer: 4
RATIONALES: Controllable risk factors include hypertension, hypercholesterolemia, obesity, lack of exercise, smoking, diabetes, stress, alcohol abuse, and use of contraceptives. Uncontrollable risk factors for coronary artery disease include gender, age, and heredity.
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an:
1. antibiotic.
2. anticoagulant.
3. antihypertensive.
4. anticonvulsant.
Correct Answer: 2
RATIONALES: During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. An antibiotic isn’t given routinely during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics afterward to reduce the risk of infection. An antihypertensive agent may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn’t indicated because this procedure doesn’t increase the risk of seizures.
An anxious client who suffered an acute myocardial infarction is transferred from the coronary care unit (CCU) to the telemetry unit. The client asks the charge nurse if he can have the same nurse care for him every day. How should the charge nurse respond?
1. `Different nurses will be assigned to you each day to avoid your becoming dependent on one nurse.`
2. `It is important for you to receive care from a variety of nurses so you can evaluate your care.`
3. `We will try to assign you the same nurse as often as possible.`
4. `It is our policy to rotate client care assignments to ensure quality care for everyone.`
Correct Answer: 3
RATIONALES: The charge nurse should try to accommodate the client’s wishes by assigning him a familiar nurse whenever possible. This should help decrease the client’s anxiety. Preventing dependency should not be a concern; allaying his anxiety should. The client should not be concerned with evaluating the quality of care rendered by multiple nurses. Providing continuity of care helps ensure quality care.
A 53-year-old client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, `I’m really worried about having this open heart surgery.` Based on this statement, how should the nurse proceed?
1. Medicate the client and document his comment.
2. Medicate the client and notify the physician about the comment.
3. Explain that cardiac catheterization doesn’t involve open heart surgery, and then medicate the client.
4. Withhold the medication and notify the physician immediately.
Correct Answer: 4
RATIONALES: The nurse should withhold the medication and notify the physician that the client doesn’t understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client doesn’t understand, he can’t give a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client’s ability to clearly understand the procedure. The nurse can’t just medicate the client and document her finding; she must notify the physician.
The visiting nurse is teaching a client with heart failure about taking his medications. The client requires six different medications that are taken at four different times per day. The client is confused about when to take each medication.
How should the nurse intervene?
1. Ask the client’s family to take turns coming to the house at each administration time to assist the client with his medications.
2. Teach a family member to fill a medication compliance aid once a week so the client can independently take his medications.
3. Ask the physician if the client can take fewer pills each day.
4. Come to the client’s house each morning to prepare the daily allotment of medications.
Correct Answer: 2
RATIONALES: The nurse should intervene by asking a family member to fill a compliance aid each week with the client’s weekly supply of medications in the appropriate time slots. Family members can’t be expected to come to the client’s house four times each day to administer medications. The physician shouldn’t change the dosing regimen just for convenience. The home care nurse can’t visit the client each morning to prepare the daily medication regimen.
A client with an acute myocardial infarction is receiving nitroglycerin (Tridil) by continuous I.V. infusion. Which statement by the client indicates that this drug is producing its therapeutic effect?
1. “I have a bad headache.”
2. “My chest pain is decreasing.”
3. “I feel a tingling sensation around my mouth.”
4. “My blood pressure must be up because my vision is blurred.”
Correct Answer: 2
RATIONALES: Nitroglycerin, a vasodilator, increases the arterial supply of oxygen-rich blood to the myocardium, thus producing its intended effect: relief of chest pain. Headache is an adverse effect of nitroglycerin. The drug shouldn’t cause a tingling sensation around the mouth and should lower, not raise, blood pressure.
A client with a myocardial infarction (MI) develops pulmonary crackles and dyspnea. A chest X-ray shows evidence of pulmonary edema. The specific type of MI the client had is most probably:
1. anterior.
2. posterior.
3. lateral.
4. inferior.
Correct Answer: 1
RATIONALES: An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea. The other types of MI aren’t usually associated with heart failure
The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
1. heparin sodium (Heparin sodium injection)
2. dexamethasone (Decadron)
3. methyldopa (Aldomet)
4. phenytoin (Dilantin)
Correct Answer: 1
RATIONALES: Administration of heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, dexamethasone may be used to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.
A client experiences orthostatic hypotension while receiving furosemide (Lasix) to treat hypertension. How should the nurse intervene?
1. Administer I.V. fluids as ordered.
2. Administer a vasodilator as prescribed.
3. Insert an indwelling urinary catheter as ordered.
4. Instruct the client to sit up for several minutes before standing.
Correct Answer: 4
RATIONALES: To minimize the effects of orthostatic hypotension, the nurse should instruct the client to rise slowly to a standing position, such as by sitting up for several minutes first. Administering I.V. fluids would be inappropriate (unless the client were dehydrated) because it would counteract the effects of furosemide, possibly leading to fluid imbalance.
Administering a vasodilator would further reduce the client’s blood pressure, worsening orthostatic hypotension. Inserting an indwelling urinary catheter would aid urine output monitoring but wouldn’t minimize the effects of orthostatic hypotension.
How long after oral administration can the nurse expect to see digoxin’s (Lanoxin) peak effect?
1. 2 to 5 minutes
2. 10 to 20 minutes
3. 30 minutes to 2 hours
4. 2 to 6 hours
Correct Answer: 4
RATIONALES: The peak effect of digoxin occurs 2 to 6 hours after an oral dose and 1 to 4 hours after an I.V. dose. Digoxin’s onset of action ranges from 30 minutes to 2 hours after an oral dose and from 5 to 30 minutes after an I.V. dose.
The unit council in the telemetry unit is responsible for performance improvement studies. What information should they gather to study whether client education about resuming sexual activity after an acute myocardial infarction (MI) is being taught?
1. The percentage of clients on the unit diagnosed with an acute MI who were taught about resuming sexual activity
2. The quality of teaching by the nurses who educate the acute MI clients on the telemetry unit
3. The amount of education the acute MI clients received on the telemetry unit
4. The nurses’ assessment of the quality of client education about resuming sexual activity after an acute MI
Correct Answer: 1
RATIONALES: The unit council needs to assess the number of clients diagnosed with an acute MI on the telemetry unit who were actually taught about resuming sexual activity. The unit council needs to identify the number of clients who were taught, not the quality of the teaching. Only education about resuming sexual activity is pertinent to this performance improvement study. The nurses’ assessment of the quality of client education is not pertinent to this study either.
A client is receiving nitroglycerin ointment (Nitrol) to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client’s response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?
1. Heart rate
2. Respiratory rate
3. Blood pressure
4. Temperature
Correct Answer: 3
RATIONALES: Hypotension and headache are the most common adverse effects of nitroglycerin. Therefore, blood pressure is the vital sign most likely to reflect an adverse effect of this drug. The nurse should check the client’s blood pressure 1 hour after administering nitroglycerin ointment. A blood pressure decrease of 10 mm Hg is within the therapeutic range. If blood pressure falls more than 20 mm Hg below baseline, the nurse should remove the ointment and report the finding to the physician immediately. An above-normal heart rate (tachycardia) is a less common adverse effect of nitroglycerin. Respiratory rate and temperature don’t change significantly after nitroglycerin administration.
A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
1. skin rash.
2. peripheral edema.
3. dry cough.
4. postural hypotension.
Correct Answer: 2
RATIONALES: Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don’t indicate that therapy is ineffective.
A client is prescribed hydralazine for blood pressure management. The nurse is teaching the client about hydralazine therapy. When should the client take his hydralazine?
1. Upon arising in the morning
2. Just before bedtime
3. On an empty stomach
4. With food
Correct Answer: 4
RATIONALES: Oral hydralazine should be taken with food to promote absorption.
What mechanical device increases coronary perfusion and cardiac output and decreases myocardial workload and oxygen consumption in a client with cardiogenic shock?
1. Cardiac pacemaker
2. Hypothermia-hyperthermia machine
3. Defibrillator
4. Intra-aortic balloon pump
Correct Answer: 4
RATIONALES: Counterpulsation with an intra-aortic balloon pump may be indicated for temporary circulatory assistance in clients with cardiogenic shock. Cardiac pacemakers are used to maintain the heartbeat at a predetermined rate.
Hypothermia-hyperthermia machines are used to cool or warm clients with abnormalities in temperature regulation. The defibrillator is commonly used for termination of life-threatening ventricular rhythms.
The monitor technician on the telemetry unit asks the charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin (Coumadin). Which response by the charge nurse is best?
1. “It’s just a coincidence; most clients with atrial fibrillation don’t receive warfarin.”
2. “Warfarin controls heart rate in the client with atrial fibrillation.”
3. “Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia.”
4. “Warfarin prevents clot formation in the atria of clients with atrial fibrillation.”
Correct Answer: 4
RATIONALES: Blood pools in the atria of clients with atrial fibrillation. As the blood pools, clots form. These clots can be forced from the atria as the heart beats, placing the client at risk for stroke. Warfarin is prescribed in most clients with atrial fibrillation to prevent clot formation and decrease the risk of stroke, not to control heart rate. Digoxin is typically prescribed to control heart rate in atrial fibrillation. Atrial fibrillation doesn’t typically progress to a lethal arrhythmia such as ventricular fibrillation.
A client is experiencing an acute myocardial infarction (MI) and I.V. morphine is prescribed. Morphine is given because it:
1. eliminates pain, reduces cardiac workload, and increases myocardial contractility.
2. lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand.
3. raises the blood pressure, lowers myocardial oxygen demand, and eliminates pain.
4. increases venous return, lowers resistance, and reduces cardiac workload.
Correct Answer: 2
RATIONALES: When given to treat acute MI, morphine sulfate eliminates pain, reduces venous return to the heart, reduces vascular resistance, reduces myocardial workload, and reduces the oxygen demand of the heart. Morphine sulfate doesn’t increase myocardial contractility, raise blood pressure, or increase venous return.
A client with end-stage heart failure is preparing for discharge. The client and his caregiver meet with the home care nurse and voice their concern that setting up a hospital bed in the bedroom will leave him feeling isolated. Which suggestion by the home care nurse best addresses this concern?
1. Place a chair in the bedroom so guests can visit with the client.
2. Set up the hospital bed in the family room so the client can be part of household activities.
3. Set up the hospital bed in the bedroom so the client can rest in a quiet environment.
4. Set up the hospital bed in the bedroom so the client can be assessed in a quiet environment.
Correct Answer: 2
RATIONALES: The client should be kept actively involved in the household to prevent feelings of isolation. This can be accomplished by setting up the hospital bed in the family room. Placing a chair in the bedroom allows the client periods of isolation when visitors aren’t present. It’s important for the client to have periods of rest; however, that can be accomplished without keeping the client isolated in a bedroom. The needs of the client should be considered before the needs of the nurse who assesses the client during an occasional visit.
A client with mitral stenosis is scheduled for mitral valve replacement. Which condition may arise as a complication of mitral stenosis?
1. Left-sided heart failure
2. Myocardial ischemia
3. Pulmonary hypertension
4. Left ventricular hypertrophy
Correct Answer: 3
RATIONALES: Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the stenotic valve, increasing pressure in the left atrium and pulmonary circulation. This may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure. Other potential complications of mitral stenosis include mural thrombi, pulmonary hemorrhage, and embolism to vital organs. Myocardial ischemia may occur in a client with coronary artery disease. Left ventricular hypertrophy is a potential complication of aortic stenosis.
A client with second-degree atrioventricular heart block is admitted to the coronary care unit. The nurse closely monitors the heart rate and rhythm. When interpreting the client’s electrocardiogram (ECG) strip, the nurse knows that the QRS complex represents:
1. atrial repolarization.
2. ventricular repolarization.
3. atrial depolarization.
4. ventricular depolarization.
Correct Answer: 4
RATIONALES: The QRS complex on the ECG strip represents ventricular depolarization. Atrial repolarization usually occurs at the same time as ventricular depolarization and can’t be distinguished on the ECG. The T wave represents ventricular repolarization. The P wave represents atrial depolarization.
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do?
1. Consider this to be a normal finding for his age and race.
2. Recommend he have his blood pressure rechecked in 1 year.
3. Recommend he have his blood pressure rechecked within 2 weeks.
4. Recommend he see his physician immediately for further evaluation.
Correct Answer: 3
RATIONALES: Although hypertension is more prevalent in the black population, a blood pressure of 150/90 mm Hg isn’t considered normal. He should have his blood pressure rechecked within 2 weeks. One year is too long to wait. He need not see his physician yet.
Before using a defibrillator to terminate ventricular fibrillation, the nurse should check the synchronizer switch. Why is this so important?
1. The delivered shock must be synchronized with the client’s QRS complex.
2. The defibrillator won’t deliver a shock if the synchronizer switch is turned on.
3. The defibrillator won’t deliver a shock if the synchronizer switch is turned off.
4. The shock must be synchronized with the client’s T wave.
Correct Answer: 2
RATIONALES: The defibrillator won’t deliver a shock to the client in ventricular fibrillation if the synchronizer switch is turned on because the defibrillator needs to recognize a QRS complex when the switch is turned on. The synchronizer switch should be turned on when attempting to terminate arrhythmias that contain QRS complexes, such as rapid atrial fibrillation that is resistant to pharmacologic measures.
The nurse just received shift report for a group of clients on the telemetry unit. Which client should the nurse assess first.
1. The client with a history of atrial fibrillation
2. The client admitted with first-degree atrioventricular (AV) block whose cardiac monitor now reveals type II second-degree AV block
3. The client with a history of heart failure who has bibasilar crackles and pitting edema in both feet
4. The client with a demand pacemaker whose monitor shows normal sinus rhythm at a rate of 90 beats/minute
Correct Answer: 2
RATIONALES: The client whose cardiac rhythm now shows type II second-degree AV block should be assessed first. The client’s rhythm has deteriorated from first-degree heart block to type II second-degree AV block and may continue to deteriorate into a lethal form of AV block (known as complete heart block). The client with a history of atrial fibrillation whose monitor reveals atrial fibrillation doesn’t need to be assessed first. Because his rhythm is chronic, he has most likely been given an anticoagulant and isn’t at immediate risk from this rhythm. The client with a history of heart failure may have chronic bibasilar crackles and pitting edema of both feet. Therefore, assessing this client first isn’t necessary. The client’s demand pacemaker fires only when the client’s intrinsic heart rate falls below the pacemaker’s set rate. In option 4, the pacemaker isn’t firing because it most likely has been set at a slower rate than the client’s intrinsic heart rate of 90 beats/minute.
The most important reason for the nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:
1. reduces stress.
2. aids in weight reduction.
3. increases high-density lipoprotein (HDL) level.
4. promotes collateral circulation.
Correct Answer: 4
RATIONALES: Regular walking is the best way to promote collateral circulation, which becomes a critical source of blood supply to limbs with compromised blood flow distal to a stenotic lesion. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — all of which are helpful for a client with peripheral vascular disease. However, these changes don’t have as significant an effect on the client’s condition as the development of collateral circulation.
A 43-year-old man was transferring a load of fire wood from his front driveway to his backyard woodpile at 10 a.m. when he experienced a heaviness in his chest and dyspnea. He stopped working and rested, and the pain subsided. At noon, the pain returned. At 1:30 p.m., his wife took him to the emergency department. Around 2 p.m., the emergency department physician diagnoses an anterior myocardial infarction (MI). The nurse should anticipate which orders by the physician?
1. Streptokinase, aspirin, and morphine sulfate administration
2. Morphine administration, stress testing, and admission to the cardiac care unit
3. Serial liver enzyme testing, telemetry, and a lidocaine infusion
4. Sublingual nitroglycerin, tissue plasminogen activator (tPA), and telemetry
Correct Answer: 4
RATIONALES: If 12 hours or fewer have passed since the onset of symptoms related to MI, thrombolytic therapy is indicated. (The client’s chest pain began 4 hours before diagnosis.) The preferred choice is tPA, which is more specific for cardiac tissue than streptokinase. Stress testing shouldn’t be performed during an MI. The client doesn’t exhibit symptoms that indicate the use of lidocaine.
A client is admitted to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client’s care, the nurse formulates interventions with which goal in mind?
1. Decreasing blood pressure and increasing mobility
2. Increasing blood pressure and reducing mobility
3. Stabilizing the heart rate and blood pressure and easing anxiety
4. Increasing blood pressure and monitoring fluid intake and output
Correct Answer: 3
RATIONALES: For a client with an aneurysm, nursing interventions focus on stabilizing the heart rate and blood pressure, to avoid aneurysm rupture. Easing anxiety also is important because anxiety and increased stimulation may speed the heart rate and boost blood pressure, precipitating aneurysm rupture. Typically, the client with an abdominal aortic aneurysm is hypertensive, so the nurse should take measures to lower the blood pressure, such as administering antihypertensive agents, as prescribed, to prevent aneurysm rupture. To sustain major organ perfusion, a mean arterial pressure of at least 60 mm Hg should be maintained. Although mobility must be assessed individually, most clients need bed rest initially when attempting to gain stability.
The nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first?
1. The client admitted with unstable angina who wants to be discharged.
2. The client who suffered an acute myocardial infarction (MI) who is complaining of constipation.
3. The client who had a pacemaker inserted yesterday and who is complaining of incisional pain.
4. The client who has his call light on.
Correct Answer: 2
RATIONALES: The client who suffered an acute MI who is complaining of constipation should be addressed first. If the client strains at stool after an MI, the vagal response may be stimulated causing bradycardia thereby provoking arrhythmias. The nurse should delegate answering the call light to the ancillary personnel. She can also delegate some of the discharge preparation, such as packing the client’s belongings. After addressing the MI client with constipation, the nurse should promptly address the pain relief needs of the client who had a pacemaker inserted the previous day
While receiving a heparin infusion to treat deep vein thrombosis, a client reports that the gums bleed when brushing the teeth. What should the nurse do first?
1. Stop the heparin infusion immediately.
2. Notify the physician.
3. Administer a coumarin derivative, as prescribed, to counteract heparin.
4. Reassure the client that bleeding gums are a normal effect of heparin.
Correct Answer: 2
RATIONALES: Because bleeding gums are an adverse effect of heparin that may indicate excessive anticoagulation, the nurse should notify the physician, who will evaluate the client’s condition. Laboratory tests, such as partial thromboplastin time, should be performed before concluding that the client’s bleeding is significant. The prescribed heparin dose may be therapeutic rather than excessive, so the nurse shouldn’t discontinue the heparin infusion, unless the physician orders this after evaluating the client. Protamine sulfate, not a coumarin derivative, is given to counteract heparin. Bleeding gums aren’t a normal effect of heparin.
The nurse is caring for a client who is awaiting heart transplantation. The client and her family express their concerns about the financial cost of the procedure. Which intervention by the nurse is most appropriate?
1. Reassure the client and her family that the cost will be covered.
2. Contact the social worker and request that she speak to the client and her family about their financial concerns.
3. Tell the client that she will be responsible for all of her costs.
4. Have the physician speak to the client and family about the costs.
Correct Answer: 2
RATIONALES: Transplantation requires a multidisciplinary team approach. A social worker is always included as part of that team. The nurse should contact the social worker and request that she speak to the client and her family about their financial concerns about the transplant. Reassuring the client that the cost will be covered is false reassurance that doesn’t address the client’s concern. Many insurance companies pay for the expenses surrounding a transplant; the client isn’t personally responsible. The physician isn’t typically involved with discussions about financial responsibilities.
After receiving shift report, the registered nurse in the cardiac step-down unit, must prioritize her client care assignment. She has an ancillary staff member available to help her care for her clients. Which of these clients should the registered nurse assess first?
1. The client with heart failure who is having some difficulty breathing.
2. The anxious client who was diagnosed with an acute myocardial infarction (MI) two days ago and who was transferred from the coronary care unit today.
3. The demanding client who underwent coronary bypass surgery three days ago.
4. The client admitted during the previous shift with new-onset controlled atrial fibrillation who has her call light on.
Correct Answer: 1
RATIONALES: The registered nurse should care for the client with heart failure who is experiencing difficulty breathing. Breathing takes precedence over the other client needs. The ancillary staff member can answer the call light of the client admitted with controlled atrial fibrillation. She can also attend to the demanding client who underwent coronary bypass surgery three days ago. Although anxiety can be detrimental to a client with an MI, anxiety doesn’t take precedence over another client’s breathing difficulty.
After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin, 325 mg P.O. daily. The nurse should teach the client that this medication has been prescribed to:
1. control headache pain.
2. enhance the immune response.
3. prevent intracranial bleeding.
4. reduce the chance of blood clot formation.
Correct Answer: 4
RATIONALES: TIAs are considered forerunners of stroke. Because strokes may result from clots in cerebral vessels, aspirin is prescribed to prevent clot formation by reducing platelet agglutination. A 325-mg dose of aspirin is inadequate to relieve headache pain in an adult. Aspirin has no effect on the body’s immune response. Intracranial bleeding isn’t associated with TIAs, and the action of aspirin probably would worsen any bleeding present.
During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route is the nurse most likely to administer?
1. 0.6 mg I.M.
2. 1 mg I.V.
3. 2 mg I.M.
4. 2 mg I.V.
Correct Answer: 2
RATIONALES: To reverse arrhythmias, bradycardia, or sinus arrest, the usual adult dosage of atropine is 0.4 to 1 mg I.V. every 2 hours as needed. The drug isn’t administered I.M. for the treatment of bradycardia
Two female nursing assistants approach the nurse on a cardiac step-down unit to report that a 45-year-old male client who experienced an acute myocardial infarction (MI) made sexual comments to them. How should the nurse intervene?
1. The nurse should explain that the client might have concerns about resuming sexual activity but is afraid to ask.
2. The nurse should report the incident to her supervisor immediately.
3. The nurse should instruct the nursing assistants to avoid answering his call light.
4. The nurse should explain that the client most likely wants extra attention.
Correct Answer: 1
RATIONALES: Sometimes clients are concerned about resuming sexual activity but are afraid to ask. Making inappropriate sexual comments provides a forum for asking questions. It’s not necessary to report the incident to the nursing supervisor immediately without investigating the situation further. The client’s call light must be answered in a timely fashion. More information is needed before assuming that the client is asking for extra attention.
Following coronary artery bypass grafting, a client begins having chest `fullness` and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
1. narrowing complex.
2. widening complex.
3. amplitude increase.
4. amplitude decrease.
Correct Answer: 4
RATIONALES: Fluid surrounding the heart such as in cardiac tamponade, suppresses the amplitude of the QRS complexes on an ECG. Narrowing and widening complexes as well as an amplitude increase aren’t what is expected on the ECG of an individual with cardiac tamponade
A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that aren’t followed by a beat. Which condition should the nurse suspect?
1. Failure to pace
2. Failure to capture
3. Failure to sense
4. Asystole
Correct Answer: 2
RATIONALES: Extra pacemaker spikes that aren’t followed by a beat may indicate failure to capture, in which the pacemaker fires but the heart doesn’t conduct the beat. In failure to pace, the pacemaker doesn’t fire when it should, causing hypotension and other signs of low cardiac output, accompanied by bradycardia or a heart rate slower than the pacemaker’s preset rate. In failure to sense, the pacemaker can’t sense the client’s intrinsic heartbeat; on the rhythm strip, spikes may fall on T waves, or they may fall regularly but at points where they shouldn’t appear. Asystole is characterized by an absent heart rate or rhythm as reflected by a flat line on the rhythm strip.
A client signed a consent form for participation in a clinical trial for implantable cardioverter-defibrillators. Which statement by the client indicates the need for further teaching before true informed consent can be obtained?
1. “This implanted defibrillator will protect me against some of those bad rhythms my heart goes into.”
2. “I wonder if there is any other way to prevent these bad rhythms.”
3. “The physician will make a small incision in my chest wall and place the generator there.”
4. “A wire from the generator will be attached to my heart.”
Correct Answer: 2
RATIONALES: Option 2 indicates that other treatment options weren’t discussed with the client. Before participation in a clinical trial, the client must be informed of all other available treatment options. Options 1, 3, and 4 are all true statements about implantable cardioverter-defibrillators.
The nurse is caring for a client with hemiparesis caused by a stroke. The client is barely responsive. Which intervention takes highest priority?
1. Performing passive range-of-motion (ROM) exercises
2. Placing the client on the affected side
3. Using hand rolls or pillows for support
4. Applying antiembolism stockings as ordered
Correct Answer: 2
RATIONALES: To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. Although performing ROM exercises, providing pillows for support, and applying antiembolism stockings may be appropriate interventions for a client who has had a stroke, maintaining a patent airway is the first concern.
A client with hypertension visits the health clinic for a routine checkup. The nurse measures the client’s blood pressure at 184/92 mm Hg and notes a 5-lb weight gain over the past month. Which nursing diagnosis reflects the most serious problem in managing a client with hypertension?
1. Noncompliance (nonadherence to therapeutic regimen)
2. Deficient knowledge (disease process)
3. Excess fluid volume
4. Imbalanced nutrition: More than body requirements
Correct Answer: 1
RATIONALES: Noncompliance is the most serious problem in managing a client with hypertension. One authority estimates that 40% to 60% of hypertensive clients fail to comply with prescribed treatment. Reasons for noncompliance include lack of symptoms, which makes the problem seem less serious; the difficulty of making required lifestyle changes, such as eating a low-sodium diet, stopping smoking, and losing or managing weight; adverse reactions to antihypertensive drugs; and the inconvenience and high cost of obtaining health care. The other options may promote or result from noncompliance. Deficient knowledge contributes to noncompliance; Excess fluid volume, caused by excess sodium intake, and Imbalanced nutrition: More than body requirements may result from noncompliance.
The nurse would obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia?
1. Calcium and magnesium
2. Potassium and calcium
3. Magnesium and potassium
4. Potassium and sodium
Correct Answer: 3
RATIONALES: Hypomagnesemia as well as hypokalemia and hyperkalemia are common causes of ventricular tachycardia. Calcium imbalances cause changes in the QT interval and ST segment. Alterations in sodium level don’t cause rhythm disturbances.
A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should avoid which of the following?
1. High volumes of fluid intake
2. Aerobic exercise programs
3. Caffeine-containing products
4. Foods rich in protein
Correct Answer: 3
RATIONALES: Caffeine is a stimulant, which can exacerbate palpitations, and should be avoided by a client with symptomatic mitral valve prolapse. High-fluid intake helps maintain adequate preload and cardiac output. Aerobic exercise helps increase cardiac output and decrease heart rate. Protein-rich foods aren’t restricted but high-calorie foods are.
A client is receiving a lidocaine (Xylocaine) I.V. infusion at 2 mg/minute to treat runs of ventricular tachycardia. The client experiences hypotension, dyspnea, and irregular heartbeats, indicating heart failure. Which action can the nurse expect the physician to take first?
1. Prescribing 100 mg of lidocaine P.O. every 6 hours
2. Decreasing the lidocaine infusion to 1 mg/minute
3. Increasing the lidocaine infusion to 3 mg/minute
4. Discontinuing the lidocaine infusion
Correct Answer: 2
RATIONALES: In a client with heart failure or hepatic disease, the maintenance infusion of lidocaine should be reduced by one-third to one-half. Because the client is currently receiving 2 mg/minute, the physician will probably decrease the rate to 1 mg/minute. Lidocaine isn’t administered in oral form because most of an absorbed dose undergoes first-pass metabolism in the liver. Increasing the rate of the lidocaine infusion can worsen heart failure. Discontinuing lidocaine isn’t warranted in the presence of life-threatening PVCs.
The nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, the nurse can anticipate using:
1. antiembolism stockings.
2. oxygen.
3. diuretics.
4. anticoagulants.
Correct Answer: 3
RATIONALES: Diuretics, such as furosemide (Lasix), reduce total blood volume and circulatory congestion. Antiembolism stockings prevent venostasis and thromboembolism formation. Oxygen administration increases oxygen delivery to the myocardium and other vital organs. Anticoagulants prevent clot formation but don’t decrease fluid volume excess.
The nurse administers furosemide (Lasix) to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
1. Increase in blood pressure
2. Increase in blood volume
3. Low serum potassium level
4. High serum sodium level
Correct Answer: 3
RATIONALES: Furosemide is a potassium-wasting diuretic. The nurse must monitor the serum potassium level and assess for signs of low potassium. As water and sodium are lost in the urine, blood pressure decreases, blood volume decreases, and urine output increases.
When assessing a client with left-sided heart failure, the nurse expects to note:
1. ascites.
2. jugular vein distention.
3. air hunger.
4. pitting edema of the legs.
Correct Answer: 3
RATIONALES: With left-sided heart failure, the client typically has air hunger and other signs of pulmonary congestion. Ascites, jugular vein distention, and pitting edema of the legs are signs of right-sided heart failure.
A client is evaluated for hypertension. The physician prescribes atenolol (Tenormin), 50 mg P.O. daily. Atenolol should have which therapeutic effect on the client?
1. Decreased cardiac output and systolic and diastolic blood pressure
2. Decreased blood pressure with reflex tachycardia
3. Increased cardiac output and systolic and diastolic blood pressure
4. Decreased peripheral vascular resistance
Correct Answer: 1
RATIONALES: As a long-acting, selective beta1 blocker, atenolol decreases cardiac output and systolic and diastolic blood pressure; however, like other beta-adrenergic blocking agents, it increases peripheral vascular resistance at rest and with exercise. Atenolol may cause bradycardia, not tachycardia.
A client develops atrial fibrillation after an acute myocardial infarction. The physician prescribes digoxin (Lanoxin), 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to:
1. an increased serum creatinine level.
2. a decreased serum digoxin level.
3. an increased serum creatine kinase (CK) level.
4. a decreased serum CK level.
Correct Answer: 3
RATIONALES: I.M. administration of digoxin isn’t recommended because it causes severe pain at the injection site and increases serum CK, which complicates interpretation of enzyme levels. Regardless of the route of administration, digoxin doesn’t increase the serum creatinine level. When digoxin is administered, the serum digoxin level will rise from zero, not decrease.
A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?
1. Race
2. Age
3. History of diabetes mellitus
4. History of aortic valve replacement
Correct Answer: 4
RATIONALES: A heart valve prosthesis, such as an aortic valve replacement, is a major risk factor for infective endocarditis. Other risk factors include a history of heart disease (especially mitral valve prolapse), chronic debilitating disease, I.V. drug abuse, and immunosuppression. Although race, age, and a history of diabetes mellitus may predispose a person to cardiovascular disease, they aren’t major risk factors for infective endocarditis.
The nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client would suggest lidocaine toxicity?
1. Nausea and vomiting
2. Pupillary changes
3. Confusion and restlessness
4. Hypertension
Correct Answer: 3
RATIONALES: The nurse should observe for signs of lidocaine toxicity, such as confusion and restlessness. Nausea and vomiting may occur with oral administration of mexiletine (Mexitil) or tocainide (Tonocard), other class IB drugs
(lidocaine isn’t administered orally). Pupillary changes and hypertension aren’t signs of lidocaine toxicity, although visual changes and hypotension may occur as adverse reactions to class IB drugs.
A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw.
He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
1. Complete the client’s registration information, perform an electrocardiogram, gain I.V. access, and take vital signs.
2. Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician.
3. Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team.
4. Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
Correct Answer: 4
RATIONALES: Cardiac chest pain is caused by myocardial ischemia. Administering supplemental oxygen increases the myocardial oxygen supply. Cardiac monitoring helps detect life-threatening arrhythmias. Ensure that the client isn’t hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team before completing the initial assessment is premature.
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?
1. Romberg’s
2. Phalen’s
3. Rinne
4. Homans’
Correct Answer: 4
RATIONALES: A positive Homans’ sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Romberg’s test assesses cerebellar function. Phalen’s test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.
A client comes to the physician’s office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse takes this opportunity to evaluate the client’s knowledge of the prescribed cardiac rehabilitation program. Which evaluation statement suggests that the client needs more instruction?
1. “Client performs relaxation exercises three times per day to reduce stress.”
2. “Client’s 24-hour dietary recall reveals low intake of fat and cholesterol.`
3. `Client verbalizes an understanding of the need to seek emergency help if the heart rate increases markedly while at rest.`
4. `Client walks 4 miles in 1 hour every day.`
Correct Answer: 4
RATIONALES: Four weeks after an MI, a client’s walking program should aim for a goal of 2 miles in less than 1 hour. Walking 4 miles in 1 hour is excessive and may induce another MI by increasing the heart’s oxygen demands. Therefore, this client requires appropriate exercise guidelines and precautions. The other options indicate understanding of the cardiac rehabilitation program. For example, the client should reduce stress, which speeds the heart rate and thus increases myocardial oxygen demands. Reducing dietary fat and cholesterol intake helps lower the risk of atherosclerosis. A sudden rise in the heart rate while at rest warrants emergency medical attention because it may signal a life-threatening arrhythmia and increase myocardial oxygen demands.
The nurse suspects that a 68-year-old client has digitalis toxicity. The nurse should assess for:
1. hearing loss.
2. vision changes.
3. decreased urine output.
4. gait instability.
Correct Answer: 2
RATIONALES: Vision changes, such as halos around objects, are signs of digitalis toxicity. Hearing loss can be detected through hearing assessment; however, it isn’t a common sign of digitalis toxicity. Intake and output aren’t affected unless there is nephrotoxicity, which is uncommon. Gait changes are also uncommon.
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
1. tracheal.
2. fine crackles.
3. coarse crackles.
4. friction rubs.
Correct Answer: 2
RATIONALES: Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
A client with chronic heart failure is receiving digoxin (Lanoxin), 0.25 mg by mouth (P.O.) daily, and furosemide (Lasix), 20 mg P.O. twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digitalis toxicity. Digitalis toxicity also may cause:
1. visual disturbances.
2. taste and smell alterations.
3. dry mouth and urine retention.
4. nocturia and sleep disturbances.
Correct Answer: 1
RATIONALES: Digitalis toxicity may cause visual disturbances (such as flickering light flashes, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (such as headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (abnormal heart rate and arrhythmias). Taste and smell alterations aren’t associated with digitalis toxicity. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.
Which treatment would be the best therapy for a stable client with digitalis toxicity?
1. Activated charcoal
2. Time and symptomatic treatment
3. Hemodialysis
4. Atropine
Correct Answer: 2
RATIONALES: Stable clients with digitalis toxicity are best treated with time while their kidneys excrete the metabolites and with the symptomatic treatment for the rhythm disturbances or nausea resulting from the toxicity. Activated charcoal is effective only if the client has taken an overdose of digitalis and a large amount of unabsorbed drug is in the GI tract, before the serum level is elevated. Hemodialysis is reserved for clients who are extremely unstable despite symptomatic treatment or who have inadequate renal function to excrete the drug. Atropine might be used to treat the bradycardia that results from digitalis toxicity, but it isn’t necessarily used to treat the toxicity itself.
To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:
1. elevational rubor.
2. no rubor for 10 seconds after the maneuver.
3. dependent pallor.
4. a 30-second filling time for the veins.
Correct Answer: 3
RATIONALES: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.
After extensive cardiac bypass surgery, a client returns to the intensive care unit on dobutamine (Dobutrex), 5 mcg/kg/minute I.V. Which classification best describes dobutamine?
1. Indirect-acting dual-active agent
2. Direct-acting beta-active agent
3. Indirect-acting beta-active agent
4. Direct-acting alpha-active agent
Correct Answer: 2
RATIONALES: Dobutamine acts directly on beta receptors. Thus, the drug can be described as a direct-acting beta-active agent. Adrenergic agents are classified according to their method of action and the type of receptor they act on. Directacting agents act directly on the sympathetically innervated organ or tissue, whereas indirect-acting agents trigger the release of a neurotransmitter, usually norepinephrine. Dual-acting agents combine direct and indirect actions. Adrenergic agents act on alpha, beta, and dopamine receptors.
A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic indicates myocardial ischemia?
1. Prolonged PR interval
2. Absent Q wave
3. Elevated ST segment
4. Widened QRS complex
Correct Answer: 3
RATIONALES: Ischemic myocardial tissue changes cause elevation of the ST segment, a peaked or inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.
A client is recovering from surgical repair of a dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurring dissection. These signs include:
1. hematuria and decreased urine output.
2. hypotension and tachycardia.
3. increased urine output and bradycardia.
4. hypotension and bradycardia.
Correct Answer: 2
RATIONALES: When caring for a client recovering from surgical repair of a dissecting aortic aneurysm, the nurse must monitor for hypotension with reflex tachycardia, decreased urine output, and unequal or absent peripheral pulses — all potential signs of bleeding or recurring dissection. Hematuria, increased urine output, and bradycardia aren’t signs of bleeding from aneurysm repair or recurring dissection.
The most common site of aneurysm formation is in the:
1. abdominal aorta, just below the renal arteries.
2. ascending aorta, around the aortic arch.
3. descending aorta, beyond the subclavian arteries.
4. aortic arch, around the ascending and descending aorta.
Correct Answer: 1
RATIONALES: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Options 2 and 4 are characteristic of Debakey type II aneurysms, whereas option 3 is indicative of Debakey type III aneurysms
The nurse is caring for a client with end-stage heart failure who is awaiting a heart transplant. The client tells the nurse that he thinks he’s going to die before a donor heart is found. He also tells the nurse that he hasn’t been attending a church but wants to talk to a priest. What action should the nurse take?
1. Contact her priest to see if he will see the client.
2. Reassure the client that he has nothing to worry about because donors are usually found in time.
3. Tell the client that it doesn’t matter if he attends a church or not.
4. Contact the clergy member who is assigned to the transplant team.
Correct Answer: 4
RATIONALES: Each multidisciplinary transplant team has a clergy person assigned. The nurse should contact that person and request that he visit the client. It isn’t appropriate for the nurse to ask her priest to see the client. Telling the client that he has nothing to worry about because donors are typically found offers false reassurance. Telling the client that it doesn’t matter if he attends a church invalidates the client’s concern.
The nurse reviews a client’s medication history before administering a cholinergic blocking agent. Which drug may have delayed absorption because of the adverse effects of a cholinergic blocking agent?
1. amantadine (Symmetrel)
2. nitroglycerin (Nitrostat)
3. digoxin (Lanoxin)
4. diphenhydramine (Benadryl)
Correct Answer: 2
RATIONALES: A cholinergic blocking agent may delay the sublingual absorption of nitroglycerin because of dry mouth. The nurse should offer the client sips of water before administering nitroglycerin. Amantadine, digoxin, and diphenhydramine can interact with a cholinergic blocking agent but not through delayed absorption. Amantadine and diphenhydramine enhance the effects of anticholinergic agents.
A client is hospitalized with end-stage cardiomyopathy. The physician, nurse, client and her family discuss the possibility of heart transplantation. After this discussion, the nurse and physician meet to discuss the case. The physician voices his concern that the client will not change her lifestyle to accommodate transplantation. Which response by the nurse indicates her role as a client advocate?
1. `She only smokes a few cigarettes per day.`
2. `With the proper support and education, she could make the necessary changes.`
3. `It’s not easy to make and maintain these kinds of changes.”
4. “A transplant would save her life.”
Correct Answer: 2
RATIONALES: In option 2, the nurse is advocating for the client by telling the physician that with proper education and support, the client could most likely make the necessary lifestyle changes. Informing the physician about the number of cigarettes the client smokes each day does not indicate advocacy. In option 3, the nurse is indicating that she is doubtful that the client could make the necessary changes. Option 4 may be true; however, this example does not display client advocacy.
The nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates a good understanding of an advance directive?
1. “I will rely on my doctor to do whatever is best for me.”
2. “Once I decide on an advance directive, I cannot change my mind.”
3. “A living will allows my decisions for health care to be known if I can’t speak for myself.`
4. `A health care power of attorney will allow my daughter to use my funds to pay for my health care costs, if I can’t do so”
Correct Answer: 3
RATIONALES: An advance directive is a document written in the form of a living will. It expresses the client’s wishes about health care, providing direction for the physician if the client becomes terminally ill and can’t express his wishes. Option 1, which requires relying on the physician to decide care, takes the decision away from the client. A client can change his mind about advance directives at any time. A health care power of attorney allows the client to designate another person to make health care decisions for the client in case that the client becomes too ill to make his own decisions.
When measuring the radial pulse of a client with known aortic insufficiency, the nurse isn’t surprised to find a `waterhammer` or Corrigan’s pulse. What are the characteristics of this pulse?
1. Weak and feeble, with a slow upstroke and prolonged peak
2. Alternating strong and weak beats
3. Rapid upstroke with two systolic peaks
4. Bounding, with a rapid rise and fall
Correct Answer: 4
RATIONALES: A “water-hammer” pulse is bounding, with a rapid rise and fall. A weak, feeble pulse with a slow upstroke and prolonged peak is called pulsus tardus. A pulse with alternating weak and strong beats and a regular rhythm is termed pulsus alternans. A pulse with a rapid upstroke and two systolic peaks is called pulsus bisferiens.
After abdominal surgery, which factor would predispose a client to deep vein thrombosis?
1. The client is 5? 9? tall and weighs 128 lb.
2. The client has been pregnant four times.
3. The client usually walks 3 miles a day.
4. The client will be immobile during and shortly after surgery.
Correct Answer: 4
RATIONALES: Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis.
Other predisposing factors for this condition include obesity and current pregnancy, which don’t apply to this client. Exercise isn’t a risk factor or preventive measure for deep vein thrombosis.
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