Chapter 7: Cardiovascular Problems

Question 1

The clinic nurse is evaluating a client who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the client is most important to report to the health care provider?

1. Stools have been black in color.
2. Bruising is present at the right groin.
3. Home blood pressure today was 104/52 mm Hg.
4. Home radial pulse rate has been 55 to 60 beats/min.

Answer 1

Ans: 1
Dark or tarry stools may indicate gastrointestinal bleeding, which is a possible adverse effect of both aspirin and clopidogrel. The client will need to continue on the medications but may need treatment with proton pump inhibitors or histamine2 blockers to decrease risk for gastrointestinal bleeding.
The other findings will also be reported to the health care provider but will not require a change in the therapeutic plan for the client. Focus: Prioritization.

Question 2

Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with heart failure? Select all that apply.

1. How to monitor and record daily weight
2. Importance of stopping exercise if heart rate increases 3. Symptoms of worsening heart failure
3. Purpose of chronic antibiotic therapy
4. How to read food labels for sodium content
5. Date and time for follow-up appointments

Answer 2

Ans: 1, 3, 5, 6
To avoid rehospitalization, topics that should be included when discharging a client with heart failure include low-sodium diet, purpose and common side effects of medications such as angiotensin-converting enzyme inhibitors and beta-blockers, what to do if symptoms of worsening heart failure occur, and follow-up appointments. The nurse will teach the client that a moderate increase in heart rate and respiratory effort is normal with exercise. Antibiotics are not included in the treatment regimen for heart failure, which is not an infectious process. Focus: Prioritization.

Question 3

The nurse is reviewing the laboratory results for a client with an elevated cholesterol level who is taking atorvastatin. Which result is most important to discuss with the health care provider?

1. Serum potassium is 3.4 mEq/L (3.4 mmol/L).
2. Blood urea nitrogen (BUN) is 9 mg/dL (3.2 mmol/L).
3. Aspartate aminotransferase (AST) is 30 units/L (0.5 μkat/L).
4. Low-density lipoprotein (LDL) cholesterol is 170 mg/dL (4.4 mmol/L).

Answer 3

Ans: 4
The client’s low-density lipoprotein level continues to be elevated and indicates a need for further assessment (e.g., the client may not be taking the atorvastatin), a change in medication, or both. Although statin medications may cause rhabdomyolysis, which could increase BUN and potassium, the client’s BUN and potassium are not elevated. Although ongoing monitoring of liver function is recommended when statins are used, this client’s AST is normal. Focus: Prioritization.

Question 4

Which finding in a client with aortic stenosis will be most important for the nurse to report to the health care provider?

1. Temperature of 102.1°F (38.9°C)
2. Loud systolic murmur over sternum
3. Blood pressure of 110/88 mm Hg
4. Weak radial and pedal pulses to palpation

Answer 4

Ans: 1
Because endocarditis is a concern with valvular disease, an elevated temperature indicates a need for further assessment and diagnostic testing (e.g., an echocardiogram and blood cultures). A systolic murmur, decreased pulse pressure, and weak pulses would be expected in a client with aortic stenosis and do not indicate an immediate need for further evaluation or treatment. Focus: Prioritization.

Question 5

A client who has just arrived in the emergency department reports substernal and left arm discomfort that has been going on for about 3 hours. Which laboratory test will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standard protocol?

1. Creatine kinase MB level
2. Troponin I level
3. Myoglobin level
4. C-reactive protein level

Answer 5

Ans: 2
Cardiac troponin levels are elevated 3 hours after the onset of myocardial infarction (MI) and are very specific to cardiac muscle injury or infarction. Creatine kinase MB and myoglobin levels also increase with MI, but creatine kinase levels take at least 6 hours to increase and myoglobin is nonspecific. Elevated C-reactive protein levels are a risk factor for coronary artery disease but are not useful in detecting acute injury or infarction. Focus: Prioritization.

Question 6

When the nurse is monitoring a 53-year-old client who is undergoing a
treadmill stress test, which finding will require the most immediate action?
1. Blood pressure of 152/88 mm Hg
2. Heart rate of 134 beats/min
3. Oxygen saturation of 91%
4. Chest pain level of 3 (on a scale of 0 to 10)

Answer 6

Ans: 4
Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization.

Question 7

The health care provider prescribes these actions for a client who was admitted with acute substernal chest pain. Which actions are appropriate to assign to an experienced LPN/LVN who is working in the emergency department? Select all that apply.

1. Attaching cardiac monitor leads
2. Giving heparin 5000 units IV push
3. Administering morphine sulfate 4 mg IV
4. Obtaining a 12-lead electrocardiogram (ECG)
5. Asking the client about pertinent medical history
6. Having the client chew and swallow aspirin 162 mg

Answer 7

Ans: 1, 4, 6
Attaching cardiac monitor leads, obtaining an ECG, and administering oral medications are within the scope of practice for LPN/LVNs. An experienced LPN/LVN would be familiar with these activities. Although anticoagulants and narcotics may be administered by LPNs/LVNs to stable clients, these are high-alert medications that should be given by the RN to this unstable client. Obtaining a pertinent medical history requires RN-level education and scope of practice. Focus: Assignment; Test Taking Tip: Remember that administration of “high alert” medications (e.g., anticoagulants and narcotics) may require a higher level of knowledge and clinical judgment, especially when you are caring for an unstable client.

Question 8

Based on this information in a client’s medical record, which topic is the highest priority for the nurse to include in the initial teaching plan for a 26- year-old client who has blood pressures ranging from 150/84 to 162/90 mm Hg?

1. Symptoms of acute stroke and myocardial infarction
2. Adverse effects of alcohol on blood pressure
3. Methods for decreasing dietary caloric intake
4. Low-sodium food choices when eating out

Answer 8

Ans: 4
Current guidelines recommend low sodium intake for lifestyle management of hypertension, and the nurse should teach the client about the high sodium content in many fast foods and how to make low-sodium choices. A 26-year-old with this level of hypertension is not likely to have a stroke or myocardial infarction. Weight loss or changes in alcohol intake are not necessary. The client’s weight and BMI are normal. Alcohol intake of less than 1 or 2 glasses of wine daily is recommended to prevent hypertension. Focus: Prioritization.

Question 9

The nurse makes a home visit to evaluate a hypertensive client who has been taking enalapril. Which finding is most important to report to the health care provider?

1. Client reports frequent urination.
2. Client’s blood pressure is 138/86 mm Hg.
3. Client complains about a frequent dry cough.
4. Client says, “I get dizzy sometimes if I stand up fast.”

Answer 9

Ans: 3
A persistent and irritating cough (caused by accumulation of bradykinin) is a possible adverse effect of angiotensin-converting enzyme inhibitors such as enalapril and is a common reason for changing to another medication category such as the angiotensin II receptor blockers. The other assessment data indicate a need for more client teaching and ongoing monitoring but would not require a change in therapy. Focus: Prioritization.

Question 10

While reviewing a hospitalized client’s medical record, the nurse obtains this information about cardiovascular risk factors. Which interventions will be important to include in the discharge plan for this client? Select all that apply.

1. Referral to community programs that assist in smoking cessation
2. Teaching about the impact of family history on cardiovascular risk
3. Education about the need for a change in antihypertensive therapy
4. Assistance in reducing emotional stress
5. Discussion of the risks associated with having a sedentary lifestyle

Answer 10

Ans: 1, 2
The client’s major modifiable risk factor is ongoing smoking. The family history is significant, and the client should be aware that this increases cardiovascular risk. The blood pressure is well controlled on the current medication, and no change is needed. There is no indication that stress is a risk factor for this client, and the client’s activity level meets the American Heart Association recommendation for at least 150 minutes of moderate activity weekly. Focus: Prioritization.

Question 11

Which client is best for the coronary care charge nurse to assign to a float RN who has come for the day from the general medical-surgical unit?

1. Client requiring discharge teaching about coronary artery stenting before going home today
2. Client receiving IV furosemide to treat acute left ventricular failure
3. Client who just transferred in from the radiology department after a coronary angioplasty
4. Client just admitted with unstable angina who has orders for a heparin infusion and aspirin

Answer 11

Ans: 2
An RN who worked on a medical-surgical unit would be familiar with left ventricular failure, the administration of IV medications, and ongoing monitoring for therapeutic and adverse effects of furosemide. The other clients need to be cared for by RNs who are more familiar with the care of clients who have acute coronary syndrome and with collaborative treatments such as coronary angioplasty and coronary artery stenting. Focus: Assignment.

Question 12

At 9:00 pm, the nurse admits a 63-year-old client with a diagnosis of acute myocardial infarction. Which finding is most important to communicate to the health care provider who is considering the use of fibrinolytic therapy with tissue plasminogen activator (alteplase) for the client?

1. The client was treated with alteplase about 8 months ago.
2. The client takes famotidine for gastroesophageal reflux disease.
3. The client has ST-segment elevations on the electrocardiogram (ECG).
4. The client reports having continuous chest pain since 8:00 am.

Answer 12

Ans: 4
Because continuous chest pain lasting for more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs are usually not recommended for clients with chest pain that has lasted for more than 12 hours. The other information is also important to communicate but would not impact the decision about alteplase use. Focus: Prioritization.

Question 13

The nurse is caring for a client who has heart failure and has a new prescription for sacubitril–valsartan. Which client information is most important to discuss with the health care provider before administration of the medication?

1. The client’s oxygen saturation is 92%.
2. The client receives lisinopril 10 mg/day.
3. The client’s blood pressure is 150/90 mm Hg.
4. The client’s potassium is 3.3 mEq/L (3.3 mmol/L).

Answer 13

Ans: 2
Because combination angiotensin receptor blocker–neprilysin blockers markedly increase the risk for angioedema in clients who are also taking angiotensin-converting enzyme inhibitors (e.g., lisinopril), the concomitant use of both lisinopril and sacubitril–valsartan is contraindicated. In addition, the risk for other adverse effects such as hyperkalemia and hypotension is increased. The other findings should be reported to the health care provider but do not indicate a need to withhold the sacubitril–valsartan. Focus: Prioritization.

Question 14

A client whose systolic blood pressure is always higher than 140 mm Hg in the clinic tells the nurse, “My blood pressure at home is always fine!” What action should the nurse take next?

1. Instruct the client about the effects of untreated high blood pressure on the cardiovascular and cerebrovascular systems.
2. Educate the client about lifestyle changes such as low-sodium diet, daily exercise, and restricting alcohol use to no more than 2 beers per day.
3. Ask the client to obtain blood pressures twice daily with an automatic blood pressure cuff at home and bring the results to the clinic in a week.
4. Provide the client with a handout describing the various types of antihypertensive medications with the medication effects and adverse effects.

Answer 14

Ans: 3
The American Heart Association recommends home blood pressure monitoring for clients with hypertension or hypertension risk factors because home blood pressure monitoring provides more accurate data about usual blood pressure than periodic monitoring. The other actions may be necessary, but further assessment of the client’s usual blood pressure is needed before decisions about therapy can be made. Focus: Prioritization.

Question 15

The nurse is working with an experienced unlicensed assistive personnel (UAP) and an LPN/LVN on the telemetry unit. A client who had an acute myocardial infarction 3 days ago has been reporting fatigue and chest discomfort when ambulating. Which nursing activity included in the care plan is best assigned to the LPN/LVN?

1. Administering nitroglycerin 0.4 mg sublingually if chest discomfort occurs during client activities
2. Monitoring pulse, blood pressure, and oxygen saturation before and after client ambulation
3. Teaching the client energy conservation techniques to decrease myocardial oxygen demand
4. Explaining the rationale for alternating rest periods with exercise to the client and family

Answer 15

Ans: 1
Administration of nitroglycerin and appropriate client monitoring for therapeutic and adverse effects are included in LPN/LVN education and scope of practice. Monitoring of blood pressure, pulse, and oxygen saturation should be delegated to the UAP. Client teaching requires RN-level education and scope of practice. Focus: Delegation, Assignment.

Question 16

The emergency department nurse is caring for a client who was just admitted with left anterior chest pain, possible acute myocardial infarction (MI). Which action will the nurse take first?

1. Insert an IV catheter.
2. Auscultate heart sounds.
3. Administer sublingual nitroglycerin.
4. Draw blood for troponin I measurement.

Answer 16

Ans: 3
The priority for a client with unstable angina or MI is treatment of pain. It is important to remember to assess vital signs before administering sublingual nitroglycerin. The other activities also should be accomplished rapidly but are not as high a priority. Focus: Prioritization.

Question 17

An 80-year-old client on the coronary step-down unit tells the nurse “I do not need to take that docusate. I never get constipated!” Which action by the nurse is most appropriate?

1. Document the medication on the client’s chart as “refused.”
2. Mix the medication with food and administer it to the client.
3. Explain that his decreased activity level may cause constipation.
4. Reinforce that the docusate has been prescribed for a good reason.

Answer 17

Ans: 3
The best option in this situation is to educate the client about the purpose of the docusate (to counteract the negative effects of immobility and narcotic use on peristalsis). Charting the medication as “refused” or telling the client that he should take the docusate simply because it was prescribed are possible actions but are not as appropriate as client education. It is unethical to administer a medication to a client who is unwilling to take it unless someone else has health care power of attorney and has authorized use of the medication. Focus: Prioritization.

Question 18

The nurse has given morphine sulfate 4 mg IV to a client who is having an acute myocardial infarction. When evaluating the client’s response 5 minutes after giving the medication, which finding indicates a need for immediate further action?

1. Blood pressure decrease from 114/65 to 106/58 mm Hg
2. Respiratory rate drop from 18 to 12 breaths/min
3. Cardiac monitor indicating sinus rhythm at a rate of 96 beats/min
4. Persisting chest pain at a level of 1 (on a scale of 0 to 10)

Answer 18

Ans: 4
The goal in pain management for the client with an acute myocardial infarction is to completely eliminate the pain (because ongoing pain indicates cardiac ischemia). Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate (although possibly a lower dose). The other data indicate a need for ongoing assessment for the possible adverse effects of hypotension, respiratory depression, and tachycardia but do not require further action at this time. Focus: Prioritization.

Question 19

The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a client who has had a myocardial infarction and the client’s spouse. The client says, “I don’t see why I need any teaching. I don’t think I need to change anything right now.” Which response is most appropriate?

1. “Do you think your family may want you to make some lifestyle changes?”
2. “Can you tell me why you don’t feel that you need to make any changes?”
3. “You are still in the stage of denial, but you will want this information later on.”
4. “Even though you don’t want to change, it’s important that you have this teaching.”

Answer 19

Ans: 2
For behavior to change, the client must be aware of the need to make changes. This response acknowledges the client’s statement and asks for further clarification. This will give the nurse more information about the client’s feelings, current diet, and activity levels and may increase the willingness to learn. The other responses (although possibly accurate) indicate an intention to teach whether the client is ready or not and are not likely to lead to changes in lifestyle. Focus: Prioritization.

Question 20

The nurse is caring for a hospitalized client with heart failure who is receiving captopril and spironolactone. Which laboratory value will be most important to monitor?

1. Sodium level
2. Blood glucose level
3. Potassium level
4. Alkaline phosphatase level

Answer 20

Ans: 3
Hyperkalemia is a common adverse effect of both angiotensin- converting enzyme inhibitors and potassium-sparing diuretics. The other laboratory values may be affected by these medications but are not as likely or as potentially life threatening. Focus: Prioritization.

Question 21

The health care provider telephones the nurse with new prescriptions for a client with angina who is already taking aspirin. Which medication is most important to clarify further with the health care provider?

1. Clopidogrel 75 mg/day
2. Ibuprofen 200 mg every 4 hours as needed
3. Metoprolol succinate 50 mg/day
4. Nitroglycerin patch 0.4 mg/hr

Answer 21

Ans: 2
Nonsteroidal anti-inflammatory drugs (NSAIDs) other than aspirin inhibit the beneficial effect of aspirin in coronary artery disease. Current American Heart Association guidelines recommend against the use of other NSAIDs for clients with cardiovascular disease. Clopidogrel, metoprolol, and topical nitroglycerin are appropriate for the client but should be verified because the orders were received by telephone. Focus: Prioritization.

Question 22

At 10:00 am, a hospitalized client receives a new order for transesophageal echocardiography as soon as possible. Which action will the nurse take first?

1. Put the client on “nothing by mouth” (NPO) status.
2. Teach the client about the procedure.
3. Insert an IV catheter in the client’s forearm.
4. Attach the client to a cardiac monitor.

Answer 22

Ans: 1
Because transesophageal echocardiography is performed after the throat is numbed using a topical anesthetic and with the use of IV sedation, it is important that the client be placed on NPO status for several hours before the test. The other actions also will need to be accomplished before the echocardiogram but do not need to be implemented immediately. Focus: Prioritization.

Question 23

A client with stable angina has a prescription for ranolazine 500 mg twice a day. Which client finding is most important for the nurse to discuss with the health care provider?

1. Heart rate is 52 beats/min.
2. Client is also taking carvedilol for angina.
3. Client reports having chronic constipation.
4. Blood pressure is 106/56 mm Hg.

Answer 23

Ans: 3
Chronic constipation is a common adverse effect of ranolazine. Ranolazine does not impact heart rate or blood pressure and can be taken with beta-blockers or nitrates. The other information may also be reported to the HCP but does not require a change in the client plan of care. Focus: Prioritization.

Question 24

The nurse assesses a client who has just returned to the recovery area after undergoing coronary arteriography. Which information is of most concern?

1. Blood pressure is 154/78 mm Hg.
2. Pedal pulses are palpable at + 1.
3. Left groin has a 3-cm bruised area.
4. Apical pulse is 122 beats/min and regular.

Answer 24

Ans: 4
The most common complication after coronary arteriography is hemorrhage, and the earliest indication of hemorrhage is an increase in heart rate. The other data may also indicate a need for ongoing assessment, but the increase in heart rate is of most concern. Focus: Prioritization.

Question 25

The nurse is working in an outpatient clinic where many vascular diagnostic tests are performed. Which task associated with vascular testing is most appropriate to delegate to experienced unlicensed assistive personnel (UAP)?

1. Measuring ankle and brachial pressures in a client for whom the ankle- brachial index is to be calculated
2. Checking blood pressure and pulse every 10 minutes in a client who is undergoing exercise testing
3. Obtaining information about allergies from a client who is scheduled for left leg contrast venography
4. Providing brief client teaching for a client who will undergo a right subclavian vein Doppler study

Answer 25

Ans: 1
Measurement of ankle and brachial blood pressures for calculation is within the UAP’s scope of practice. Calculating the ABI and any referrals or discussion with the client are the responsibility of the supervising RN. The other clients require more complex assessments or client teaching, which should be done by an experienced RN. Focus: Delegation.

Question 26

While working on the cardiac step-down unit, the nurse is precepting a newly graduated RN who has been in a 6-week orientation program. Which client will be best to assign to the new graduate?

1. A 19-year-old client with rheumatic fever who needs discharge teaching before going home with a roommate today
2. A 33-year-old client admitted a week ago with endocarditis who will be receiving a scheduled dose of ceftriaxone 2 g IV
3. A 50-year-old client with newly diagnosed stable angina who has many questions about medications and nursing care
4. A 75-year-old client who has just been transferred to the unit after undergoing coronary artery bypass grafting yesterday

Answer 26

Ans: 2
The new RN’s education and hospital orientation would have included safe administration of IV medications. The preceptor will be responsible for the supervision of the new graduate in assessments and client care. The other clients require more complex assessment or client teaching by an RN with experience in caring for clients with these diagnoses. Focus: Assignment.

Question 27

The nurse is monitoring the cardiac rhythms of clients in the coronary care unit. Which client will need immediate intervention?

1. Client admitted with heart failure who has atrial fibrillation with a rate of 88 beats/min while at rest
2. Client with a newly implanted demand ventricular pacemaker who has occasional periods of sinus rhythm at a rate of 90 to 100 beats/min
3. Client who has had an acute myocardial infarction and has sinus rhythm at a rate of 76 beats/min with frequent premature ventricular contractions
4. Client who recently started taking atenolol and has a first-degree heart block, with a rate of 58 beats/min

Answer 27

Ans: 3
Premature ventricular contractions occurring in the setting of acute myocardial injury or infarction can lead to ventricular tachycardia and/or ventricular fibrillation (cardiac arrest), so rapid treatment is necessary. The other clients also have dysrhythmias that will require further assessment, but these are not as immediately life threatening as the premature ventricular contractions in the setting of myocardial infarction. Focus: Prioritization.

Question 28

A client in the emergency department who is being monitored with a portable cardiac monitor/defibrillator develops this rhythm. Which action will the nurse take first?

1. Defibrillate at 200 joules.
2. Start cardiopulmonary resuscitation (CPR).
3. Administer epinephrine 1 mg IV.
4. Intubate and manually ventilate.

Answer 28

Ans: 1
Research indicates that rapid defibrillation improves the success of resuscitation in cardiac arrest. If defibrillation is unsuccessful in converting the client’s rhythm into a perfusing rhythm, CPR should be initiated. Administration of medications and intubation are later interventions. Determining which of these interventions will be used first depends on other factors, such as whether IV access is available. Focus: Prioritization.

Question 29

Two weeks ago, a client with heart failure received a new prescription for carvedilol 12.5 mg orally. Which finding by the nurse who is evaluating the client in the cardiology clinic is of most concern?

1. Reports of increased fatigue and activity intolerance
2. Weight increase of 0.5 kg over a 1-week period
3. Sinus bradycardia at a rate of 48 beats/min
4. Traces of edema noted over both ankles

Answer 29

Ans: 3
Research indicates that mortality is decreased when clients with heart failure use beta-blocking medications such as carvedilol. When beta-blocker therapy is started for clients with heart failure, heart failure symptoms may initially become worse for a few weeks, so increased fatigue, activity intolerance, weight gain, and edema are not indicative of a need to discontinue the medication at this time. However, a heart rate of 48 beats/min indicates a need to decrease the carvedilol dose. Focus: Prioritization.

Question 30

The nurse has just received a change-of-shift report about these clients on the coronary step-down unit. Which one will the nurse assess first?

1. A 26-year-old client with heart failure caused by congenital mitral stenosis who is scheduled for balloon valvuloplasty later today
2. A 45-year-old client with constrictive cardiomyopathy who developed acute dyspnea and agitation about 1 hour before the shift change
3. A 56-year-old client who underwent coronary angioplasty and stent placement yesterday and has reported occasional chest pain since the procedure
4. A 77-year-old client who was transferred from the intensive care unit 2 days ago after coronary artery bypass grafting and has a temperature of 100.6°F (38.1°C)

Answer 30

Ans: 2
The client’s symptoms indicate acute hypoxia, so immediate further assessments (e.g., assessment of oxygen saturation, neurologic status, and breath sounds) are indicated. The other clients also should be assessed soon because they are likely to require nursing actions such as medication administration and teaching, but they are not as acutely ill as the dyspneic client. Focus: Prioritization.

Question 31

The charge nurse in a long-term care facility that employs RNs, LPNs/LVNs, and unlicensed assistive personnel (UAP) has developed a plan for the ongoing assessment of all residents with a diagnosis of heart failure. Which activity included in the plan is most appropriate to assign to an LPN/LVN team member?

1. Weighing all residents with heart failure each morning
2. Listening to lung sounds and checking for edema each week
3. Reviewing all heart failure medications with residents every month
4. Updating activity plans for residents with heart failure every quarter

Answer 31

Ans: 2
LPN/LVN education and scope of practice include data collection such as listening to lung sounds and checking for peripheral edema when caring for stable clients. Weighing the residents should be delegated to a UAP. Reviewing medications with residents and planning appropriate activity levels are nursing actions that require RN-level education and scope of practice. Focus: Delegation, Assignment.

Question 32

The nurse is participating as a team member in the resuscitation of a client who has had a cardiac arrest. The health care provider who is directing the resuscitation asks the nurse to administer epinephrine 1 mg IV. After giving the medication, which action should the nurse take next?

1. Prepare to defibrillate the client.
2. Offer to take over chest compressions.
3. State: “Epinephrine 1 mg IV has been given.”
4. Continue to monitor the client’s responsiveness.

Answer 32

Ans: 3
The American Heart Association recommends “closed loop” communication between team members who are involved in resuscitation of a client. The other actions may also be needed, but the initial action after administering a medication is to assure that the team leader knows that the prescribed medication has been administered. Focus: Prioritization.

Question 33

During a home visit to an 88-year-old client who is taking digoxin

0. 25 mg/day to treat heart failure and atrial fibrillation, the nurse obtains this assessment information. Which finding is most important to communicate to the health care provider?
1. Apical pulse 68 beats/min and irregular
2. Digoxin taken with meals
3. Vision that is becoming “fuzzy”
4. Lung crackles that clear after coughing

Answer 33

Ans: 3
The client’s visual disturbances may be a sign of digoxin toxicity. The nurse should notify the health care provider and obtain an order to measure the digoxin level. An irregular pulse is expected with atrial fibrillation; there are no contraindications to taking digoxin with food; and crackles that clear with coughing are indicative of atelectasis, not worsening of heart failure. Focus: Prioritization.

Question 34

The nurse is ambulating a cardiac surgery client whose heart rate suddenly increases to 146 beats/min. In which order will the nurse take the following actions?

1. Call the client’s health care provider.
2. Have the client sit down.
3. Check the client’s blood pressure.
4. Administer as needed (PRN) oxygen by nasal cannula.

Answer 34

Ans: 2, 4, 3, 1
Because the increased heart rate may be associated with a drop in blood pressure and with lightheadedness, the nurse’s first action should be to decrease risk for a fall by having the client sit down. Cardiac ischemia may be causing the client’s tachycardia, and administration of supplemental oxygen should be the next action. Assessment of blood pressure should be done next. Finally, the health care provider should be notified about the client’s response to activity because changes in therapy may be indicated. Focus: Prioritization; Test Taking Tip: Consider that safety concerns (e.g., fall prevention) are usually the highest priority when deciding the order in which to take listed actions.

Question 35

A client who has endocarditis with vegetation on the mitral valve suddenly reports severe left foot pain. The nurse notes that no pulse is palpable in the left foot and that it is cold and pale. Which action should the nurse take next?

1. Lower the client’s left foot below heart level.
2. Administer oxygen at 4 L/min to the client.
3. Notify the health care provider about the change in status.
4. Reassure the client that embolization is common in endocarditis.

Answer 35

Ans: 3
The client’s history and symptoms indicate that acute arterial occlusion has occurred. Because it is important to return blood flow to the foot rapidly, the health care provider should be notified immediately so that interventions such as balloon angioplasty or surgery can be initiated. Changing the position of the foot and improving blood oxygen saturation will not improve oxygen delivery to the foot. Telling the client that embolization is a common complication of endocarditis will not reassure a client who is experiencing acute pain. Focus: Prioritization.

Question 36

A resident in a long-term care facility who has venous stasis ulcers is treated with an Unna boot. Which nursing activity included in the resident’s care is best for the nurse to delegate to the unlicensed assistive personnel (UAP)?

1. Teaching family members the signs of infection
2. Monitoring capillary perfusion once every 8 hours
3. Evaluating foot sensation and movement each shift
4. Assisting the client in cleaning around the Unna boot

Answer 36

Ans: 4
Assisting with hygiene is included in the role and education of UAP. Assessments and teaching are appropriate activities for licensed nursing staff members. Focus: Delegation.

Question 37

A client with acute coronary syndrome is receiving a continuous heparin infusion. The client is to receive 700 units/hour. Based on the heparin concentration on the label, the nurse will set the infusion pump to deliver ________________________ mL/hr.

Answer 37

Ans: 17.5 mL/hr
Each mL of the solution contains heparin 40 units; 700 units/hour equals 17.5 mL/hr. Focus: Prioritization.

Question 38

The clinic nurse obtains this information about a client who is taking warfarin after having a deep vein thrombosis. Which finding is most indicative of a need for a change in therapy?

1. Blood pressure is 106/54 mm Hg.
2. International normalized ratio (INR) is 1.2.
3. Bruises are noted at sites where blood has been drawn.
4. Client reports eating a green salad for lunch every day.

Answer 38

Ans: 2
An INR of 1.2 is not within the expected therapeutic range of 2 to 3 and indicates a need for an increase in warfarin dose. The blood pressure is in the low-normal range. Although the client will be encouraged to avoid injury, increased bruising is common when clients are taking anticoagulants and not a reason to discontinue the medication. Although foods that are high in vitamin K will have an impact on INR, this is not a concern when these foods are eaten consistently because the warfarin dose will be adjusted accordingly. Focus: Prioritization.

Question 39

The nurse in the cardiovascular clinic receives telephone calls from four clients. Which client should be scheduled to be seen most urgently?

1. Client with peripheral arterial disease who complains of leg cramps when walking
2. Client with atrial fibrillation who reports episodes of lightheadedness and syncope
3. Client with a new permanent pacemaker who has severe itchiness at the wound site
4. Client with angina who took nitroglycerin twice in the last week while exercising

Answer 39

Ans: 2
Lightheadedness and syncope may indicate that the client’s heart rate is either too fast or too slow, affecting brain perfusion and causing risk for complications such as falls. The other clients will also need to be seen, but the data indicate that the symptoms of their diseases are relatively well controlled. Focus: Prioritization.

Question 40

During the initial postoperative assessment of a client who has just been transferred to the postanesthesia care unit after repair of an abdominal aortic aneurysm, the nurse obtains these data. Which finding has the most immediate implications for the client’s care?

1. Arterial line indicates a blood pressure of 190/112 mm Hg.
2. Cardiac monitor shows frequent premature atrial contractions.
3. There is no response to verbal stimulation.
4. Urine output is 40 mL of amber urine.

Answer 40

Ans: 1
Elevated blood pressure in the immediate postoperative period puts stress on the graft suture line and could lead to graft rupture and hemorrhage, so it is important to lower blood pressure quickly. The other data also indicate the need for ongoing assessments and possible interventions but do not pose an immediate threat to the client’s hemodynamic stability. Focus: Prioritization; Test Taking Tip: When deciding which client findings are most important, think about which findings may lead quickly to a poor client outcome and which data are normal for a given situation (such as nonresponsiveness in a client who has just arrived in the recovery area after surgery).

Question 41

The nurse is developing a standardized care plan for the postoperative care of clients undergoing cardiac surgery. The unit is staffed with RNs, LPN/LVNs, and unlicensed assistive personnel. Which nursing activity will need to be performed by RN staff members?

1. Removing chest and leg dressings on the second postoperative day and cleaning the incisions with antibacterial swabs
2. Reinforcing client and family teaching about the need to deep breathe and cough at least every 2 hours while awake
3. Developing an individual plan for discharge teaching based on discharge medications and needed lifestyle changes
4. Administering oral analgesic medications as needed before helping the client out of bed on the first postoperative day

Answer 41

Ans: 3
Development of plans for client care or teaching requires RN-level education and is the responsibility of the RN. Wound care, medication administration, assisting with ambulation, and reinforcing previously taught information are activities that can be assigned or delegated to other nursing personnel under the supervision of the RN. Focus: Assignment, Delegation.

Question 42

The nurse is preparing to administer the following medications to a client with multiple health problems who has been hospitalized with deep vein thrombosis. Which medication is most important to double-check with another licensed nurse?

1. Famotidine 20 mg IV
2. Furosemide 40 mg IV
3. Digoxin 0.25 mg PO
4. Warfarin 2.5 mg PO

Answer 42

Ans: 4
Anticoagulant medications are high-alert medications and require special safeguards, such as double-checking of medications by two nurses before administration. Although the other medications require the usual medication safety procedures, double-checking is not needed. Focus: Prioritization.

Question 43

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be most useful to monitor?

1. Serum potassium
2. B-type natriuretic peptide
3. Blood urea nitrogen
4. Hematocrit

Answer 43

Ans: 2
Research indicates that B-type natriuretic peptide levels increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate heart failure from other causes of dyspnea and fatigue such as pneumonia. The other values should also be monitored but do not indicate whether the client has heart failure. Focus: Prioritization

Question 44

A client who is scheduled for a coronary arteriogram is admitted to the hospital on the day of the procedure. Which client information is most important for the nurse to communicate to the health care provider (HCP) before the procedure?

1. Blood glucose level is 144 mg/dL (8 mmol/L).
2. Cardiac monitor shows sinus bradycardia, rate 56 beats/min.
3. Client reports chest pain that occurred yesterday.
4. Client took metformin 500 mg this morning.

Answer 44

Ans: 4
Because use of metformin may lead to acute lactic acidosis when clients undergo procedures that use iodine-based contrast dye, metformin should be held for 24 hours before and 48 hours after coronary arteriogram. The arteriogram will need to be rescheduled. The other information will also be reported to the HCP but would not be unusual in clients with coronary artery disease. Focus: Prioritization.