Cardiology

Question 1

The nurse is monitoring a client who has recently undergone pericardiocentesis. Following the procedure, the nurse assesses the client and finds a decreased blood pressure, distended neck veins, and clear lungs. The nurse suspects that the client has developed which of the following?

1) Heart failure
2) Cardiac tamponade
3) Pericarditis
4) Cardiomyopathy

Answer 1

Cardiac tamponade
Rationale: Cardiac tamponade occurs as a result of accumulation of fluid in the pericardial sac. This restricts filling of the cardiac chambers and thus reduces stroke volume, cardiac output, and blood pressure. Because the right atrium is also affected, jugular venous distention (JVD) occurs and the lungs are clear. In heart failure (option 1), the cardiac chambers are dilated, and the increase in volume and pressure is reflected back to the lungs causing crackles to develop as an early sign. Pericarditis (option 3) is one cause of cardiac tamponade. Signs of pericarditis include a temperature elevation and chest pain. Cardiomyopathy may cause heart failure with the development of crackles (option 4).

Question 2

A 54-year-old male client was recently diagnosed with subacute bacterial endocarditis (SBE). The nurse determines that the client understands the discharge teaching when he makes which statement?

1) “I need a referral to a dietician to understand a low- sodium diet.”
2) “I have to call my doctor so I can get antibiotics before seeing the dentist.”
3) “Can I take the antibiotics as a pill now?’
4) “If I quit smoking, it will help the endocarditis.”

Answer 2

“I have to call my doctor so I can get antibiotics before seeing the dentist.”

Rationale: Once a client is diagnosed with SBE, he or she is at risk for repeated episodes. Taking prophylactic antibiotics prior to dental care is an important activity to prevent further infections. There is no routine sodium restriction with SBE unless heart failure develops (option 1). Antibiotic treatment for SBE is given by the IV route for the entire course (option 3). Although stopping smoking will decrease his risk factor for coronary artery disease, it does not affect the SBE (option 4).

Question 3

The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client’s condition is worsening after noting which of the following with client assessment?

1) Sinus tachycardia becomes normal sinus rhythm
2) Urine drainage is increased in amount
3) A cough develops with pink frothy sputum
4) Falls asleep when not disturbed

Answer 3

A cough develops with pink frothy sputum
Rationale: Heart failure is the accumulation of fluid in the alveoli characterized by increased crackles, tachypnea, tachycardia, pink frothy sputum, decreased SO2 and PO2. The amount and severity of symptoms indicates the severity of the disease. The client in heart failure presents with acute restlessness and anxiety and is unable to fall asleep when acutely short of breath (option 4). The SNS stimulation not only causes the anxiety but also a tachycardia. As the SNS stimulation decreases and heart failure resolves, the heart rate declines (option 1). Urine output is generally decreased in heart failure clients but is increased when treated with diuretic therapy (option 2).

Question 4

A client is scheduled for coronary angiography. In reviewing the client’s record, what significant finding would the nurse report to the healthcare provider before the diagnostic procedure?

1) Client reported an allergy to shrimp.
2) Client’s electocardiogram shows atrial fibrillation
3) Potassium level is 4.0 mEq/L
4) Client has a history of chronic renal failure

Answer 4

Client reported an allergy to shrimp.
Rationale: The contrast medium or dye typically used for cardiac angiography is iodine based. The client with a known allergy to shellfish is at risk for anaphylaxis and requires the use of an alternate (hypoallergenic) contrast medium. Atrial fibrillation (option 2) and chronic renal failure (option 4) are not contraindications to cardiac angiography. A value of 4.0 mEq/L is normal value for potassium (option 3).

Question 5

The nurse is implementing a discharge teaching plan for a client newly diagnosed with heart failure. When discussing fluid status with the client, the nurse would explain the importance of doing which of the following?

1) Restricting fluid intake to apx 800 mL/ day
2) Taking an extra diuretic if there is decreased urination for several days
3) Recording body weight every day before breakfast and report a weight gain of 3 or more pounds in a week
4) Keeping track of daily output and calling hp if it is less than 1 L on anyday

Answer 5

Recording body weight every day before breakfast and report a weight gain of 3 or more pounds in a week.
Rationale: Daily weight is the most sensitive indicator of changes in fluid status. It is more accurate for a client at home than urine output (option 4). A fluid restriction (option 1) may be recommended for a client with advanced heart failure, but it is not a method of monitoring fluid status. The client should never adjust the dose of his or her medications independently (option 2).

Question 6

The nurse is caring for a client with complete heart block who is being prepared to have a temporary transvenous pacemaker inserted. In briefly explaining the blockage to the cardiac conduction system to the client, the nurse would point out which area on the diagram shown? Select the affected area.

Answer 6

Atrioventricular node (AV node, bundle of His)
Rationale: Atrioventricular (AV) node heart block occurs because of conduction abnormalities at AV node . First-degree block indicates a slowed AV nodal conduction (PR interval greater than 0.2 second duration). Second-degree indicates intermittent AV nodal block that can be either Mobitz Type 1 or Type 2. Third-degree block (complete heart block) indicates a complete dissociation between atrial and ventricular conduction fibers because of a loss of impulse transmission through the AV node. The other areas are unaffected.

Question 7

A client is getting ready to go home after acute myocardial infarction (AMI). The client is asking questions about the prescribed medications, and wants to know why metoprolol (Lopressor) was prescribed. The nurse’s best response would be which of the following?

1) “Your heart was beating too slowly, and metoprolol increases your heart rate.”
2) “Lopressor helps to increse the blood to the heart by dialating your coronary arteries.”
3) “Lopressor helps make your heart beat stronger to supply more blood to your boby.”
4) “Lopressor slows your heart rate and decreases the amount of work it has to do so it can heal.”

Answer 7

“Lopressor slows your heart rate and decreases the amount of work it has to do so it can heal.”

Rationale: Metoprolol (Lopressor) is a beta adrenergic blocker that slows the heart rate and decreases myocardial contractility (option 4). These actions reduce cardiac workload. Because of this, options 1 and 3 cannot be true. Nitroglycerine is a drug that dilates the coronary arteries (option 2).

Question 8

A client is taking digoxin (Lanoxin) and furosemide (Lasix) for heart failure. The nurse approves of which of the following client selections that is the best menu choice for this client?

1) Chicken with baked potato and cantaloupe.
2) Ham and cheese omelet with low- cholesterol egg substitute
3) Grilled cheeseand and pan- browned potatoes
4) Pizza with low- fat mozzarella cheese and pepperoni

Answer 8

Chicken with baked potato and cantaloupe.
Rationale: Furosemide is a loop diuretic that causes a loss of serum potassium. When taken concurrently with digoxin, it can potentiate digoxin toxicity. For clients who are taking a diuretic regularly, especially with concurrent digoxin, they should be instructed to eat foods high in potassium and low in sodium to prevent additional fluid overload with heart failure and prevent excess potassium loss. Chicken, potato, and cantaloupe are all potassium-rich foods (option 1), while the foods in options 2, 3, and 4 are higher in sodium. Note that the foods in options 3 and 4 are also higher in fat.

Question 9

The nurse is caring for a newly admitted client with a diagnosis of restrictive cardiomyopathy. When planning this client’s care, which of the following would be the most appropriate nursing diagnosis?

1) Fear related to new onset of symptoms.
2) Hopelessness related to lack of cure and debilitating symptoms.
3) Defecient knowledge related to medication regime.
4) Activity intolerance related to decreased cardiac output.

Answer 9

Activity intolerance related to decreased cardiac output.
Rationale: All clients with cardiomyopathy have some decrease in their cardiac output and corresponding activity intolerance (option 4). The experiences of fear (option 1), hopelessness (option 2), or deficient knowledge (option 3) are client specific and must be evaluated on an individual basis. Any or all of these may be present, but more data would be needed to determine whether the other nursing diagnoses apply.

Question 10

The nurse working on a cardiac telemetry unit prepares to utilize an external pacemaker after noting that an assigned client has a blood pressure of 70/52 and has developed which of the following cardiac dysrhythmias?

1) Ventricular fibrillation.
2) Atrial fibrillation.
3) Ventricular tachycardia.
4) Second-degree heart block.

Answer 10

Second-degree heart block.
Rationale: The client with severe bradycardia, third-degree or complete heart block, or second-degree heart block (which has a high potential to progress to complete AV block) are those who are most likely to need an external pacemaker as a temporary therapy until definitive treatment can be given. Defibrillation is the only effective and definitive treatment for a client who is in ventricular fibrillation (option 1). A client in rapid atrial fibrillation (option 2) and unstable ventricular tachycardia (option 3) may require synchronized cardioversion to terminate the abnormal rhythm.

Question 11

The nurse has admitted a client to the emergency department with complaints of chest pain over the previous 2 hours. There are no clear changes on the 12-lead electrocardiogram (ECG). The nurse would expect which laboratory test to provide confirmation of a myocardial infarction (MI)?
CK of 320 with MB of 12%

Answer 11

CK of 320 with MB of 12%
Rationale: A CK level > 150 with > 5% MB isoenzyme indicates myocardial damage from acute myocardial infarction (option 3). An MM band relates to skeletal muscle damage (option 2). Elevated potassium is not indicative of myocardial infarction (option 1). Elevated white blood count (WBC) is an indicator of many conditions including MI (option 4).

Question 12

The nurse is preparing to discharge a client after coronary artery bypass graft (CABG) surgery. The client is taking several new medications including digoxin (Lanoxin), metoprolol (Lopressor), and furosemide (Lasix). The client reports nausea and anorexia. Before reporting this new finding to the health care provider, the nurse checks which priority laboratory test result?
Digoxin level

Answer 12

Digoxin level
Rationale: Nausea and anorexia are signs of digitalis toxicity (option 4). Although hypokalemia can predispose the client to digitalis toxicity, it is not the most important value to note. The sodium level and INR (options 2 and 3) are not applicable.

Question 13

The registered nurse (RN) has finished reviewing the 07:00 shift report on a telemetry unit. Which of the following would be the best client for the RN to assign to the licensed practical nurse (LPN)?

Answer 13

Rationale: A stable client with complex dressings is an appropriate assignment for a LPN, because the procedures are appropriate for an LPN (option 1). Initial assessment (new admission from the ED) (option 2), the assessment of a client before and after a complex procedure (PTCA) (option 4) and discharge teaching (option 3) are all responsibilities of the professional registered nurse and may not be delegated to the LPN.

Question 14

The nurse is caring for a client with a history of hypertension who is being treated with metoprolol (Lopressor), hydrochlorothiazide (Hydrodiuril), and captopril (Capoten). The client has a blood pressure of 120/80 mmHg, and a pulse rate of 48. Which of the following is the best action by the nurse?

Answer 14

Administer the captopril and the hydrochlorothiazide, withhold the metoprolol, and notify the health care provider.
Rationale: The client’s heart rate reveals bradycardia and metoprolol, a beta blocker, decreases the heart rate (option 2). Neither the captopril nor the hydrochlorothiazide lower the heart rate, and may be safely administered to maintain control of the hypertension. When a dose of medication is withheld, it is the responsibility of the nurse to notify the health care provider of the action and rationale.

Question 15

The nurse has finished reviewing the intershift report on a cardiac unit. The nurse should plan to see which of the following assigned clients first?

Answer 15

Client receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain.
Rationale: A client with endocarditis is at risk for thrombus formation, and chest pain and anxiety are signs of pulmonary embolism (PE), which is a life-threatening complication that requires immediate attention (option 3). The other conditions are serious but not as pressing as the client with possible PE. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy which requires assessment (option 1); a temperature of 101°F requires additional assessment (option 4); and a client who is ambulating for the first time will be assessed by the nurse (option 2). The nurse can assess all of these clients once the life-threatening problem is assessed.

Question 16

A client with a new diagnosis of atrial fibrillation is being discharged to home. The nurse explains that which of the following is an important symptom to report to the physician?

Answer 16

Hemoptysis
Rationale: A serious complication of atrial fibrillation is pulmonary embolism (option 4). Chest pain and hemoptysis are common symptoms of pulmonary embolism. Irregular pulse is expected with atrial fibrillation (option 1). Fatigue may accompany atrial fibrillation in some individuals (option 3) particularly if the heart rate is elevated. Fever is not associated with atrial fibrillation (option 2), and is not necessarily included in discharge teaching. Another serious complication of atrial fibrillation not addressed in the question is stroke, so a change in level of consciousness or other signs of stroke would also warrant immediate attention.

Question 17

The nurse is caring for a client with a history of renal failure and a new myocardial infarction. The nurse is reviewing laboratory findings and calls the health care provider to report which result?

Answer 17

Calcium level of 7.0 mg/dL
Rationale: Renal failure is a common cause of hypocalcemia and a value of 7.0 mg/dL is below the normal range of serum calcium, which is 9-11 mg/dL (option 3). Options 1 and 2 are within normal ranges for potassium (3.5-5.1 mEq/L) and sodium (135-145 mEq/L) and option 4 is within the therapeutic range of digoxin (0.5-2.0 ng/mL).

Question 18

A client has had a permanent pacemaker inserted in the operating room as treatment for complete heart block. The nurse determines that which of the following client outcomes indicates a successful procedure?

Answer 18

Client’s cardiac monitor shows paced beats at the rate of 68 per minute
Rationale: The client is not allowed to ambulate for 24 hours to prevent dislodging of the electrodes (option 1). Normal sinus rhythm, heart rate of 80 and a BP of 120/80 do not explicitly reflect pacemaker function (options 2 and 3). Paced beats indicate that the pacemaker is functioning (option 4).

Question 19

The nurse is caring for a client with a diagnosis of aortic stenosis. The client reports episodes of angina and passing out recently at home. The client has surgery scheduled in two weeks. Which of the following would be the nurse’s best explanation about activity at this time?

Answer 19

Rationale: Symptomatic aortic stenosis has a poor prognosis without surgery because of a fixed cardiac output. Restricting activity limits myocardial oxygen consumption and demand for an increased cardiac output (option 1). Since the incidence of sudden death is high in this population, it is prudent to decrease the strain on the heart while awaiting surgery. Each of the incorrect options has some degree of exercise or activity that could increase the cardiac demand more than the cardiac muscle can accommodate.

Question 20

The nurse is caring for a client who just underwent cardiac angiography. The catheter insertion site has no bleeding or signs of hematoma. The vital signs and distal pulses remain in the client’s normal range. The intravenous fluids were discontinued. The client is not hungry or thirsty and refuses any food or fluids, asking to be left alone to rest. Which of the following is the nurse’s best response?

Answer 20

“It is important to drink fluids after this procedure, to protect your kidney function. I will bring you a pitcher of water for you to drink.”

Rationale: The contrast medium (dye) used in angiography is nephrotoxic, and the client should have adequate fluids after the procedure to eliminate the dye (option 3). Resting is not contraindicated after the procedure as long as the client has adequate fluids (option 1). Leg exercises are not recommended (option 4). Although a client can walk 6 or more hours after angiography, the most important intervention that the client needs is to encourage fluids (option 2).

Question 21

The nurse on a telemetry unit has just taken change of shift report. Which client should the nurse assess first?

Answer 21

Client with new multifocal premature ventricular beats
Rationale: New onset of multifocal premature ventricular beats may indicate ventricular irritability and this client is at risk to go into ventricular tachycardia. This client is the nurse’s first priority (option 3). A client who is in atrial fibrillation (option 1) should be assessed next followed by the client with first-degree heart block (option 4) so that the nurse can determine the adequacy of their cardiac output, but their condition is less immediate. The client who has converted to normal sinus rhythm can be assessed last because this client is in the normal cardiac rhythm, indicating lowest risk (option 2).

Question 22

The night nurse is caring for a client with an acute exacerbation of heart failure. The nurse plans for adequate rest for this client by which of the following?

Answer 22

Getting a recliner chair for the client
Rationale: Paroxysmal nocturnal dyspnea is a frequent symptom of acute heart failure. The recliner will allow the client to rest better with the head elevated (option 1). In the acute exacerbation, fluids are not usually encouraged (option 3) and an indwelling urinary catheter is often used to obtain accurate intake, so frequent trips to the bathroom are not necessary (option 2). Hourly vital signs are not necessary with the information given (option 4).

Question 23

The nurse is discharging a client to home after an extensive myocardial infarction with considerable damage to the left ventricle. The client now tires easily and tells the nurse that he is depressed and thinks that his life is worthless. Which of the following is the most appropriate response by the nurse?

Answer 23

“You have just been through a very difficult time. I can arrange for you to talk to someone about your feelings while you continue your recovery.”

Rationale: Neither false reassurance nor advice is helpful with a client who expresses feelings of depression after a major change of function (options 1 and 2). Exploration is not appropriate during a discharge because the nurse cannot follow up (option 4). Validation of the client’s feelings and providing a resource to follow up on the depression is the most appropriate response for the nurse at this time (option 3).

Question 24

The client with coronary artery disease is starting a program to lower the blood cholesterol level. Which foods should the nurse advise the client to increase in the diet?

Answer 24

Whole grain breads and cereals

Rationale: Although low-fat desserts (option 3) and egg whites (option 1) are good to substitute for high-fat desserts and whole eggs, it is not necessary to increase the proportion of these foods in the diet. Whole grain breads and cereals are high in fiber and should be a larger portion of a diet to lower cholesterol (option 2). Many fish are recommended (because omega-3 fatty acids that have been shown to reduce triglycerides), but shellfish are high in cholesterol and are not recommended (option 4).

Question 25

The homecare nurse is caring for a client who has been taking warfarin (Coumadin) anticoagulant therapy after a valve replacement. The client has a prothrombin time (PT) of 66 seconds with an international normalized ratio (INR) of 4.5. The nurse checks for an order for which of the following?

Answer 25

Vitamin K

Rationale: Vitamin K is the antidote for warfarin (Coumadin) (option 1). Potassium chloride will not reduce the effect of warfarin (option 2). Protamine sulfate is the antidote for heparin (option 3). Administration of another anticoagulant would be contraindicated in this client (option 4).

Question 26

A client has recently had a major myocardial infarction. The nurse determines that the client understands discharge teaching when the client makes which of the following statements?

Answer 26

“I told my wife that I could have sexual relations once I can climb two flights of stairs without any difficulty.”

Rationale: Diet (option 1), stress, and smoking (option 2) are three modifiable risk factors for coronary artery disease. The client does not indicate understanding of any diet modifications, and smoking is not an appropriate stress reducer for an individual recovering from MI. Sexual relations may be resumed once the client can walk up two flights of stairs without dyspnea or chest pain (option 3). After a myocardial infarction, exercise should be increased incrementally. It may take a long time to return to the pre-MI level of exercise (option 4).

Question 27

The nurse is caring for a client who was diagnosed with pericarditis. The nurse would question an order for which medication that was ordered for this client?

Answer 27

Heparin sodium (Liquaemin)

Rationale: Because of the risk of cardiac tamponade, anticoagulants are contraindicated with pericarditis (option 2). Non-steroidal anti-inflammatory medications such as ibuprofen are recommended for pericarditis (option 1). Potassium chloride is indicated when a client’s potassium level is low (option 3). Prednisone (Deltasone) may be required as treatment (option 4)

Question 28

The nurse is caring for the client on the day after coronary artery bypass graft (CABG) surgery. An appropriate nursing diagnosis for this client is which of the following?

Answer 28

Ineffective breathing pattern related to pain
Rationale: All clients recovering from cardiac surgery are at risk for Ineffective breathing pattern related to pain (option 2) because of the extensive nature of the surgery. The prognosis is generally improved after successful cardiac surgery (option 1) and there is little risk of sudden cardiac death (option 4). Nurses typically manage clients for excess fluid volume because of the volume of fluids used during surgery and possible decreased cardiac output in the immediate postoperative period (option 3).

Question 29

The home care nurse is caring for a client with heart failure who has a new prescription for captopril (Capoten). The nurse makes it a priority to give which of the following instructions to the client?

Answer 29

Avoid standing suddenly, because it might cause dizziness and fainting.
Rationale: Captopril may increase heart rate initially (option 1). Clients often experience hypotension, dizziness and fainting especially with the first dose (option 2). Cough (option 3) and metallic taste (option 4) are benign side effects of captopril and do not indicate serious issues with the treatment.

Question 30

A client presents to the clinic with a temperature of 102° F, malaise, anorexia, and petechiae on the trunk. The white blood count (WBC) is normal. The client states that she probably just has the flu. The nurse is especially careful to assess which of the following?

Answer 30

Heart sounds

Rationale: The presenting symptoms (particularly the petechiae on the trunk) strongly suggest subacute bacterial endocarditis (SBE). Cardiac murmurs are present in about 90% of individuals with endocarditis (option 1). The other responses would not provide additional data to support a diagnosis of SBE.

Question 31

A client is being treated for new onset heart failure with a sodium-controlled diet, digoxin (Lanoxin) and furosemide (Lasix). The ECG monitor shows a new U wave. Based on this new finding the nurse determines that it is important to note which of the following laboratory test results?

Answer 31

Potassium 3.0 mEq/L

Rationale: A side effect of digoxin and furosemide is that they promote the excretion of potassium and a U wave is a sign of hypokalemia. The nurse should note the low potassium level (normal 3.5-5.1 mEq/L) (option 2). The sodium (normal 135-145 mEq/L), calcium (normal 9-11 mg/dL), and magnesium (normal 1.5-2.5 mEq/L) levels would not provide information about this side effect.

Question 32

The nurse is caring for a client who has a central venous pressure (CVP) monitor. The nurse prepares to measure the CVP by placing the client in which of the following positions?

Answer 32

Supine, with the transducer at the level of the right atrium

Rationale: The transducer must be at the same level as the right atrium in order to obtain an accurate measurement (option 1). The client may be flat or in a semi fowlers position as long as the client is completely on his or her back and the transducer is level with the right atrium. It is the nurse’s responsibility to level the CVP transducer to this point at regular intervals according to policy and before each measurement.

Question 33

The nurse on a telemetry unit is caring for a client who has infrequent premature ventricular contractions (PVCs) noted on the continuous ECG monitor. In preparing discharge instructions, which of the following statements is most appropriate to say to this client?

Answer 33

“Avoid caffeine and nicotine, because they may contribute to your irregular heartbeats.”

Rationale: It is recommended that clients having PVCs eliminate caffeine and nicotine (making option 2 correct and option 4 incorrect).Vitamin K is associated with bleeding and not the development of PVCs (option 1). There is no evidence in the question that this client has a potassium deficiency (option 3), or is at risk for one.

Question 34

The nurse is caring for a client with a new onset of atrial fibrillation. The client presents with hypotension and dizziness. The nurse is administering digoxin (Lanoxin) and is assessing the apical pulse. The nurse expects to hear which of the following? Select all that apply.

Answer 34

Very rapid ventricular rate; Rhythm that is irregularly irregular.

Rationale: In atrial fibrillation up to 600 atrial impulses are reaching the AV node at irregular intervals and those conducted through to the ventricles are random; therefore atrial fibrillation is characterized by an irregularly irregular QRS rhythm (option 3). The symptoms of hypotension and dizziness indicate a decrease in cardiac output which is consistent with a rapid ventricular rate (option 1). A regular rhythm with intermittent irregular beats could be premature beats with a regular rhythm (option 2). A regular rhythm with intermittent pauses could be a heart block or the compensatory pause following a premature ventricular contraction (option 4). The atrial rate cannot be auscultated (option 5).

Question 35

The nurse in the emergency room is administering t-PA (Activase) for an acute myocardial infarction. In order to avoid a serious complication of this treatment, the nurse plans to do which of the following as a priority?

Answer 35

Assess client’s neurological status frequently

Rationale: Cerebrovascular accident (CVA) is the most significant complication of thrombolytic therapy. The most important intervention to detect this complication is frequent assessment of neurological status (option 1). Testing for occult blood is important with these clients to detect GI or urinary tract bleeding, a less serious complication (option 2). PTT monitoring (option 3) determines the level of anticoagulation but does not identify a specific area of bleeding. Teaching a client to use a soft toothbrush is important to prevent bleeding gums, a minor complication of this therapy (option 4).

Question 36

The homecare nurse is caring for a client with cardiomyopathy whose symptoms have become more severe over the last year. On the first visit the client reports extreme fatigue and dyspnea with any activity. The client is irritable and withdrawn. The best response by the nurse is which of the following?

Answer 36

“It must be difficult to experience these changes.”

Rationale: Irritability and withdrawal may be a sign of feelings of depression. Validating the difficulty of the client’s experience is an intervention to create an environment of acceptance and empathy (option 4). The prognosis is often poor with advanced cardiomyopathy and little can be done to increase the client’s activity level because of the low cardiac output (options 1 and 2). The symptoms usually become worse as the disease progresses (option 3).

Question 37

The nurse is caring for a client with subacute bacterial endocarditis (SBE). In assessing for complications of SBE, the nurse is especially alert for which of the following symptoms?

Answer 37

Sudden onset of dyspnea, anxiety, and tachycardia

Rationale: The most significant complication is arterial embolization of the vegetations. Sudden onset dyspnea, anxiety, and tachycardia are signs of pulmonary embolization (option 3). Chills and fever may be symptoms of SBE but do not signal a complication (option 1). Bleeding gums and occult blood are not symptoms of a direct complication of SBE (option 2). The client with SBE usually has a normal WBC (option 4).

Question 38

The homecare nurse is visiting a client who has heart failure. The client denies any changes in how she feels. The nurse notes that the client has gained 3 pounds in the last week, and the client is concerned about the weight gain. Which of the following is the best statement for the nurse to make at this time?

Answer 38

“Let’s review what medications you have taken this week.”

Rationale: In a client with heart failure, a weight gain of 3 to 5 pounds over a week is a significant indicator of an increase in retained fluid. The fluid increase indicates that the therapeutic regime is not adequate for this client. It is important for the nurse to ascertain if the client has been taking his or her prescribed diuretics, and consult with the primary care provider before the client’s fluid overload becomes excessive (option 3). It is not appropriate to provide false reassurance to a client (option 2). Diet alone is not adequate to treat this increase in fluids (options 1 and 4).

Question 39

The nurse is caring for a client who was just admitted to the cardiac care unit with a myocardial infarction (MI). The nurse is most concerned about achieving which client outcome?

Answer 39

The client will be pain-free.

Rationale: Pain is usually the first presenting sign of new or extended MI and stimulates the SNS to increase heart rate and contractility. These actions increase myocardial oxygen demand and increase ischemia further. It is essential to relieve the pain to alleviate this self-perpetuating cycle (option 3). The activity order for a client immediately post-MI is usually bedrest with commode privileges with ambulation about the third day (option 1). Although an important client outcome is to be free from life-threatening dysrhythmias, clients frequently have benign dysrhythmias after a MI, and many are not in normal sinus rhythm (option 4). Maintaining a balanced intake and output is important, but not as critical as remaining pain-free (option 2).

Question 40

The nurse is caring for a client with continuous ECG monitoring. The nurse observes that the client’s rhythm has changed to the rhythm. After activating the emergency response system, the next best action by the nurse is to do which of the following?

Answer 40

Immediately defibrillate the client

Rationale: The rhythm shown in the figure is ventricular fibrillation. This is a cardiac emergency and immediate defibrillation is the recommended response (option 4). Administration of intravenous lidocaine is recommended for ventricular tachycardia (option 3). Checking vital signs (option 2) and calling the health care provider (option 1) are included once the emergency response system is activated.

Question 41

A client is prescribed sublingual nitroglycerine for the treatment of angina pectoris. The nurse concludes that what response from the client indicates understanding of this medication?

1) “My healthcare provider gave me a year’s supply of nitroglycerin tablets.”
2) “I will carry my nitroglycerin tablets in the inside pocket of my jacket, so they are always close to me.”
3) “I usually take 3 of my nitroglycerin tablets at the same time. I find that they work better that way.”
4) “I have a small metal labeled case for a few nitroglycerine tablets that I carry with me when I go out.”

Answer 41

“I have a small metal labeled case for a few nitroglycerine tablets that I carry with me when I go out.”

Rationale: Nitroglycerine tables are light sensitive and should be stored in a dry, dark container (option 4). Nitroglycerine loses potency over time and should be replaced every 6 months or sooner as needed (option 1). Exposure to moisture, light, or to heat, as in the pocket of a jacket (option 2) may decrease the effectiveness of the tablet. One nitroglycerine tablet should be taken at a time five minutes apart (option 3); taking more that one tablet at a time can actually cause severe hypotension.

Question 42

The nurse is caring for a client with a diagnosis of first-degree heart block. The nurse anticipates that the client’s cardiac rhythm strip will reveal which of the following? Select all that apply.

1) Number of QRS complexes are half the number of P waves.
2) PR interval is consistent
3) QTis prolonged
4) P wave rate is usually slower than the QRS rate
5) PR interval is prolonged

Answer 42

PR interval is consistent; PR interval is prolonged.

Rationale: In first-degree heart block, the PR interval is prolonged (> 0.20 second) but consistent in length from complex to complex (options 2 and 5). The number of P waves and QRS complexes are equal in number (options 1 and 4). The QT segment could become prolonged because of the effects of some anti-dysrhythmic drugs (option 3).

Question 43

The nurse is caring for a client who has just returned from the cardiac catheterization lab following a percutaneous transluminal coronary angioplasty (PTCA). The client is receiving a continuous infusion of heparin. The urine is now tea colored. What action should the nurse take next?
Assess the insertion site for bleeding and measure pulse and blood pressure.
1) Notify the hp and ask for an order for an aPTT.
2) Monitor the urine for any additional change in color.
3) Assess the insertion site for bleeding and measure pulse and blood pressure.
4) Ask the client if there is any chest pain.

Answer 43

Assess the insertion site for bleeding and measure pulse and blood pressure.

Rationale: Heparin is an anticoagulant that is given following a PTCA to prevent clot formation at the site of the PTCA. If the therapeutic level of heparin is exceeded, the client may bleed. Tea-colored urine is a sign of blood in the urine and additional assessment data is needed regarding other possible sources of bleeding or hypovolemia due to hemorrhage (option 3). Once this additional important data is gathered quickly, the healthcare provider would be notified (option 1). Further observation of the color of the urine could potentially worsen the bleeding as the coagulation profile would be further prolonged (option 2). While the nurse will ask the client if chest pain is present after an angioplasty because of the risk of coronary spasm, there is no relationship between tea colored urine and chest pain (option 4).

Question 44

The nurse is caring for a client being discharged after valve replacement surgery using a St. Jude mechanical valve. The nurse is reviewing the instructions for the client’s follow-up care and determines that the client understands the instructions when the client states:

1) “I will take Warfarin (Coumadin) for 2 months and my blood drawn every week until I stop taking the drug.”
2) “I will remind the doctor to give me a prescription for an anticoagulant medication everytime I go to the dentist.”
3) “I will need to take anticoagulant medication for the rest of my life.”
4) “I won’t take any anticoagulant medication or blood thinners because they may cause a problem with my new valve.”

Answer 44

“I will need to take anticoagulant medication for the rest of my life.”

Rationale: A mechanical valve requires life-long anticoagulation therapy to decrease the risk of thrombus formation (option 3). If a valve is replaced with a tissue valve, anticoagulation may be required during the immediate postoperative period but is not necessarily lifelong. Therefore, the statements in options 1 and 4 cannot be correct. It is recommended to take antibiotics prior to dental care (option 2).

Question 45

The nurse is caring for a client on the second postoperative day after coronary artery bypass (CABG) surgery. The client has a nursing diagnosis of Impaired gas exchange. Which action would the nurse take to best assist the client with this diagnosis?

1) Assist client with deep breathing and vigorous coughing every hour.
2) Ensure that client uses the incentive spirometer every hour.
3) P

Answer 45

Ensure that client uses the incentive spirometer every hour.

Rationale: Atelectasis is the number one complication in the post-op CABG client. Hourly incentive spirometry and deep breathing are the preferred techniques for lung expansion (option 2). Vigorous coughing (option 1) is discouraged for post-CABG clients because it may increase intrathoracic pressure and cause instability in the sternal area. Premedication before ambulation will facilitate activity tolerance by reducing pain (option 3) but will not directly affect gas exchange. Auscultating lungs (option 4) will detect adventitious lung sounds resulting from the ineffective breathing pattern, but it is an assessment, not an action to encourage effective breathing. In addition, once a shift lung assessment is insufficient in the early post-operative period.

Question 46

A client who just underwent cardiac catheterization insists on getting up to go to the bathroom to urinate immediately after returning to his room. Which of the following would be the nurse’s best response?

Answer 46

If you bend your leg, you will risk bleeding from the insertion site. It is an artery, and it could lead to complications.”

Question 47

The nurse is caring for a client admitted to the Emergency Department (ED) with chest pain. He reports that chest pain developed while mowing the lawn and he stopped and rested on the sofa, as is typical for him. This time the pain was not relieved by rest so he came to the ED. The chest pain is relieved following administration of 2 sublingual nitroglycerine tablets. The nurse draws which conclusion about this client’s status?

Answer 47

Client most likely has unstable angina.

Rationale: Bedrest is prescribed to allow the arterial puncture to seal and reduce the risk of bleeding. Explaining the rationale to the client is the best way to facilitate the client’s cooperation (option 2). Although the other options (1, 3, and 4) may be true statements, they do not address the need for the care restrictions in this client at this time.

Question 48

The nurse is assessing a client at 07:30 in the morning on a day when the client has a cardiac stress test scheduled for 11:30. The client reports that no breakfast was delivered this morning and the client is hungry. Which of the following is the nurse’s best action?

Answer 48

Have nursing assistant get the client cereal with milk and orange juice.

Rationale: The client should have a light meal with no caffeine before a cardiac stress test (option 4) and should refrain from eating or drinking for 2 to 3 hours before the test. Options 2 and 3 are incorrect because they do not follow this guideline. Caffeine (option 1) may cause sympathetic nervous system stimulation resulting in an increase in heart rate and blood pressure. This could make the results of the test difficult to determine.

Question 49

A hospitalized client has continuous electrocardiographic (ECG) monitoring, and the monitor shows that the rhythm has suddenly changed to ventricular tachycardia (VT). What is the first action that the nurse should take?

Answer 49

Quickly assess the client’s level of consciousness, blood pressure, and pulse.

Rationale: The best first action is to assess the client’s level of consciousness and assess if the VT is perfusing the body by measuring the BP and pulse (option 3). If the client is in a pulseless ventricular tachycardia, immediate defibrillation (option 2) is performed by an ACLS certified nurse. If the client has a good BP and pulse and is awake and alert, the nurse may administer intravenous lidocaine (option 1) as ordered. A precordial thump (option 4) may be effective in converting a witnessed VT to a normal rhythm but will only be performed after assessing the client.

Question 50

The physician has diagnosed acute myocardial infarction (AMI) on the basis of electrocardiogram (ECG) changes for a client in the Emergency Department (ED). The nurse assesses the client frequently, and notes that the client seems forgetful, and periodically asks the nurse to explain the ECG and noninvasive blood pressure monitors. The nurse concludes that the client’s response is most likely due to which of the following reasons?

Answer 50

Client is showing signs of fear and anxiety.

Rationale: Anxiety and fear are common responses to a diagnosis of myocardial infarction because of the possibility of death (option 2). This prevents the client and family from absorbing the detailed explanations about the care being provided. Memory lapses are not a common symptom of myocardial infarction (option 4). There is not adequate information to determine that this memory lapse is associated with Alzheimer’s disease (option 1), and this would not be the best time to make that determination. Nurses in the ED are able to explain procedures well to their clients (option 3).