Deck 3 Module 16 Perfusion

Question 1

The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate?

A) “You will need to have an echocardiogram to determine the reason for the extra sound.”
B) “You are likely experiencing heart failure due to the extra fluid that accumulates during this time in pregnancy.”
C) “You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy.”
D) “You have what is known as atrial gallop, and this is cause for concern.”

Answer 1

C) “You have what is known as a ventricular gallop, and it can be a normal finding during this trimester of pregnancy.”

Rationale: Two other heart sounds may be present in some healthy individuals. The third heart sound (S3) may be heard in children, in young adults, or in pregnant females during the third trimester. It is heard after S2 and is termed a ventricular gallop. When the atrioventricular (AV) valves open, blood flow into the ventricles may cause vibrations. These vibrations create the S3 sound during diastole. There is no need for an echocardiogram. While the S3 sound can be associated with heart failure, this is not the case during pregnancy. S4, also known as an atrial gallop, can also be present in healthy individuals.

Question 2

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client’s potential health problem?

A) Encouraging ambulation every 30 minutes
B) Instructing on deep breathing
C) Administering medications appropriate to increase heart rate
D) Positioning to increase blood return

Answer 2

B) Instructing on deep breathing

The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Encouraging ambulation every 30 minutes would negatively impact oxygenation. Periods of rest should occur between activities, and no activity should be too strenuous. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart include Trendelenburg, which would negatively impact oxygenation.

Question 3

An older adult client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be prescribed for this client?

A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids

Answer 3

A) Beta blocker

Rationale: Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Digoxin should be avoided because it increases the force of contractions. Nitrates should be avoided because they increase blood pressure. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.

Question 4

The nurse is caring for a client admitted to the hospital with lower extremity edema and shortness of breath. Which electrocardiogram finding indicates the client is at risk for an alteration in perfusion?

A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric

Answer 4

C) PR interval 0.30 seconds

Rationale: The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The U wave is not normally seen. The ST segment should be isoelectric.

Question 5

The nurse is instructing a client on lifestyle changes to promote a healthy cardiovascular system. Which of the following should be included in this teaching session? Select all that apply.

A) Limit exercise to 15 minutes a day
B) Reduce saturated fats in the diet
C) Avoid cigarette smoking
D) Wear elastic hose
E) Limit fluid intake

Answer 5

B) Reduce saturated fats in the diet
C) Avoid cigarette smoking

Rationale: Interventions that help promote a healthy cardiovascular system are to avoid cigarette smoking and reduce saturated fats in the diet. Clients should exercise for at least 30 minutes most days of the week to maintain a healthy cardiovascular system. Wearing elastic hose and limiting fluid intake are not known to contribute to a healthy cardiovascular system.

Question 6

The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?

A) At the fifth intercostal space
B) At the left nipple
C) At the right nipple
D) At the eighth intercostal space

Answer 6

B) At the left nipple

Rationale: When assessing a pediatric client, it may be more beneficial to auscultate the apical pulse in the area of the left nipple at the fourth intercostal space. The other answer options are not appropriate.

Question 7

The nurse is caring for a client who is scheduled to receive metoprolol (Lopressor). What should the nurse teach the client about this medication?

A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids.

Answer 7

B) Change positions slowly.

Rationale: Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly because this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. Protein restriction is not indicated with this medication. The client should not be instructed to increase fluids.

Question 8

Which statements are correct regarding the various layers of the heart? Select all that apply.

A) The endocardium covers the entire heart and great vessels.
B) The endocardium is the muscular layer of the heart that contracts during each heartbeat.
C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.
E) The myocardium has four layers.

Answer 8

C) The outermost layer of the heart is the epicardium.
D) The myocardium consists of myofibril cells.

Rationale: The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.

Question 9

A client’s stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute (bpm). What is the client’s cardiac output (CO) rounded to the nearest liter?

Answer 9

6 Liters (L)

Rationale: CO = SV × HR
85mL = 0.085 L
CO = 0.085 × 71 = 6.035 = 6 L

Question 10

Blood pressure is influenced by all except which factor?

A) Pumping action of the heart
B) Peripheral vascular resistance
C) Heart rate
D) Blood volume

Answer 10

C) Heart rate

Rationale: The factors that determine blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume and viscosity. Heart rate by itself does not determine blood pressure.

Question 11

Which nursing intervention related to perfusion can be performed independently?

A) Administration of drug regimens
B) Insertion of device to measure central venous pressure (CVP)
C) Teaching relaxation techniques
D) Thoracentesis

Answer 11

C) Teaching relaxation techniques

The nurse can teach relaxation techniques as an independent intervention to provide psychosocial support to the client. The nurse must administer drug regimens only under the order of a physician or nurse practitioner. Although nurses can monitor central venous pressure, they are not responsible for inserting the device to measure CVP. A physician or nurse practitioner usually performs a thoracentesis.

Question 12

The nurse is reviewing objective data obtained during the assessment of a pregnant woman in her 34th week of gestation. Which finding would be cause for concern?

A) Pulse 103 bpm
B) Blood pressure 108/70
C) Hematocrit 24%
D) WBC count 10,340/mm3

Answer 12

C) Hematocrit 24%

Rationale: During pregnancy, red blood cell (RBC) production and plasma volume increase, but because plasma volume increases more than RBC volume, the hematocrit decreases slightly. However, this client is experiencing a significant decrease in hematocrit, indicating that she is not producing adequate RBCs. The pulse normally increases by 10-15 bpm during pregnancy, blood pressure decreases slightly, and WBC count increases. Findings within the given ranges are normal during pregnancy and are not cause for concern at this point.

Question 13

The nurse is caring for a client diagnosed with dilated cardiomyopathy. Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply.

A) Fatigue
B) Lower extremity edema
C) Syncope
D) Dyspnea
E) Angina

Answer 13

A) Fatigue
B) Lower extremity edema
D) Dyspnea

Rationale: Clinical manifestations of dilated cardiomyopathy include dyspnea, orthopnea, weakness, fatigue, peripheral edema, and ascites. Syncope and angina are commonly associated with hypertrophic cardiomyopathy and other forms of cardiomyopathy, but not with dilated cardiomyopathy.

Question 14

A client states to the nurse, “I know I have high blood pressure, but I don’t want to take medication.” Based on this data, which health problem is the client at risk for developing?

A) Gastritis
B) Diabetes
C) Cardiomyopathy
D) Metabolic syndrome

Answer 14

C) Cardiomyopathy

Rationale: Hypertension places the client at risk for development of cardiomyopathy. Hypertension has not been associated with gastritis, diabetes, or metabolic syndrome.

Question 15

A client diagnosed with cardiomyopathy reports having to rest between activities during the day. The client asks the nurse why this is occurring. Which reason should the nurse include in the response to the client?

A) Increased stroke volume
B) Decreased cardiac output
C) An elongated and dilated aorta
D) Increased blood pressure

Answer 15

B) Decreased cardiac output

Rationale: Decreased cardiac output is a result of decreased efficiency and contractibility of the myocardium. Rest could be required after each activity that puts physiological stress on the heart. Less blood is pumped from the heart to the rest of the body with a decreased cardiac output, and this has a direct effect on the activity level that can be tolerated. It is unknown if the client has increased stroke volume, an elongated and dilated aorta, or high blood pressure.

Question 16

A client admitted with the diagnosis of cardiomyopathy becomes short of breath with ambulation and eating and fatigued with routine care activities. Which nursing diagnosis does the nurse include in the client’s plan of care?

A) Imbalanced Nutrition: Less than Body Requirements
B) Deficient Knowledge
C) Activity Intolerance
D) Self-Care Deficit

Answer 16

C) Activity Intolerance

Rationale: The client is short of breath with ambulation and eating and fatigued with routine care activities. The nursing diagnosis of Activity Intolerance is appropriate for the client at this time. Shortness of breath with meals does not indicate that the client has Imbalanced Nutrition. There is not enough information to determine if the client has a knowledge deficit. Fatigue with routine care activities does not necessarily mean that the client has a Self-Care Deficit.

Question 17

The nurse identifies the diagnosis of Excess Fluid Volume as appropriate for a client with cardiomyopathy. Which interventions should the nurse emphasize when planning this client’s care? Select all that apply.

A) Monitor B-type natriuretic peptide (BNP) level.
B) Provide oxygen as prescribed.
C) Assess respiratory status and lung sounds every 4 hours and as needed.
D) Provide information about activity upon discharge.
E) Monitor intake and output.

Answer 17

C) Assess respiratory status and lung sounds every 4 hours and as needed.
E) Monitor intake and output.

Rationale: Interventions appropriate for the nursing diagnosis of Excess Fluid Volume include assessing respiratory status and lung sounds every 4 hours and as needed, and monitoring intake and output. Monitoring BNP level and providing oxygen are interventions appropriate for the diagnosis of Decreased Cardiac Output. Providing information about activity upon discharge would be appropriate for the nursing diagnosis of Activity Intolerance.

Question 18

The nurse is providing teaching to a client diagnosed with cardiomyopathy. What statement made by the client indicates the discharge teaching was effective?

A) “I will exercise as much as possible, regardless of feeling weak and short of breath.”
B) “My pants getting tight around the waist means I’m eating too much and should cut back on food.”
C) “I will eat foods containing sodium only if drinking water with them.”
D) “I will see my cardiologist next week to discuss implanting a pacemaker.”

Answer 18

D) “I will see my cardiologist next week to discuss implanting a pacemaker.”

Rationale: Pacemakers are needed in some clients with cardiomyopathy to prevent sudden cardiac death. The client should discuss the need for a pacemaker with his cardiologist. The other client statements indicate that discharge teaching was not effective and the client needs additional instruction and follow-up.

Question 19

The nurse is caring for a client with hypertrophic cardiomyopathy. Based on this diagnosis, which class of medications does the nurse anticipate being prescribed?

A) Digoxin
B) Vasodilators
C) Nitrates
D) Beta blockers

Answer 19

D) Beta blockers

Beta blockers may be prescribed to relax the heart, stabilize the rhythm, and slow the heart’s pumping action in clients with hypertrophic cardiomyopathy. Digoxin is contraindicated for the client with hypertrophic cardiomyopathy. Vasodilators and nitrates are not used to treat hypertrophic cardiomyopathy.

Question 20

A client with cardiomyopathy receiving diuretic therapy has a urine output of 200 mL in 8 hours. Which action by the nurse is correct?

A) Assist the client to ambulate.
B) Document a normal urine output.
C) Notify the healthcare provider.
D) Measure abdominal girth.

Answer 20

C) Notify the healthcare provider.

Rationale: The nurse should notify the healthcare provider, because a urine output of 200 cc in 8 hours is less than 30 cc per hour. The client could be dehydrated despite having peripheral edema. The nurse should not assist the client out of bed to ambulate at this time. This is not a normal urine output. Abdominal girth is not an objective measurement of fluid volume; daily weight is more precise.

Question 21

A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. Which is inappropriate for the nurse to include in the teaching session?

A) Dilated cardiomyopathy
B) Restrictive cardiomyopathy
C) Hypotrophic cardiomyopathy
D) Arrythmogenic right ventricular dysplasia

Answer 21

C) Hypotrophic cardiomyopathy

Rationale: The types of cardiomyopathy include dilated, restrictive, hypertrophic, arrythmogenic right ventricular dysplasia, and unclassified.

Question 22

The nurse is caring for a client diagnosed with cardiomyopathy. The client experiences tachycardia. Which medication does the nurse anticipate being prescribed?

A) ACE Inhibitor
B) Angiotensin II receptor blocker
C) Beta blocker
D) Cardiac glycoside

Answer 22

C) Beta blocker

Rationale: A client with cardiomyopathy experiencing tachycardia may take a beta blocker to lower the heart rate. ACE inhibitors and angiotensin II receptor blockers are used to decrease blood pressure in a client with cardiomyopathy. Cardiac glycosides are used in congestive heart failure and do not assist in lowering the heart rate in a client with cardiomyopathy.

Question 23

A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis?

A) Spacing out nursing activities so client fatigue is lessened
B) Assisting with client activities of daily living (ADLs) as necessary
C) Using passive and active range-of-motion (ROM) exercises as tolerated
D) Consulting with a physical therapist on an activity plan

Answer 23

A) Spacing out nursing activities so client fatigue is lessened

Rationale: The client who is experiencing activity intolerance should have nursing interventions implemented that encourage and preserve client energy. Assisting the client with ADLs, utilizing ROM exercises, and consulting with physical therapy are all interventions that support this nursing diagnosis. The nurse should cluster nursing activities, not space them out, in order to conserve client energy. This allows the client to rest between periods of nursing care.

Question 24

A nurse is educating a client with cardiomyopathy about diet choices that are appropriate for the client’s condition. Which statement is inappropriate for the nurse to include in the teaching session?

A) “It is important to monitor your sodium intake.”
B) “Increasing your dietary protein helps with cardiac cell repair.”
C) “Here is a list of high-fat, high-cholesterol foods to avoid.”
D) “I have notified the dietitian regarding your condition in order to provide you with more information.”

Answer 24

B) “Increasing your dietary protein helps with cardiac cell repair.”

Rationale: Diet is an important part of long-term management of heart failure. It also contributes to reducing fluid retention. The nurse should instruct the client with cardiomyopathy to monitor sodium intake and to avoid high-fat, high-cholesterol food. Instructing the client to increase protein is not appropriate and is not shown effective in managing cardiomyopathy. Consulting with the dietitian is appropriate with this client.

Question 25

A 14-year-old child was recently diagnosed with hypertrophic cardiomyopathy. During a follow-up appointment, the mother asks the nurse, "How will this affect my child's ability to play football in the fall?" How should the nurse respond? A) "This shouldn't affect his ability to play football." B) "Children with cardiomyopathy should not play football." C) "He could participate in flag football but not tackle football." D) "This may actually make him a better, stronger football player."

Answer 25

B) "Children with cardiomyopathy should not play football." Rationale: Children with cardiomyopathy should not play competitive sports due to the possibility of collapse or increased heart failure. Depending on the child's clinical status, low-impact activities may be appropriate, but this should be discussed with the child's physician.

Question 26

A 72-year-old client diagnosed with hypertrophic cardiomyopathy (HCM) is speaking to the healthcare team about treatment options. Which treatment option would likely not be recommended for this client, even though it is commonly used to treat younger clients with this condition? A) Defibrillator implantation B) Beta-blocker administration C) Calcium channel blocker administration D) Physical activity restrictions

Answer 26

A) Defibrillator implantation Rationale: Treatment guidelines for older clients with HCM are not well established, although they may include the use of beta blockers and/or calcium channel blockers. The client will also likely have restrictions on physical activity. However, the low morbidity and mortality rates among older clients do not support the use of the defibrillator devices frequently implanted in younger clients.

Question 27

The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother? A) "Did you consume any alcohol before you knew you were pregnant?" B) "Is there a history of diabetes in your family?" C) "Was the baby's father exposed to any toxins in the work environment?" D) "Do you have a history of hypertension?"

Answer 27

A) "Did you consume any alcohol before you knew you were pregnant?" Rationale: Most congenital heart defects occur during the first 8 weeks of pregnancy and are a combination of environmental and genetic factors. Fetal exposure to alcohol is one of the greatest factors for the development of these defects. Asking the mother if she consumed alcohol before she was aware that she was pregnant is an appropriate question when determining the cause of the heart defect. A history of hypertension will not cause a fetus to develop a congenital heart defect. The father's exposure to toxins in the work environment is not known to cause congenital heart defects of children. Maternal diabetes can impair fetal heart development, but a family history of diabetes is not known to cause congenital heart defects.

Question 28

The nurse is analyzing data collected after assessing a child with a congenital heart defect that decreases pulmonary blood flow. Which nursing diagnosis would be applicable for this client? A) Acute Pain B) Ineffective Breathing Pattern C) Decreased Cardiac Output D) Excess Fluid Volume

Answer 28

C) Decreased Cardiac Output Rationale: Nursing diagnoses for clients with congenital heart defects that decrease pulmonary blood flow include Decreased Cardiac Output, Risk for Infection, Caregiver Role Strain, and Activity Intolerance. Acute Pain and Ineffective Breathing Pattern are appropriate nursing diagnoses for a child following cardiac surgery. Excess Fluid Volume is a nursing diagnosis seen in the care of a client with a congenital heart defect that increases pulmonary blood flow.

Question 29

The nurse is planning care for a pediatric client recovering from surgery to repair a congenital heart defect. Which intervention should the nurse include to support the client's fluid status? A) Encourage oral intake of fluids when permitted. B) Limit oral and intravenous intake of fluids. C) Continue normal saline administration even after oral intake is normal. D) Convert the intravenous line to a saline lock immediately after surgery.

Answer 29

A) Encourage oral intake of fluids when permitted. Rationale: The child should be encouraged to begin oral fluids and nutrition when permitted. Although oral fluids are rarely limited, intake and output should be carefully assessed. Fluids and antibiotics should be provided as ordered until the child's oral intake is normal. Once normal, the line can be converted to a heparin or saline lock.

Question 30

The nurse provides discharge instructions to the parents of a child recovering from surgery to repair a congenital heart defect. What statement indicates that teaching has been effective? A) "Our child should be restricted in play and activity for at least 6 months." B) "Our child will need to take antibiotics prior to having dental surgery." C) "Fluids should be restricted to maximize lung function." D) "Our child should not return to normal activities for at least 2 years."

Answer 30

B) "Our child will need to take antibiotics prior to having dental surgery." Rationale: Since the child is at risk for infective endocarditis, prophylactic antibiotics are indicated for invasive procedures. The child should be encouraged to gradually return to normal activities, including play. The child's activity should not be restricted for 6 months to 2 years. The child should not restrict fluids.

Question 31

The nurse is caring for a premature infant diagnosed with patent ductus arteriosus (PDA). Which medication should the nurse anticipate administering to this client? A) Indomethacin B) Propranolol C) Antibiotics D) Prostaglandin E1

Answer 31

A) Indomethacin Rationale: Intravenous indomethacin often stimulates the closure of the PDA in premature infants. Prophylactic antibiotics are used in some clients with a congenital heart defect, but this is not common for infants with PDA. Propranolol is used to treat tetralogy of Fallot. Prostaglandin E1 is used with some congenital heart defects to maintain a PDA, not help close the PDA. B) Intravenous indomethacin often stimulates the closure of the PDA in premature infants. Prophylactic antibiotics are used in some clients with a congenital heart defect, but this is not common for infants with PDA. Propranolol is used to treat tetralogy of Fallot. Prostaglandin E1 is used with some congenital heart defects to maintain a PDA, not help close the PDA.

Question 32

A baby will be having surgery to correct a congenital heart defect. On which topic should the parents be instructed regarding the care of the child before surgery? A) Restricting immunizations until after the surgery B) Preventing exposure to infection C) Implementing no particular precautions D) Restricting fluids for a week before the surgery

Answer 32

B) Preventing exposure to infection Rationale: Preoperative care of a baby having surgery to correct a congenital heart defect should include prevention from infection with good hand washing. There are precautions that the parents should take to ensure the child is in optimal health prior to the surgery. Immunizations should be continued. The parents may be instructed to withhold food and fluids several hours before the surgery. Fluids would not be restricted for a week before surgery.

Question 33

The nurse is assessing a toddler diagnosed with tetralogy of Fallot (TOF). Which clinical manifestations does the nurse anticipate during the physical assessment? Select all that apply. ``` A) Palpable thrill in the pulmonic area B) Nail clubbing C) Cough D) Apneic periods E) Knee-chest position ```

Answer 33

A) Palpable thrill in the pulmonic area B) Nail clubbing E) Knee-chest position Rationale: Manifestations of TOF include a palpable thrill in the pulmonic area, clubbing of the fingers due to reduce oxygenation, and the knee-chest position, which the child will perform to decrease the return of systemic venous blood to the heart. A cough and apneic periods are not manifestations of this congenital heart defect.

Question 34

Which best describes how congenital defects are categorized? A) By the severity of defect B) By the pathophysiology and hemodynamics of defect C) By the location of defect D) By the infant's age when the defect was diagnosed

Answer 34

B) By the pathophysiology and hemodynamics of defect Rationale: Congenital heart defects are categorized by their pathophysiology and hemodynamics. They are not categorized by the severity of the defect, location of the defect, or the infant's age when the defect is diagnosed.

Question 35

The nurse is caring for a child who has just been diagnosed with an atrial septal defect (ASD). Which manifestations would the nurse expect upon assessment? Select all that apply. A) Pulmonary artery hypotension B) Midsystolic murmur at lower right sternal border C) Mitral valve regurgitation with cleft on mitral valve D) S1 heart tone may be split due to forceful left ventricular contraction

Answer 35

C) Mitral valve regurgitation with cleft on mitral valve E) Congestive heart failure Rationale: ASD occurs when there is an opening in the atrial septum, permitting left-to-right shunting of blood. Midsystolic murmur may be auscultated at the lower left sternal border due to increased blood flow across the tricuspid valve. Mitral valve regurgitation may occur with a cleft on the mitral valve. S1 heart tones may be split due to forceful right ventricular contraction. Finally, pulmonary artery hypertension and congestive heart failure may occur.

Question 36

The nurse is providing teaching to the parents of a child born with tetralogy of Fallot (TOF). Which statement should the nurse include in her teaching regarding this defect? A) "Increased pulmonary blood flow causes symptoms with this disease." B) "This disease consists of pulmonic stenosis, left ventricular hypertrophy, ventricular septal defect, and an overriding aorta." C) "Your child has a decreased amount of red blood cells because of this disease." D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta."

Answer 36

D) "This disease consists of pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta." Rationale: TOF consists of four defects—pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. This disease is also characterized by decreased pulmonary blood flow and polycythemia (increased red blood cells due to hypoxia).

Question 37

The nurse is caring for an infant diagnosed with hypoplastic left heart syndrome. The client has recently been scheduled for surgery to repair the defect. Which procedure does the nurse anticipate needing to provide client teaching about to the client's family? A) Norwood procedure B) Jatene procedure C) Rastelli procedure D) Damus-Kaye-Stansel procedure

Answer 37

A) Norwood procedure Rationale: Hypoplastic left heart syndrome is repaired using the Norwood, Glenn, and Fontan procedures, depending on the child's age. The Jatene procedure and the Damus-Kaye-Stansel procedure surgically repair the Transposition of Great Arteries (TGA). The Rastelli procedure is used to repair TGA with ventricular septal defect and pulmonary stenosis.

Question 38

During what period of gestation do congenital heart defects usually develop? A) First 8 weeks of gestation B) Second trimester C) Third trimester D) Last 4 weeks of gestation

Answer 38

A) First 8 weeks of gestation Rationale: Most congenital heart defects develop during the first 8 weeks of gestation. They are usually the result of combined genetic and environmental factors.

Question 39

The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct? A) A Cesarean section is preferred because you will lose less blood than with a vaginal birth. B) A Cesarean section is preferred because there is a lower risk of infection than with a vaginal birth. C) A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.

Answer 39

D) A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section. Rationale: Vaginal delivery is preferable to Cesarean section for most clients with congenital heart defects because they will likely lose less blood with vaginal birth. Risk of wound infection and thrombophlebitis are also concerns with Cesarean birth. Dilated aorta, pulmonary hypertension, and aortic stenosis are contraindications for vaginal delivery.

Question 40

The nurse is caring for an adult client who was diagnosed with a congenital heart defect as a child, which was later repaired with surgery. Which common complication of a heart defect should the nurse monitor that the client may still be at risk for? A) Deep vein thrombosis B) Endocarditis C) Atherosclerosis D) Shock

Answer 40

B) Endocarditis Rationale: Common complications of congenital heart defects that develop during adulthood include dysrhythmias, endocarditis, stroke, heart failure, pulmonary hypertension, and heart valve problems. Congenital heart defects do not normally cause deep vein thrombosis, atherosclerosis, or shock.

Question 41

The nurse is documenting assessment findings on a client with angina. Which term should the nurse use to describe chest pain that occurs at night and is unrelated to activity? A) Nonanginal pain B) Prinzmetal angina C) Unstable angina D) Stable angina

Answer 41

B) Prinzmetal angina Rationale: Prinzmetal (variant) angina is unrelated to activity and often occurs at night. Stable angina is induced by exercise and is relieved by rest or nitroglycerin. Unstable angina occurs with increasing frequency, severity, and duration. The pain is unpredictable. The client has been diagnosed with angina, and, therefore, the chest pain the client is experiencing is likely angina, not non-anginal pain.

Question 42

The nurse is caring for a client who has had a myocardial infarction. The client states, "I have been smoking for 35 years, what good will quitting do?" Which response is best? A) "Your risk of continued coronary artery disease will decrease by half when you stop." B) "Quitting will enhance the effects of your medications." C) "Your medications will not work if you smoke." D) "Quitting will ensure you don't develop any complications."

Answer 42

A) "Your risk of continued coronary artery disease will decrease by half when you stop." Rationale: Smoking cessation reduces the risk for coronary heart disease by 50% no matter how long the person has smoked. It will reduce the possibility of lung cancer, decrease complications, and possibly enhance medication effects, but the primary focus for this client is the effect on coronary artery disease.

Question 43

The nurse is preparing preoperative teaching for a client scheduled for a ventricular assist device (VAD). Which should the nurse include in these instructions? A) Need to stay on bedrest for a week or more B) Cardiac pain postoperatively is to be expected C) Risk for postoperative infection D) Expect to be ambulating the evening of surgery

Answer 43

C) Risk for postoperative infection Rationale: Clients with VAD are at considerable risk for infection; strict aseptic technique is used with all invasive catheters and dressing changes. The client may or may not be on bedrest for a week or more after the surgery. Cardiac pain postoperatively is not to be expected and could indicate a myocardial infarction. The client, however, will most likely not be ambulating the evening of the surgery.

Question 44

``` The nurse is instructing an older adult client about atorvastatin (Lipitor) to treat elevated cholesterol. Which side effects should the nurse advise the client to report to the healthcare provider? A) Headaches and nausea B) Muscle pain and weakness C) Bruising and excessive bleeding D) Shortness of breath and coughing ```

Answer 44

B) Muscle pain and weakness Rationale: Clients taking statins, such as atorvastatin (Lipitor), should promptly report muscle pain, tenderness, or weakness; skin rash, hives, or changes in skin color; and abdominal pain, nausea, or vomiting. Headaches, bruising or bleeding, and shortness of breath or coughing are not common side effects that need to be reported to the physician.

Question 45

The nurse is providing care to a client who has experienced several episodes of angina. Which agent does the nurse anticipate being ordered to reduce the intensity and frequency of an angina episode? A) The client will experience relief of chest pain with therapeutic lifestyle changes. B) The client will experience relief of chest pain with statin therapy. C) The client will experience relief of chest pain with nitrate therapy. D) The client will experience relief of chest pain with anticoagulant therapy.

Answer 45

C) The client will experience relief of chest pain with nitrate therapy. Rationale: A primary goal in the treatment of angina is to reduce the intensity and frequency of angina episodes. Rapid-acting organic nitrates are the drugs of choice for terminating an acute angina episode. Therapeutic lifestyle changes are significant if the client is to maintain a healthy heart. Statins are used to decrease cholesterol levels. Anticoagulant therapy is used to prevent additional thrombi from forming post-myocardial infarction.

Question 46

A client recovering from an acute myocardial infarction is prescribed aspirin. Which teaching points should the nurse include regarding this prescription? Select all that apply. A) Report any itching after seven days of taking. B) Check with your healthcare provider before taking herbal remedies. C) Take at a different time of day than warfarin. D) Report bleeding or bruising to the healthcare provider. E) Do not skip any scheduled appointments to have blood drawn for labs.

Answer 46

B) Check with your healthcare provider before taking herbal remedies. D) Report bleeding or bruising to the healthcare provider Rationale: Itching is not a common side effect of aspirin therapy. Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can increase the effect of the aspirin. Aspirin and Coumadin are not to be taken concurrently. Bleeding and bruising can occur and should be reported to the healthcare provider. Aspirin inhibits platelet aggregation and clot formation. No lab appointments will be made just for aspirin therapy.

Question 47

A client with angina is experiencing acute chest pain. The client rates the pain as a 7 out of 10. The client's vital signs include P 119, R 24, BP 98/63, T 99.1°F, and SpO2 89%. Which actions would the nurse implement at this time? Select all that apply. A) Administer antianxiety medication as prescribed. B) Coach in nonpharmacologic pain management techniques. C) Implement bedrest. D) Administer morphine sulfate 2 mg intravenous push as prescribed. E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed.

Answer 47

C) Implement bedrest. D) Administer morphine sulfate 2 mg intravenous push as prescribed. E) Administer oxygen at 2 liters/minute via nasal cannula as prescribed. Rationale: Interventions for the client experiencing acute chest pain include keeping the client on bedrest, administering morphine sulfate as prescribed, and administering oxygen as prescribed. Antianxiety medications are not effective in acute chest pain. Nonpharmacologic pain management techniques are not appropriate for an episode of acute chest pain.

Question 48

A nurse is teaching a client about the different types of angina. Which client statement indicate the need for follow up teaching? A) "Stable angina is the most common form of angina." B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise." C) "Unstable angina occurs with increasing frequency, severity, and duration." D) "Clients with unstable angina are at risk for a heart attack."

Answer 48

B) "Prinzmetal angina is atypical angina that occurs with strenuous exercise." Rationale: Angina results from ischemia and can be a one-time event or a chronic condition. There are three types of angina: stable, unstable, and Prinzmetal. Stable angina is the most common form of angina and is relieved with rest and nitrate medications. Unstable angina occurs with increasing frequency, severity, and duration. Clients with unstable angina are at risk for a heart attack, or myocardial infarction. Prinzmetal angina is atypical angina that is unrelated to activity.

Question 49

The nurse is providing care to a female client who is diagnosed with coronary artery disease. The client states to the nurse, "I don't know how this happened." Which response by the nurse is the most appropriate? A) "Women who take oral contraceptives are more likely to develop this disease." B) "Women who have children later in life often develop this disease" C) "Women with a history of sexually transmitted infections are more likely to develop this disease." D) "Women who conceive through the use of in-vitro fertilization are more likely to develop this disease."

Answer 49

A) "Women who take oral contraceptives are more likely to develop this disease." Rationale: Risk factors for coronary artery disease that are unique to women include premature menopause, oral contraceptive use, and hormone replacement therapy (HRT). Having children later in life, a history of sexually transmitted infections, and the use of in-vitro fertilization do not increase the risk of coronary artery disease for women.

Question 50

The nurse is teaching a client about the associated health risks of cocaine use. Which statement should the nurse use to describe how cocaine can cause myocardial infarction (MI)? A) Cocaine significantly increases the serum triglyceride level, leading to the development of an atheroma. B) Cocaine alters the body's clotting mechanisms, leading to thrombus formation. C) Cocaine increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction. D) Cocaine alters electrolyte balance, leading to arrhythmias

Answer 50

C) Cocaine increases sympathetic nervous system stimulation, increasing blood pressure and vasoconstriction. Rationale: Acute MI may develop as a result of cocaine intoxication. Cocaine increases sympathetic nervous system activity by both increasing the release of catecholamines from central and peripheral stores and interfering with the reuptake of catecholamines. This increased catecholamine concentration stimulates the heart rate and increases its contractility, increases the automaticity of cardiac tissues and the risk of dysrhythmias, and causes vasoconstriction and hypertension. The other answers do not occur with cocaine intoxication.

Question 51

A community health nurse is providing education to a group of adults regarding myocardial infarction (MI). When discussing ways to prevent the number of MI-related deaths, which statement by the nurse is inappropriate? A) "It is important to learn how to perform cardiopulmonary resuscitation (CPR)." B) "Be sure to take a baby aspirin every day to help prevent an MI." C) "Increase your knowledge of the manifestations of MI." D) "Seek immediate medical attention when you suspect an MI."

Answer 51

B) "Be sure to take a baby aspirin every day to help prevent an MI." Rationale: When educating clients regarding ways to decrease the number of MI-related deaths, the nurse will stress the importance of prevention. Learning about the manifestations of MI, as well as learning CPR, is appropriate. Clients should be taught to seek immediate medical attention when they suspect an MI. However, instructing all clients to take a baby aspirin every day to help prevent an MI is inappropriate, as not all clients should take this medication.

Question 52

What is the most common clinical manifestation of coronary artery disease? A) Chest pain B) Dyspnea C) Irritability D) Tachycardia

Answer 52

A) Chest pain Rationale: Coronary artery disease is often asymptomatic. When clinical manifestations do occur, the most common indications are angina and myocardial infarction. Angina, acute coronary syndrome, and acute myocardial infarction are all characterized by the presence of chest pain of various intensities. Although dyspnea, irritability, and tachycardia may also be present in some clients, chest pain is the classical manifestation of coronary artery disease.

Question 53

For a client with coronary artery disease, what can the nurse recommend to the client to help decrease cardiac workload and sympathetic nervous system stimulation? A) Physical rest B) Psychological rest C) Fluid intake D) Fluid restriction

Answer 53

A) Physical rest Rationale: For the client with coronary artery disease, physical rest helps decrease cardiac workload and sympathetic nervous system stimulation, promoting comfort. Information and emotional support help decrease anxiety and promote psychological rest. Although fluid overload may increase cardiac workload, the nurse should not restrict fluids unless prescribed by the physician.

Question 54

The nurse is caring for a 76-year-old client with a history of angina. What atypical age-related warning sign of a myocardial infarction should the nurse need to include in client teaching? A) Cool, clammy skin B) Chest pain C) Tachycardia D) Abdominal pain

Answer 54

D) Abdominal pain Rationale: Older adults commonly have atypical symptoms of myocardial infarction, such as difficulty breathing, confusion, fainting, dizziness, abdominal pain, or cough. Cool, clammy skin; chest pain; and tachycardia are all symptoms of myocardial infarction that are more common in younger individuals but less common in older individuals.

Question 55

The nurse is completing an assessment on a newly admitted client. What finding would alert the nurse that the client may be experiencing a deep venous thrombosis (DVT)? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with edema D) Sharp pain in both legs

Answer 55

C) Swelling in one leg with edema Rationale: Manifestations of DVT include swelling in one leg with pitting edema because the clot is obstructing the venous return from the leg. Shortness of breath that subsides after activity and two-plus palpable pulses are not manifestations of DVT. Pain in the affected extremity is usually dull and aching, not sharp.

Question 56

The nurse is planning care for a group of clients. Which client should the nurse identify as having the greatest risk for developing deep venous thrombosis (DVT)? A) The client recovering from laparoscopic gallbladder surgery B) The client admitted with new-onset type II diabetes mellitus C) The client admitted with community-acquired pneumonia D) The client recovering from knee replacement surgery

Answer 56

D) The client recovering from knee replacement surgery Rationale: Between 40% and 85% of clients recovering from total knee replacement surgery develop a DVT because of the procedure and prolonged immobility after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a lower risk for DVT because prolonged immobility will not occur.

Question 57

The nurse is caring for a breastfeeding client recovering from a cesarean section. The physician diagnoses her with superficial venous thrombosis. Which intervention should the nurse anticipate carrying out first? A) Encourage to ambulate freely B) Aspirin 650 mg every 4 hours C) Apply warm, moist compresses D) Provide methylergonovine (Methergine) IM

Answer 57

C) Apply warm, moist compresses Rationale: The treatment for superficial venous thrombosis involves resting the extremity, administering anti-inflammatory agents, and applying warm, moist compresses over the affected vein. Ambulation would increase the inflammation. Heparin or warfarin is preferred over aspirin for treatment of venous thrombosis, and both are safe for lactating mothers. Methylergonovine is given only for postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.

Question 58

The nurse is planning care for a client with deep venous thrombosis (DVT). Which problem would be a priority for this client? A) Infection B) Fluid volume C) Peripheral perfusion D) Sleep pattern

Answer 58

C) Peripheral perfusion Rationale: Ineffective peripheral tissue perfusion is the priority, because it is related to obstructed venous return, which is the underlying cause of the DVT. Risk for infection would be a priority if complications of infection were present; however, this is not the case. Excess fluid volume and disturbed sleep pattern are incorrect because they are not related to the underlying cause.

Question 59

``` The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply. A) Avoid crossing the legs B) Avoid long car trips C) Avoid prolonged standing or sitting D) Take frequent walks E) Take a daily aspirin dose of 650 mg ```

Answer 59

A) Avoid crossing the legs C) Avoid prolonged standing or sitting D) Take frequent walks Rationale: The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should also be instructed to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips. The client should not be instructed to take a daily aspirin, because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the DVT.

Question 60

A client diagnosed with a deep vein thrombosis (DVT) is receiving intravenous heparin. Which is the priority outcome for this client? A) The client will not disturb the intravenous infusion. B) The client will comply with dietary restrictions. C) The client will not experience bleeding. D) The client will keep the right leg elevated on two pillows.

Answer 60

C) The client will not experience bleeding An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important, but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important, but not as high a priority as an absence of bleeding.

Question 61

A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse? A) Assess pulse, respirations, and blood pressure. B) Apply oxygen and elevate the head of the bed. C) Reassure the client and notify family members. D) Increase the rate of heparin infusion.

Answer 61

B) Apply oxygen and elevate the head of the bed. Rationale: Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation. Although reassuring the client and notifying family members are important, they are not a higher priority than promoting oxygenation. Increasing the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider.

Question 62

A client being treated for a deep venous thrombosis (DVT) is experiencing pain. Which interventions should the nurse implement? Select all that apply. A) Apply an egg-crate mattress on the bed. B) Maintain bedrest as ordered. C) Apply warm moist heat to the area four times a day. D) Encourage position changes every 2 hours. E) Measure calf and thigh diameter daily.

Answer 62

B) Maintain bedrest as ordered. C) Apply warm moist heat to the area four times a day. E) Measure calf and thigh diameter daily. Rationale: Interventions to address pain include applying warm moist heat to the area four times a day, maintaining bedrest as ordered, and measuring calf and thigh diameter daily. Applying an egg-crate mattress on the bed and encouraging position changes every 2 hours would be appropriate for the client experiencing Ineffective Peripheral Tissue Perfusion.

Question 63

The three pathological factors that are associated with the formation of a thrombus are known as what? A) Rastelli syndrome B) Holter triad C) Vena cava syndrome D) Virchow's triad

Answer 63

D) Virchow's triad Rationale: Three pathological factors, called Virchow's triad, are associated with the formation of a thrombus: circulatory stasis, vascular damage, and hypercoagulability. The Rastelli procedure is used to repair some congenital heart defects. A Holter monitor is used record the electrical activity of the heart over 24 to 48 hours. A vena cava filter is used to prevent thrombi from traveling up to the heart from the legs.

Question 64

What characteristic of veins increases the risk for the development of a thrombus? A) Low blood flow B) High pressure C) Retrograde blood flow D) Presence of plaque

Answer 64

A) Low blood flow Rationale: Venous thrombi tend to occur at sites where the vein is normal but blood flow is low. High pressure in the veins does not stimulate the formation of a thrombus. Retrograde blood flow is associated with postthrombotic syndrome, which occurs after a deep vein thrombosis has already developed. Arterial thrombi tend to occur at sites of arterial plaque rupture.

Question 65

What is the most accurate tool for assessing and diagnosing venous thrombosis? A) Ascending contrast venography B) Duplex venous ultrasonography C) Magnetic resonance imaging D) Plethysmography

Answer 65

A) Ascending contrast venography Rationale: All four of these diagnostic tests can be used to help diagnose a venous thrombosis. However, ascending contrast venography is the only invasive test, and it is the most accurate diagnostic tool for venous thrombosis. The other tests are noninvasive and may not be able to directly visualize the clot.

Question 66

Both a 40-year-old male and a 70-year-old male are placed on anticoagulant therapy after diagnosis of a deep vein thrombosis (DVT). When providing teaching to these clients about their medication, how should the nurse individualize care for each? A) The younger client will need more frequent monitoring than the older client. B) The older client will need more frequent monitoring than the younger client. C) The older client will take a lower dose than the younger client. D) The younger client will take a lower dose than the older client.

Answer 66

B) The older client will need more frequent monitoring than the younger client. Rationale: Anticoagulant therapy is commonly used to treat both older and younger adults with DVT. Most drugs are administered in a similar fashion and at comparable doses in older and younger clients, but monitoring may occur more frequently in older adults.

Question 67

A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply. ``` A) Tachycardia B) Increased blood glucose level C) Decreased breath sounds D) Confusion E) Thick, tenacious bronchial secretions ```

Answer 67

A) Tachycardia C) Decreased breath sounds D) Confusion Rationale: Clinical manifestations of DIC include tachycardia, decreased breath sounds, and confusion. Increased blood glucose and thick bronchial secretions are not associated with this health problem.

Question 68

The nurse is caring for a client who has been admitted to labor and delivery. What should the nurse recognize as risk factors for disseminating intravascular coagulation (DIC)? Select all that apply. ``` A) Multiparity B) Placental abruption C) Preterm labor D) Fetal death E) Gestational diabetes ```

Answer 68

B) Placental abruption D) Fetal death Rationale: The risk of developing DIC increases in pregnant women who have preeclampsia, fetal death, amniotic fluid embolism, placental abruption, or septic abortion. Multiparity, preterm labor, and gestational diabetes do not cause DIC.

Question 69

The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this client? A) Frequent ambulation B) Maintenance of skin integrity C) Preparation for radiograph procedures D) Restricting fluids

Answer 69

B) Maintenance of skin integrity Rationale: Impairment of skin integrity can lead to bleeding in DIC. The client with DIC should be placed on bedrest. DIC is not diagnosed with radiograph examination but by serum lab studies. Fluids need to be monitored but will not be restricted

Question 70

A client with disseminated intravascular coagulation (DIC) is anxious and has decreased oxygen saturation. Which is the priority nursing diagnosis for this client? A) Acute Pain B) Impaired Gas Exchange C) Ineffective Peripheral Tissue Perfusion D) Anxiety

Answer 70

B) Impaired Gas Exchange Rationale: The decrease in oxygen saturation is a result of impairment in the client's gas exchange. Anxiety could contribute to the client's impaired gas exchange but is not the primary problem to address. Decreased oxygen saturation and anxiety would not be addressed with the diagnoses of Ineffective Peripheral Tissue Perfusion and Acute Pain.

Question 71

The nurse has identified Ineffective Peripheral Tissue Perfusion as a nursing diagnosis for a client with disseminated intravascular coagulation (DIC). What intervention would be appropriate for the client? A) Carefully repositioning the client every 2 hours B) Administering oxygen C) Monitoring oxygen saturation D) Encouraging deep breathing and coughing

Answer 71

A) Carefully repositioning the client every 2 hours Rationale: The intervention appropriate for the client experiencing ineffective peripheral tissue perfusion is to carefully reposition the client every 2 hours because position changes facilitate circulation and tissue perfusion. The other interventions would be appropriate if the client were experiencing impaired gas exchange.

Question 72

The nurse is evaluating care provided to a client with disseminated intravascular coagulation (DIC). Which finding indicates care has been successful for this client? A) Heart rate 110 beats per minute B) Oxygen saturation level 86% C) Urine output 20 mL per hour D) No evidence of bleeding

Answer 72

D) No evidence of bleeding Rationale: Care provided to a client with DIC is successful when there is no further bleeding. Heart rate of 110 beats per minute, oxygen saturation of 86%, and urine output of 20 mL per hour would indicate the need for further treatment.

Question 73

A client diagnosed with disseminated intravascular coagulation (DIC) is currently bleeding through the gastrointestinal tract. Which does the nurse anticipate administering to this client as a first line treatment? A) Aspirin B) Warfarin (Coumadin) C) Fresh frozen plasma and platelets D) Heparin

Answer 73

A) Aspirin Rationale: When bleeding is the major manifestation of DIC, fresh frozen plasma and platelet concentrates are given first to restore clotting factors and platelets. Aspirin and Coumadin are not indicated in the treatment of DIC. Heparin may be administered if bleeding is not controlled by plasma and platelets and if the client has manifestations of thrombotic problems.

Question 74

A client with disseminated intravascular coagulation (DIC) is experiencing joint pain. Which nursing intervention is appropriate for this client? A) Splints B) Cool compresses C) Heat D) Ice

Answer 74

B) Cool compresses Rationale: Joint pain associated with DIC can be reduced by applying cool compresses to the affected joints to reduce the transmission of pain impulses. Splints may hinder joint mobility and are not indicated for the care of this client. Heat will encourage bleeding and should not be applied to this client. Ice should not be applied but rather cool compresses.

Question 75

A nurse caring for a client with suspected disseminated intravascular coagulation (DIC). Which test result is common in DIC? A) Decreased prothrombin time B) Increased platelet count C) Decreased fibrinogen level D) Decreased partial thromboplastin time

Answer 75

C) Decreased fibrinogen level Rationale: Diagnostic tests are used to confirm the diagnosis of DIC and evaluate the risk for hemorrhage. DIC causes prolonged prothrombin and partial thromboplastin times due to the depletion of clotting factors. Decreased fibrinogen occurs in DIC, also due to decreased clotting factors. Platelet count is also decreased.

Question 76

A nurse is assessing a client during labor and delivery. Which condition should the nurse recognize as a risk factor for disseminated intravascular coagulation (DIC)? A) Gestational diabetes B) Polyhydramnios C) Placental abruption D) Placenta previa

Answer 76

C) Placental abruption Rationale: Acute DIC can occur in pregnant clients, most often with pregnancies complicated by preeclampsia, placental abruption, fetal demise, amniotic fluid embolism, and septic abortion. Gestational diabetes, polyhydramnios, and placenta previa are not risk factors for DIC.

Question 77

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Ineffective Peripheral Tissue Perfusion. Which actions interventions are appropriate for this diagnosis? Select all that apply. A) Monitor the client's level of consciousness and mental status. B) Elevate the client's knees on the bed or with a pillow. C) Minimize the use of tape on the client's skin. D) Assess extremity pulses, warmth, and capillary refill. E) Carefully reposition the client at least every 2 hours.

Answer 77

A) Monitor the client's level of consciousness and mental status. C) Minimize the use of tape on the client's skin. D) Assess extremity pulses, warmth, and capillary refill. Rationale: Thrombi and emboli forming throughout the microcirculation in DIC affect the perfusion of multiple organs and tissues. The nurse should not elevate the client's knees on the bed or with a pillow because this may impair arterial and venous flow to the lower legs and feet, increasing vascular stasis and the risk for thrombosis. The nurse should monitor the client's level of consciousness and mental status due to the risk of cerebral emboli. Preventing skin trauma reduces the risk for bleeding. The nurse will assess extremity pulses, warmth, and capillary refill, which facilitates the early treatment of impaired perfusion. Position changes facilitate circulation and tissue perfusion and provide an opportunity to assess for purpura, pallor, and bleeding.

Question 78

A client with disseminated intravascular coagulation (DIC) has a nursing diagnosis of Impaired Gas Exchange. Which action is appropriate when providing care based on this nursing diagnosis? A) Place the client in low-Fowler position to improve gas exchange B) Monitor the client's oxygen saturation intermittently C) Encourage frequent amulation D) Use continuous endotracheal suctioning instead of coughing and deep breathing

Answer 78

A) Place the client in low-Fowler position to improve gas exchange Rationale: Micro clots in the pulmonary vasculature are likely to interfere with gas exchange in the client with DIC. The nurse should place the client in Fowler or high-Fowler position to improve gas exchange. Oxygen saturation levels are a noninvasive means of assessing gas exchange and should be monitored continuously. The client must remain on bedrest to reduces oxygen demands and cardiac workload. Cautious nasotracheal suctioning is indicated only if cough is ineffective or an endotracheal tube is in place. Deep breathing increases respiratory depth and improves alveolar ventilation and oxygenation.

Question 79

Which pathological change related to disseminated intravascular coagulation (DIC) occurs late in the course of the disease? A) Hemorrhage B) Formation of small clots C) Damage to the endothelium D) Brain ischemia

Answer 79

A) Hemorrhage Rationale: Damage to the endothelium is one of the triggers that stimulates the clotting cascade. This increases the presence of thrombin, which causes small clots to form in the microvasculature. If these thrombi and emboli impair tissue perfusion, ischemia of organs such as the brain can occur. When clotting factors are depleted and fibrin degradation products are released, hemorrhage occurs.

Question 80

The nurse is caring for a client with congestive heart failure (CHF) who frequently wakes during the night frightened and short of breath. Based on this data, what is the client experiencing? A) Cardiomyopathy B) Paroxysmal nocturnal dyspnea C) High-output failure D) Multisystem heart failure

Answer 80

B) Paroxysmal nocturnal dyspnea Rationale: Paroxysmal nocturnal dyspnea occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night. This causes fluid overload and pulmonary congestion. The client awakens at night short of breath and frightened. The client is not experiencing cardiomyopathy, high-output failure, or multisystem heart failure.

Question 81

The nurse is planning care for several clients. Which client should the nurse identify as being at greatest risk of developing heart failure? A) A 69-year-old African American male with hypertension B) A 50-year-old African American female who smokes C) A 75-year-old Caucasian male who is overweight D) A 52-year-old Caucasian female with asthma

Answer 81

A) A 69-year-old African American male with hypertension Rationale: Age above 65, African American race, and hypertension lead to an increased risk for developing heart failure. Smoking and obesity are also risk factors. The 69-year-old African American male with hypertension has three risk factors, whereas the other clients have between zero and two risk factors.

Question 82

The nurse is caring for a child with congestive heart failure (CHF). Which clinical manifestations does the nurse anticipate when assessing this child? Select all that apply. ``` A) Excessive sweating B) Hypertension C) Bradycardia D) Difficulty breathing E) Increased appetite ```

Answer 82

A) Excessive sweating D) Difficulty breathing Rationale: Children typically do not have the same symptoms of heart failure as adults. Symptoms in children include difficulty breathing, excessive sweating, low blood pressure (not hypertension), and poor feeding or growth (not increased appetite). Bradycardia is not a typical finding in children with heart failure.

Question 83

During an assessment, a client with left-sided congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care? A) Excess Fluid Volume B) Ineffective Health Management C) Noncompliance D) Activity Intolerance

Answer 83

A) Excess Fluid Volume Rationale: The client is experiencing acute shortness of breath because of the excess fluid. Excess Fluid Volume is the nursing diagnosis that is the priority at this time. Activity Intolerance will improve once the Excess Fluid Volume is addressed. Noncompliance or Ineffective Health Management related to the inability to purchase medications should be addressed after the client's physiological problems are resolved.

Question 84

The nurse is assessing a client being treated for congestive heart failure (CHF). Which physical findings would indicate that the client's condition is not improving? Select all that apply. ``` A) Urine output 160 ml over 8 hours B) Pulse oximetry reading of 96% C) Temperature of 98.6°F (37°C) D) Wheezing of breath sounds in all lobes E) Moderate amount of clear, thin mucus ```

Answer 84

A) Urine output 160 ml over 8 hours D) Wheezing of breath sounds in all lobes Rationale: A urine output of less than 30 ml/hour should be reported to the healthcare provider and is an indication of a worsening of CHF. Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in CHF. These sounds indicate that the client's condition is not improving. A pulse oximetry reading of 96%, temperature reading of 98.6°F, and moderate clear mucus are all normal findings.

Question 85

A client is prescribed enalapril (Vasotec) for treatment of heart failure. Which adverse effect should the nurse assess for following the initial administration of this drug? A) Jaundice B) Ototoxicity C) Low blood pressure D) Blurred vision

Answer 85

C) Low blood pressure Rationale: Severe hypotension can occur after the initial administration of enalapril (Vasotec). Jaundice and ototoxicity are adverse effects of diuretics. Blurred vision is a sign of digitalis toxicity.

Question 86

The nurse is positioning a client with left-sided heart failure in bed. Which sleeping position is most appropriate for this client? A) Reclining with 3 pillows under head B) Lying on the left side with 1 pillow under head C) Lying supine with 1 pillow under head D) Lying in the Sims position with 2 pillows under head

Answer 86

A) Reclining with 3 pillows under head Rationale: The client with left-sided cardiac failure could develop orthopnea. Being in an upright position with 3 pillows under the head will ease the work of breathing. Lying on the left side, lying supine, or lying in the Sims position, even with 1-2 pillows, will not help alleviate or prevent the development of orthopnea.

Question 87

The nurse is performing an assessment of a client. Which should the nurse recognize as a noncardiac risk factor for heart failure? A) Myocardial Infarction B) Hypertension C) Hyperthyroidism D) Congenital Heart Defects.

Answer 87

C) Hyperthyroidism Rationale: Heart failure may be caused by acute cardiac events such as myocardial function, conditions causing increased cardiac workload (hypertension, congenital defects), or noncardiac conditions, such as hyperthyroidism.

Question 88

Which is true about the physiology of neuroendocrine compensatory mechanism? A) Increased venous return increases ventricular filling and myocardial stretch, increasing the force of contraction. B) Decreased cardiac output stimulates the sympathetic nervous system and catecholamine release. C) Increased renal perfusion stimulates the renin-angiotensin system. D) Antidiuretic hormone is released from the adrenal gland.

Answer 88

B) Decreased cardiac output stimulates the sympathetic nervous system and catecholamine release. Rationale: In the neuroendocrine response, the cardiac output is decreased. This stimulates the sympathetic nervous system, causing catecholamine release. Decreased cardiac output combined with decreased renal perfusion stimulates the renin-angiotensin system. In addition, antidiuretic hormone is released from the posterior pituitary. In the Frank-Starling mechanism, increased venous return increases ventricular filling and myocardial stretch, increasing the force of contraction.

Question 89

A client with heart failure is admitted to the hospital for the placement of an implantable defibrillator. The client appears comfortable at rest, but displays dyspnea with activities of daily living (ADLs). Which stage of heart failure does the nurse recognize when reading the client's health record? A) Stage I B) Stage II C) Stage III D) Stage IV

Answer 89

C) Stage III Rationale: This client is in stage III heart failure, or moderate heart failure. In this stage, the client is comfortable at rest but displays dyspnea with less than normal physical activity. Also, in this stage, surgical intervention includes implantation of a defibrillator.

Question 90

When planning care for this client, which does the nurse understand about systolic heart failure? A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system B) Results when the heart cannot completely relax in diastole, disrupting normal filling C) Decreases passive diastolic filling, increasing the importance of atrial contraction to preload D) Results from decreased ventricular compliance caused by hypertrophic and cellular changes and impaired relaxation of the heart muscle

Answer 90

A) Occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system Rationale: Heart failure is commonly classified as either systolic or diastolic heart failure, based on the underlying pathology. Systolic heart failure occurs when the ventricle fails to contract adequately to eject a sufficient volume of blood into the arterial system. All other choices are true of diastolic heart failure, not systolic.

Question 91

The nurse is counseling a female client who wants to become pregnant. The client was diagnosed with heart failure 3 years ago and is currently in stage II heart failure. What information should the nurse include in her client teaching related to pregnancy and heart failure? A) Women with stage II heart failure should not attempt to become pregnant. B) Women with stage II heart failure should receive additional monitoring during pregnancy. C) Women with stage II heart failure should take ACE inhibitors during the pregnancy. D) Women with stage II heart failure should stop taking diuretics during the pregnancy.

Answer 91

B) Women with stage II heart failure should receive additional monitoring during pregnancy. Rationale: Women with stage II heart failure may be able to carry and deliver a baby, but they should be counseled about risk prior to becoming pregnant and should be carefully monitored during pregnancy and the postpartum period. ACE inhibitors are contraindicated during pregnancy due to potential adverse effects on the fetus. Diuretics are commonly prescribed for pregnant women with heart failure, especially if pulmonary edema is present.

Question 92

A client reports morning headaches that extend into the neck and go away as the day wears on. Based on this initial data, which assessment finding does the nurse anticipate? A) Elevated blood pressure B) Tachycardia C) Otitis media D) Swollen lymph nodes

Answer 92

A) Elevated blood pressure Rationale: A headache, generally in the back of the head and neck, that is present on awakening and subsides during the day is an early sign of hypertension. The nurse would expect that the client's blood pressure would be elevated. This type of headache is not directly associated with tachycardia, otitis media, or swollen lymph nodes.

Question 93

The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective? A) "I won't be able to run in marathons anymore." B) "I know I need to give up my cigarettes and alcohol." C) "I need to get started on my medications right away." D) "My father had hypertension, did nothing, and lived to be 90 years old."

Answer 93

B) "I know I need to give up my cigarettes and alcohol." Rationale: Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacologic methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need for pharmacotherapy, so the client may not have to take medication right away. Increasing physical activity is an important lifestyle modification for controlling hypertension. The fact that the client's father had hypertension and lived to be 90 years old does not mean that the client will have the same experience; the client is in denial.

Question 94

The nurse is caring for a client who has not been adhering to treatment with anti-hypertension medication. Which approach to addressing this issue should the nurse use? A) Indifference B) Nonjudgmental C) Demanding D) Confrontational

Answer 94

B) Nonjudgmental Rationale: The nurse who listens to the client openly and nonjudgmentally will both validate the client's self-esteem and communicate the idea of partnership in the treatment plan for the client. Indifference or demanding or confrontational attitudes will likely elicit a negative response from the client, and the client will be less likely to change his behavior.

Question 95

An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care? A) Monitor serum sodium levels B) Assess postural blood pressures C) Monitor serum creatinine levels D) Monitor blood pressure every 2 hours

Answer 95

B) Assess postural blood pressures Rationale: Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely to occur. Also, clients treated for hypertension could have an increase in sensitivity to the medications. Postural blood pressure assessment allows the nurse to prevent orthostatic hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical client. Sodium and creatinine levels assess renal function.

Question 96

The nurse instructs a client about the medication nifedipine (Procardia) for hypertension. Which client statement indicates that additional teaching is needed? A) "This medication will cause my ankles to swell, which is normal." B) "I need to drink 6 to 8 glasses of water each day." C) "I will call my doctor if I gain weight or become short of breath." D) "I need to eat foods high in fiber when taking this medication."

Answer 96

A) "This medication will cause my ankles to swell, which is normal." Rationale: Swelling in the feet or ankles when taking this medication should be reported to the healthcare provider. This medication can cause constipation, so drinking 6—8 glasses of water each day and increasing fiber in the diet are appropriate interventions cited by the client. The client should notify the healthcare provider with weight gain or shortness of breath.

Question 97

The nurse is caring for a client with hypertension. Which diagnostic tests should the nurse anticipate being ordered to rule out secondary causes? Select all that apply. ``` A) Cerebral angiogram B) Intravenous pyelogram C) Renal ultrasonography D) Cardiac catheterization E) Myelogram ```

Answer 97

B) Intravenous pyelogram C) Renal ultrasonography Rationale: When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram and renal ultrasonography to determine if the renal system is the cause of the hypertension. Cerebral angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the cause for secondary hypertension.

Question 98

A client has a blood pressure of 142/92 mmHg. Which classification is appropriate for the nurse to use when documenting this data? A) Normal B) Hypertension stage I C) Prehypertension D) Hypertension stage II

Answer 98

B) Hypertension stage I Rationale: Blood pressure values in the adult are classified as either normal (<120/<80 mmHg), prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or hypertension stage II (≥160/≥100).

Question 99

Which best describes the effects of the renal system on blood pressure? A) "The release of the catecholamines epinephrine and norepinephrine cause an increase in blood pressure." B) "The release of renin causes an increase in blood pressure." C) "The release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) cause an increase in blood pressure." D) "The synthesis and release of adrenomedullin causes an increase in blood pressure."

Answer 99

B) "The release of renin causes an increase in blood pressure." Rationale: A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II in the lungs. Angiotensin II is a vasoconstrictor and also promotes sodium and water retention, raising blood pressure. Catecholamines, ANP, BNP, and adrenomedullin do help regulate blood pressure, but they are not released from the kidneys.

Question 100

A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. What is the mechanism of action of this drug? A) Prevents conversion of angiotensin I to angiotensin II B) Prevents beta-receptor stimulation in the heart C) Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells D) Blocks alpha-receptors in the vascular smooth muscle

Answer 100

D) Blocks alpha-receptors in the vascular smooth muscle Rationale: Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the vascular smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium channel blockers inhibit the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells.

Question 101

) Which risk factor for hypertension is modifiable? A) Age B) Ethnicity C) Family history D) Tobacco use

Answer 101

D) Tobacco use Rationale: Age, race/ethnicity, family history, and genetic factors are all nonmodifiable risk factors for hypertension. Hypertension has many modifiable risk factors, including tobacco use, high sodium intake, obesity, excess alcohol consumption, and low activity level.

Question 102

Which physiological changes associated with aging increase the risk of hypertension in older adults? A) Increase in systolic blood pressure B) Increase in diastolic blood pressure C) Increase in the pulse pressure D) Decrease in the diastolic blood pressure

Answer 102

A) Increase in systolic blood pressure Rationale: An age-related increase in the systolic blood pressure is the primary factor leading to the high incidence of hypertension in older adults. Unlike the diastolic blood pressure, which tends to rise until approximately age 50 and then decline, the systolic blood pressure continues to rise with age. The pulse pressure, which is the difference between the systolic and diastolic blood pressures, does not determine hypertension status.

Question 103

Which strategy to prevent hypertension is correct? A) Increase salt intake B) Reduce physical activity C) Decrease stress D) Take hot baths

Answer 103

C) Decrease stress Baths that are too hot can increase blood pressure, so they should be avoided. Avoiding cool baths will not help prevent hypertension. Reducing salt intake, increasing physical activity, and decreasing stress are all strategies to prevent hypertension.

Question 104

The nurse is caring for a 13-year-old female with a BMI of 30.4. When taking the child's vital signs, the nurse documents a blood pressure of 121/83. How would this blood pressure be categorized for this client? A) Normal blood pressure B) Prehypertension C) Hypertension D) Hypotension

Answer 104

C) Hypertension Rationale: For a 13-year-old female, the systolic blood pressure should be between 96-103 mmHg and the diastolic blood pressure should be between 58-61 mmHg. Prehypertension is defined as having a blood pressure between the 90th and 95th percentile for the child's age, height, and sex. Hypertension is defined as having blood pressure above the 95th percentile or a blood pressure higher than 120/80.

Question 105

) The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse? A) Blood pressure of 142/92 mmHg B) Pulse of 92 beats per minute C) Respiratory rate of 24 per minute D) Weight gain of 16 oz per week

Answer 105

A) Blood pressure of 142/92 mmHg Rationale: A pregnant client's blood pressure should not be greater than 140/90 mmHg, and if it is elevated, it could be a sign of gestational hypertension or preeclampsia. The pregnant client's heart and respiratory rates will increase slightly as a result of an increased circulatory volume and a decrease in intrathoracic space. Weight gain should average a pound per week in the second and third trimesters.

Question 106

The nurse is assessing a client who is 20 weeks pregnant. Which health issue should the nurse recognize as increasing this client's risk for the development of preeclampsia? A) Treatment for vitamin D deficiency B) Surgery for ruptured appendix 1-year prior C) Fibrocystic breast disease D) Obesity

Answer 106

D) Obesity Rationale: One risk factor for the development of preeclampsia is obesity. The other choices will not predispose the client to developing preeclampsia.

Question 107

``` The nurse identifies assessment findings for a client with preeclampsia. Blood pressure is 158/100 mmHg; urinary output 50 mL/hour; crackles in the lungs on auscultation; urine protein 1+; 1+ edema hands, feet, ankles. On the next hourly assessment, which new assessment finding would indicate worsening of the condition? A) Blood pressure 159/100 mmHg B) Urinary output 40 mL/hour C) Urine protein 2+ D) Lungs clear to auscultation ```

Answer 107

C) Urine protein 2+ Rationale: The assessment finding most abnormal is the increase in urine protein. This indicates worsening of the condition. Urinary output is still greater than 30 mL/hour, so this is not concerning yet. The blood pressure increase is not significant. Lungs clear to auscultation is an improvement in her condition.

Question 108

During a routine prenatal visit, a client who is 24 weeks pregnant has a blood pressure of 143/91. The client's blood pressure at her previous visit was 121/82. A urine dipstick test reveals a trace amount of protein. The nurse identifies which nursing diagnosis as appropriate for the client at this time? A) Risk for Imbalanced Fluid Volume B) Chronic Pain C) Risk for Delayed Development D) Constipation

Answer 108

A) Risk for Imbalanced Fluid Volume Rationale: The rise in blood pressure and protein in the urine could indicate that preeclampsia is developing. Because preeclampsia is often accompanied by fluid retention, the client would be at risk for imbalanced fluid volume. The other nursing diagnoses are not appropriate for the client at this time.

Question 109

The community nurse is caring for a client who is 32 weeks pregnant and diagnosed with preeclampsia. Which statement indicates that the client requires additional teaching? A) "It is normal for my urine may become darker and smaller in amount each day." B) "I should call the doctor if I develop a headache or blurred vision." C) "Pain in the top of my abdomen is a sign my condition is worsening." D) "Lying on my left side as much as possible is good for the baby."

Answer 109

A) "It is normal for my urine may become darker and smaller in amount each day." Rationale: Oliguria is a complication of preeclampsia caused by renal involvement and is a sign that the condition is worsening. It is not an expected outcome and should be reported to the physician. Headache and blurred vision or other visual disturbances are an indication of worsening preeclampsia, and should be reported to the physician. Epigastric pain is an indication of liver enlargement, a symptom of worsening preeclampsia, and should be reported to the physician. Left lateral position maximizes uterine and renal blood flow, and therefore is the optimal position for a client with preeclampsia.

Question 110

The nurse is providing postpartum care for a client who gave birth by cesarean section several hours ago. The client had preeclampsia during the last 3 weeks of pregnancy. Which interventions are appropriate for this client within the first 48 hours after birth? Select all that apply. ``` A) Assessment of deep tendon reflexes B) Assessment of intake and output C) Oxygen 2 liters nasal cannula as prescribed D) Seizure precautions E) Vital sign assessment ```

Answer 110

A) Assessment of deep tendon reflexes B) Assessment of intake and output D) Seizure precautions E) Vital sign assessment Rationale: Even though the client with preeclampsia usually improves rapidly after giving birth, seizures can still occur during the first 48 hours postpartum. Nursing management during the postpartal period also includes deep tendon reflexes, intake and output assessment, and vital signs. Oxygen is not usually indicated after delivery.

Question 111

A client with preeclampsia begins to demonstrate manifestations of seizure activity. Which intervention by the nurse is most likely to protect the client and fetus from injury? A) Elevate the client's legs B) Place the client on the left side and protect the airway C) Place the client in the supine position D) Elevate the head of the bed

Answer 111

B) Place the client on the left side and protect the airway Rationale: The client should be placed on the side to aid in circulation to the placenta. The airway needs to be maintained to ensure oxygenation throughout the seizure. The client's legs should not be elevated. The client should not be placed in the supine position. The head of the bed should not be elevated.

Question 112

A nurse is teaching a group of pregnant clients regarding seizures associated with eclampsia. Which statement associated with eclampsia are accurate? A) "The tonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles." B) "The clonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity." C) "Seizures are rare in eclampsia, but they occur sometimes." D) "Seizures do not occur in preeclampsia."

Answer 112

D) "Seizures do not occur in preeclampsia." Rationale: Seizures do not occur in preeclampsia; eclampsia is diagnosed once a client has a seizure, so seizures are not rare in eclampsia. The tonic phase of a grand mal seizure is evidenced by muscular contraction and rigidity. The clonic phase of a grand mal seizure is evidenced by alternate contraction and relaxation of the muscles.

Question 113

A nurse working on an antepartum unit is providing care for a client with preeclampsia. Which laboratory value does the nurse anticipate for this client? A) Increased platelet count B) Decreased liver enzymes C) Decreased blood urea nitrogen (BUN) D) Increased serum creatinine

Answer 113

D) Increased serum creatinine Rationale: Preeclampsia decreases renal perfusion, causing an increase in both serum creatinine and blood urea nitrogen (BUN). Preeclampsia can also cause a decrease in platelet count and increase in liver enzymes.

Question 114

A pregnant client is diagnosed with HELLP syndrome. Based on this diagnosis, which laboratory findings are consistent with diagnosis of HELLP? A) Decreased liver enzymes B) Hemolysis C) Elevated lipid panel D) Increased platelet count

Answer 114

B) Hemolysis Rationale: HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) is thought to be related to severe preeclampsia. Elevated lipid panel is not a characteristic of HELLP syndrome.

Question 115

Which action should the nurse carry out for the laboring client who has been diagnosed with preeclampsia? A) Place the client in the room closest to the nurse's station, even if it is a shared room. B) Place the client in left lateral position when the client feels the urge to push. C) Monitor client's fetus intermittently while client is in first stage of labor. D) Encourage the client to be alone in the room without family in order to maintain a quiet environment.

Answer 115

B) Place the client in left lateral position when the client feels the urge to push. Rationale: A laboring client with preeclampsia is at risk for the development of eclampsia with subsequent seizures. The nurse should place the client in left lateral position because this position improves circulation to the placenta and fetus; the client should remain in this position when pushing if possible. If possible, the nurse should place the client in a private room to promote a nonstimulating environment. However, the client should always have support with her, not be alone during labor. The nurse will monitor the client's fetus continuously during labor.

Question 116

Which is believed to be the cause of preeclampsia? A) Placental dysfunction B) Liver disease C) Anxiety D) Low sodium intake

Answer 116

A) Placental dysfunction Rationale: The exact cause of preeclampsia is unknown. However, it has been identified as a disorder of placental dysfunction leading to a syndrome of endothelial dysfunction with associated vasospasm. The other answers are incorrect.

Question 117

A nurse is caring for a pregnant client who is hypertensive. Which additional clinical manifestations leads the nurse to believe that the client is experiencing early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain

Answer 117

B) Excessive protein in the urine Rationale: Early signs of preeclampsia include high blood pressure and evidence of protein in the urine. Later symptoms include persistent headache and right-sided abdominal pain. Severe epigastric pain is a symptom of HELLP syndrome.

Question 118

) During a blood pressure screening, an older adult client tells the nurse about chest fluttering while doing yard work. The client reports no other symptoms and the frequency is intermittent. Which action is correct by the nurse? A) Suggest the client stop exercising B) Reassure these are normal changes associated with aging C) Ensure the client is evaluated by his/her medical provider D) Check laboratory values for hypothyroidism

Answer 118

C) Ensure the client is evaluated by his/her medical provider Rationale: New-onset dysrhythmias may signal the onset of a serious underlying illness that requires further medical evaluation. Exercise intolerance would include shortness of breath, which the client does not report. These symptoms are not normal cardiac changes. Chest fluttering can be a sign of hyperthyroidism, not hypothyroidism.

Question 119

The nurse is assessing an adult client with a cardiac dysrhythmia. Which finding would the nurse identify as possibly contributing to this client's dysrhythmia? A) Drinks caffeinated coffee in the morning and for lunch B) Does not smoke or ingest any alcohol C) Plays golf three times a week and gardens daily D) Takes antihypertensive medication as prescribed

Answer 119

A) Drinks caffeinated coffee in the morning and for lunch Rationale: Caffeine increases the risk of ectopic beats and rapid heart rates. The client is a non-smoker and does not ingest alcohol, both of which would contribute to cardiac dysrhythmias. Engaging in routine physical activity will not cause dysrhythmias or conduction defects. Antihypertensive medications are not associated with cardiac dysrhythmias.

Question 120

An adult client is experiencing paroxysmal supraventricular tachycardia. Which nursing interventions are appropriate based on the data provided? Select all that apply. A) Initiate oxygen therapy B) Prepare for cardioversion C) Begin anticoagulation therapy as prescribed D) Administer intravenous adenosine as prescribed E) Administer a beta blocker as prescribed

Answer 120

A) Initiate oxygen therapy B) Prepare for cardioversion D) Administer intravenous adenosine as prescribed E) Administer a beta blocker as prescribed Rationale: Management of paroxysmal supraventricular tachycardia includes carotid sinus massage, oxygen therapy, adenosine, beta blockers, and synchronized cardioversion. Anticoagulant therapy is not a part of the management for this dysrhythmia.

Question 121

A client admitted with a cardiac dysrhythmia reports being easily fatigued and has difficulty performing normal daily activities. Which nursing diagnosis should the nurse select to address this client's issue? A) Excess Fluid Volume B) Activity Intolerance C) Depression D) Situational Low Self-Esteem

Answer 121

B) Activity Intolerance Rationale: The client is experiencing fatigue and frustration with the inability to perform normal daily activities. The nursing diagnosis to address this client's issue would be Activity Intolerance. There is no evidence that the client is experiencing excess fluid volume. The client may or may not be experiencing depression. The client may develop situational low self-esteem if the diagnosis of Activity Intolerance is not addressed.

Question 122

The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client? A) Restrict fluids B) Encourage bedrest C) Monitor serum electrolyte levels D) Instruct in a low-fat diet

Answer 122

C) Monitor serum electrolyte levels Rationale: The nurse should monitor serum electrolyte levels because electrolyte imbalances affect cardiac depolarization and repolarization and may cause dysrhythmias. There is no evidence to suggest the client needs to have fluids restricted. More information is needed before determining whether the client needs to be on bedrest. There is no evidence to suggest the client needs instruction on a low-fat diet.

Question 123

A client is receiving procainamide hydrochloride (Pronestyl) for treatment of a dysrhythmia. Which is an appropriate client outcome related to adhering to the provided medication instruction? A) The client will monitor the pulse and not take the medication if the pulse is less than 60. B) The client will take the medication as directed, even when feeling well. C) The client will take the medication on an empty stomach. D) The client will take the medication with food.

Answer 123

B) The client will take the medication as directed, even when feeling well. Rationale: It is very important for clients to understand that medication must be taken as directed, even if the client is feeling well. The beta-adrenergic blocking drugs cause bradycardia, not group 1A cardiac antiarrhythmic drugs like procainamide hydrochloride (Pronestyl). Procainamide hydrochloride (Pronestyl) can be taken on an empty stomach or with food.

Question 124

A client is scheduled for temporary pacemaker insertion. What instruction will this client need prior to discharge? A) Dizziness is to be expected. B) There are no special precautions. C) Wear a tight-fitting shirt to help hold the pacemaker in place. D) Use battery-powered equipment.

Answer 124

D) Use battery-powered equipment. Rationale: When available, battery-powered equipment should be used instead of electrical equipment. Dizziness is not to be expected and should be reported to the healthcare provider. The client should wear loose-fitting clothing.

Question 125

A client with sepsis has a temperature of 40°C. Which dysrhythmia is most likely to occur in this client? A) Bradydysrhythmia B) Tachydysrhythmia C) Wolff-Parkinson-White dysrhythmia D) Long QT dysrhythmia

Answer 125

B) Tachydysrhythmia Rationale: Stressors such as fever, sepsis, and hyperthyroidism may precipitate paroxysmal supraventricular tachycardia, which is a tachydysrhythmia. Fever does not cause bradydysrhythmia. Wolff-Parkinson-White and long QT are both syndromes which are caused by genetic cardiac problems.

Question 126

A nurse caring for a client in the in the intensive care unit (ICU) notes that the client is experiencing a ventricular tachycardia dysrhythmia. Which rhythm is a type of ventricular tachycardia? A) Sinus tachycardia B) Atrial flutter C) Junctional escape D) Torsades de Pointes

Answer 126

D) Torsades de Pointes Rationale: Torsades de Pointes is a type of ventricular tachycardia. Sinus tachycardia, atrial flutter, and junctional escape are all supraventricular rhythms, not ventricular rhythms.

Question 127

A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse? A) Administer epinephrine B) Immediately defibrillate the client C) Assess the cardiac monitor electrodes D) Assess the client's pulse

Answer 127

D) Assess the client's pulse Rationale: According to the American Heart Association (AHA) CPR guidelines, after five rounds of CPR, the nurse should assess the client's pulse. All other choices are incorrect actions by the nurse.

Question 128

Which property of cardiac cells is mechanical in nature? A) Automaticity B) Excitability C) Conductivity D) Contractility

Answer 128

D) Contractility Rationale: Cardiac cells have five unique properties. Four of these properties are electrical: automaticity, excitability, conductivity, and refractoriness. The fifth property is cardiac muscle's mechanical response to electrical stimulation: contractility.

Question 129

Which dysrhythmia is most commonly associated with sudden cardiac death (SCD)? A) Atrial flutter B) Ventricular fibrillation C) Paroxysmal supraventricular tachycardia D) Junctional escape rhythm

Answer 129

B) Ventricular fibrillation Rationale: Ventricular fibrillation most commonly leads to sudden cardiac death. The other dysrhythmias are not normally associated with SCD.

Question 130

The nurse is caring for a 6-year-old child when the child goes into cardiac arrest. When performing compressions for CPR, what should the nurse do? A) Place thumbs side by side and perform compressions below the nipple line B) Use two fingers in the upright position to perform compressions C) Use two fingers plus the heel of the other hand to perform compressions D) Use both hands on the lower half of the breastbone to perform compressions

Answer 130

C) Use two fingers plus the heel of the other hand to perform compressions Rationale: When performing CPR on neonates, thumbs should be placed side by side, or overlapping in very small neonates, and compressions should be performed below the nipple line. For infants, two fingers placed in the upright position should be used for compressions. For children, the provider should use two fingers plus the heel of the other hand to perform compressions. For adults, use both hands on the lower half of the breastbone to perform compressions.

Question 131

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. Which clinical manifestations does the nurse anticipate during the client's assessment? Select all that apply. A) Pulses absent in the extremity with the wound B) Wound that is pink with skin warm C) Ulceration that is pale in color D) Skin surrounding ulcer that is cool to the touch E) Surrounding skin brown in color

Answer 131

B) Wound that is pink with skin warm E) Surrounding skin brown in color Rationale: ) Manifestations of a venous status ulcer are a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is an arterial ulcer.

Question 132

A client diagnosed with peripheral vascular disease (PVD) is obese, has a 30-year history of cigarette smoking, and works as a contractor. When discussing risk factors for PVD, which statement by the nurse is appropriate? A) "Nicotine causes vasospasms, which reduce blood flow to the legs." B) "Obesity is a factor in cardiovascular disease but not peripheral vascular disease." C) "Nicotine primarily affects coronary arteries and the lungs." D) "Your current occupation is a major risk factor."

Answer 132

A) "Nicotine causes vasospasms, which reduce blood flow to the legs." Rationale: The vasoconstrictive properties of nicotine will worsen the client's PVD by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular disease and PVD; however, the nurse should focus on smoking cessation as a first priority with this client.

Question 133

) The nurse is planning care for an older adult client with chronic venous insufficiency. Which will the nurse include in the client's teaching plan? A) Keep the legs dependent as much as possible and elevate only when asleep. B) Wear elastic hose as prescribed. C) Standing will prevent the progression of the disease. D) Cross legs only at the knees.

Answer 133

B) Wear elastic hose as prescribed Rationale: Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The legs should be elevated during rest and when asleep. The nurse should instruct the client to avoid sitting or standing for long periods of time. Crossing the legs should be avoided.

Question 134

The nurse is planning care for a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity. Which intervention is appropriate for the nurse to include in the plan of care? A) Restrict fluids B) Keep the skin clean and dry, and moisturize areas of dryness C) Encourage bedrest with legs elevated on pillows D) Consult a dietitian for low-protein diet

Answer 134

B) Keep the skin clean and dry, and moisturize areas of dryness Rationale: The client with PVD who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A fluid restriction would dry tissues and not promote good skin turgor. Bedrest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client.

Question 135

The nurse is evaluating teaching provided to a client with peripheral vascular disease (PVD). Which client observation indicates teaching has been effective? A) Sitting in a chair with a pillow behind knees B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer C) Sitting in a chair with left leg crossed over the right D) Smoking a pipe instead of cigarettes

Answer 135

B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer Rationale: The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding PVD. Sitting in a chair with a pillow behind the knees or with legs crossed would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.

Question 136

A client with peripheral vascular disease (PVD) asks the nurse what types of exercise would improve the client's condition and overall health. Which type of exercise will the nurse include in the response to the client? A) Passive ROM B) Weight lifting C) Yoga D) Team sports

Answer 136

C) Yoga Rationale: Yoga is considered a complementary therapy used to reduce stress and improve circulation. Active ROM exercises should be encouraged rather than passive ROM exercises. Weight lifting may increase blood pressure and cause harm to fragile blood vessels. Clients with PVD should have gradual increases in duration and intensity of exercise, so team sports would not be appropriate.

Question 137

A client with peripheral vascular disease (PVD) is experiencing pain. Which nursing intervention addresses the client's pain? A) Elevate legs in bed B) Keep the extremities warm C) Encourage to ambulate several times each day D) Apply cool compresses to the extremities

Answer 137

B) Keep the extremities warm Rationale: The nurse should help keep the client's extremities warm, as heat promotes vasodilation and reduces pain. Elevating the legs in bed and encouraging the client to ambulate are more appropriate for promoting tissue perfusion and will not immediately address the client's pain. Cool compresses will constrict vessels and cause more pain.

Question 138

A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. Which should the nurse include when teaching the client about intermittent claudication? A) It causes pain that occurs during periods of inactivity. B) It causes pain that increases when the legs are elevated and decreases when the legs are dependent. C) It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. D) It is often described as a burning sensation in the lower legs.

Answer 138

C) It causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. Rationale: Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest. The other descriptions apply to rest pain, not intermittent claudication.

Question 139

A client is admitted to the hospital for a surgical intervention due to peripheral vascular disease (PVD). The nurse should be prepared to answer questions about which procedure? A) Stent placement B) Endarterectomy C) Percutaneous transluminal angioplasty D) Atherectomy

Answer 139

B) Endarterectomy Rationale: Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are nonsurgical interventions for PVD.

Question 140

What causes brown pigmentation of the lower extremities in clients with venous stasis? A) The necrosis of subcutaneous fat due to tissue hypoxia B) Breakdown of red blood cells in the congested tissues C) Reduced inflammatory and immune response from congested circulation D) Skin atrophy caused by lack of circulation

Answer 140

B) Breakdown of red blood cells in the congested tissues Rationale: Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with peripheral vascular disease, they are not responsible for the cause of brown pigmentation to the skin.

Question 141

A home care nurse is explaining the application of an Unna boot to a client with a stasis ulcer. Which statement about this dressing is accurate? A) "A nurse will change this dressing every 2 days." B) "It is important that you maintain strict bedrest." C) "The dressing will be applied to the entire length of your leg." D) "The dressing I am applying is semi-rigid."

Answer 141

D) "The dressing I am applying is semi-rigid." Rationale: The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing covers the foot and lower leg but not the entire leg. The dressing allows a client to be ambulatory and does not make the client maintain strict bedrest.

Question 142

Which form of peripheral vascular disease is characterized by thickening, loss of elasticity, and calcification of arterial walls? A) Arteriosclerosis B) Atherosclerosis C) Chronic venous insufficiency D) Deep venous thrombosis

Answer 142

A) Arteriosclerosis Rationale: Arteriosclerosis is characterized by thickening, loss of elasticity, and calcification of arterial walls. Atherosclerosis is a form of arteriosclerosis in which deposits of fat and fibrin obstruct and harden the arteries. Chronic venous insufficiency is a disorder of inadequate venous return over a prolonged period. Deep venous thrombosis is the presence of a blood clot in a deep vein.

Question 143

Which client has the highest risk of developing peripheral vascular disease (PVD)? A) 83-year-old African American male B) 78-year-old African American female C) 64-year-old Hispanic male D) 75-year-old White female

Answer 143

A) 83-year-old African American male Rationale: PVD primarily affects older adults, with greater prevalence seen in adults over age 80. Men are more often affected then women. African Americans are at greatest risk compared to other races.

Question 144

The nurse caring is caring for a client who is recovering from a hysterectomy. Which clinical manifestation supports that the client is experiencing a pulmonary embolism (PE)? A) Nausea B) Decreased urine output C) Dyspnea and chest pain D) Activity intolerance

Answer 144

C) Dyspnea and chest pain Rationale: The most common symptoms of PE are dyspnea and pleuritic chest pain. Other manifestations include anxiety, cough, diaphoresis, hemoptysis, tachycardia, tachypnea, crackles, and a low-grade fever. Nausea, decreased urine output, and activity intolerance are not clinical manifestations of a PE.

Question 145

The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. Which assessment finding caused the nurse to draw this conclusion? A) Body mass index (BMI) 35.8 B) Former cigarette smoker C) Blood pressure 132/88 mmHg D) Age 45 years

Answer 145

A) Body mass index (BMI) 35.8 Rationale: Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the client's weight.

Question 146

The nurse is providing discharge instructions to an older adult client who is going home after having a total knee replacement. Which should the nurse include in the discharge teaching to decrease the client's risk for developing a thrombosis or pulmonary embolism (PE)? Select all that apply. ``` A) Place pillows under the knees when in bed. B) Use compression stockings. C) Limit ambulation. D) Limit fluids. E) Continue with leg exercises. ```

Answer 146

B) Use compression stockings. E) Continue with leg exercises. Rationale: A client being discharged after having orthopedic surgery is at increased risk for PE. The nurse should instruct the client to use compression stockings and continue with leg exercises to reduce the risk of deep vein thrombosis formation. The client should avoid placing pillows under the knees, be encouraged to ambulate, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction.

Question 147

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this client? A) Ineffective Tissue Perfusion B) Anxiety C) Impaired Gas Exchange D) Impaired Physical Mobility

Answer 147

C) Impaired Gas Exchange Rationale: ) A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing impaired gas exchange. This would be the priority for the client at this time. The client may have ineffective tissue perfusion; however, this is not the priority. The client may be experiencing anxiety; however, this is not the priority at this time either. There is not enough information to determine whether the client is at risk for impaired mobility.

Question 148

The nurse is planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output? A) Provide oxygen B) Keep protamine sulfate at the bedside C) Monitor pulmonary arterial pressures D) Assess for bleeding

Answer 148

C) Monitor pulmonary arterial pressures Rationale: The client with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures. Oxygen would be appropriate for the client with impaired gas exchange. Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the client who is taking heparin.

Question 149

The nurse is providing teaching about long-term anticoagulant therapy to a client recovering from a pulmonary embolism. Which client statement indicates that instruction has been effective? A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor to avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."

Answer 149

B) "I need to use a soft toothbrush and an electric razor to avoid injuries." Rationale: Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush, and use an electric razor. The client should avoid green salads because of the vitamin K content. The statements about bruising being normal and expecting bloody sputum mean the client is in need of additional instruction on anticoagulant therapy.

Question 150

A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication? A) Infection B) Delayed wound healing C) Contractures D) Deep vein thrombosis

Answer 150

D) Deep vein thrombosis Rationale: The best care for a pulmonary embolism (PE) is prevention. Since surgical clients have an increased risk of developing a PE postoperatively, instructions should include ways to encourage movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower extremity circulation and prevent the development of a deep vein thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures.

Question 151

The nurse is preparing to discharge a client recovering from a pulmonary embolism (PE). Which topics should the nurse to include in the teaching session? Select all that apply. A) Limit the use of over-the-counter medications B) Diet to include green leafy vegetables C) Symptoms of recurrence D) Anticoagulant administration schedule E) Resume normal activity level

Answer 151

C) Symptoms of recurrence D) Anticoagulant administration schedule Rationale: The nurse should instruct the client in symptoms of bleeding or recurrence of a PE and the schedule for anticoagulation administration. The client being discharged after treatment for a PE needs to be instructed in avoiding all over-the-counter medications, avoiding green leafy vegetables because of vitamin K, and adhering to the physician's prescribed activity level.

Question 152

The nurse is providing care to several clients on a medical-surgical unit. Which client is at highest risk for a nonthrombotic pulmonary embolism (PE)? A) The client who is receiving intravenous pain medication B) The client who is postoperative from a femur fracture repair C) The client with a primary abdominal tumor D) The client who uses intravenous illicit drugs

Answer 152

B) The client who is postoperative from a femur fracture repair Rationale: Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the circulation. The other clients may be at risk for PE; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli.

Question 153

The nurse is caring for a client who develops dyspnea and chest pain. Which diagnostic finding is consistent with a pulmonary embolism (PE)? A) Lack of infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG

Answer 153

D) Tachycardia and nonspecific T-wave changes on EKG Rationale: With PE, tachycardia and nonspecific T-wave changes occur on EKG. Pulmonary infiltration is common on a chest x-ray. The client with a PE will likely have respiratory alkalosis from rapid breathing, not metabolic alkalosis. The end-tidal CO2 (EtCO2) monitor will be decreased, not increased, due to rapid breathing.

Question 154

The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism (PE). The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.

Answer 154

C) Heparin and warfarin (Coumadin) are usually initiated at the same time. Rationale: Heparin and warfarin are usually initiated at the same time for the treatment of PE. Anticoagulant therapy is the standard first-line treatment of PE. While major hemorrhage is uncommon, bleeding may occur. Warfarin (Coumadin), not heparin, alters the synthesis of vitamin K-dependent clotting factors.

Question 155

What increases after an embolus has become trapped in the pulmonary microvasculature? A) Perfusion B) Ventilation C) Dead space D) Alveolar surfactant

Answer 155

C) Dead space Rationale: Dead space, or areas of the lung that are ventilated but not perfused, increases. Both perfusion and ventilation are decreased after a pulmonary embolism. Alveolar surfactant also decreases, increasing the risk for atelectasis (collapsed lung).

Question 156

The nurse is caring for a child with a fractured femur who complains of sudden chest pain and difficulty breathing. Which test would the nurse question if it was ordered by the physician? A) D-dimer test B) V/Q scans C) Computerized tomography pulmonary angiography D) Magnetic resonance pulmonary angiography

Answer 156

A) D-dimer test Rationale: Although V/Q scans, computerized tomography pulmonary angiography, and magnetic resonance pulmonary angiography are useful in diagnosing children with PE, the D-dimer test is not. Therefore, if the physician ordered a D-dimer test, the nurse may need to question this order.

Question 157

The nurse is caring for a pregnant woman with a suspected pulmonary embolism without DVT. With regard to diagnostic tests to confirm the diagnosis what should the nurse anticipate being ordered for the client? Select all that apply. A) V/Q scan B) Computerized tomography pulmonary angiography C) Chest x-ray D) Non-stress test

Answer 157

A) V/Q scan B) Computerized tomography pulmonary angiography C) Chest x-ray Rationale: For pregnant women who have a suspected pulmonary embolism without DVT, a chest x-ray should be performed. If the chest x-ray is normal, a V/Q scan should be performed, followed by computerized tomography pulmonary angiography if the V/Q scan is inconclusive. If the chest x-ray is abnormal, the computerized tomography pulmonary angiography should be performed first rather than the V/Q scan. A Doppler ultrasound and non-stress test may provide information of fetal wellbeing, but are not used to diagnose a PE.

Question 158

Which assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply. ``` A) Slight increase in pulse B) Dry, warm skin C) Increased urine output D) Normal respirations E) Slight decrease in blood pressure ```

Answer 158

A) Slight increase in pulse D) Normal respirations E) Slight decrease in blood pressure Rationale: Manifestations of early hypovolemic shock include a slight increase in pulse, normal respirations, and normal to slightly decreased blood pressure. Manifestations also include cool, moist skin and a slight decrease in urine output.

Question 159

A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate? A) "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B) "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D) "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."

Answer 159

C) "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." Rationale: Obvious bleeding suggests hypovolemic shock; trauma to the brain or spinal cord suggests neurogenic shock; inadequate cardiac output suggests cardiogenic shock; a recent infection may indicate septic shock; and a history of allergies with a sudden onset of symptoms may suggest anaphylactic shock. Liver failure, kidney failure, and respiratory failure are not types of shock.

Question 160

A client who is taking beta-adrenergic blockers for angina is experiencing hypovolemic shock. Which does the nurse anticipate being the priority collaborative intervention for this client? A) Administering analgesics for control of pain B) Assessing the cause of bleeding C) Providing replacement of volume D) Establishing invasive cardiac monitoring

Answer 160

D) Establishing invasive cardiac monitoring Rationale: Clients who take beta blockers may not present with tachycardia as an early indicator of shock. These individuals will require early invasive monitoring to avoid excessive or inadequate volume restoration. Replacement of volume would occur after invasive cardiac monitoring is established. Pain would be a consideration but would not be attended to as a first priority. Assessing the cause of bleeding would also occur after establishing invasive cardiac monitoring.

Question 161

The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client? A) Deficient Fluid Volume B) Ineffective Coping C) Ineffective Airway Clearance D) Decreased Cardiac Output

Answer 161

D) Decreased Cardiac Output Rationale: The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping. There is not enough information to determine whether the client has ineffective airway clearance.

Question 162

The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client? A) Auscultate breath sounds for inspiratory stridor B) Auscultate breath sounds for crackles C) Auscultate breath sounds for hyperresonance D) Auscultate for an absence of breath sounds in the lower lobes

Answer 162

B) Auscultate breath sounds for crackles Rationale: ) Because albumin 5% is a volume expander and pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. Stridor is auscultated with airway obstruction, not pulmonary edema. Hyperresonance is assessed by percussion, not auscultation. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.

Question 163

The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective? A) "It's a protein that causes my kidneys to conserve fluid." B) "It's a protein that pulls water into my blood vessels." C) "It's a liquid that has electrolytes in it to pull water into my blood vessels." D) "It's a super-concentrated salt solution that helps me conserve body fluid."

Answer 163

B) "It's a protein that pulls water into my blood vessels." Rationale: Colloids are proteins or other large molecules that stay suspended in the blood for long periods because they are too large to easily cross membranes. They draw water molecules from the cells and tissues into the blood vessels through their ability to increase plasma oncotic pressure. Albumin 5% does not act on the kidneys. Crystalloids are intravenous (IV) solutions that contain electrolytes, not proteins, in concentrations resembling those of plasma. They are used to replace lost fluids and promote urine output. Albumin 5% is not a concentrated saline solution.

Question 164

A client is receiving intravenous nitroprusside (Nipride) for shock. Which adverse reactions will the nurse assess this client for when administering the infusion? Select all that apply. ``` A) Muscle spasms B) Tachycardia C) Confusion D) Gastrointestinal bleeding E) Disorientation ```

Answer 164

A) Muscle spasms B) Tachycardia C) Confusion E) Disorientation Rationale: Nausea, muscle spasms, and disorientation are signs of thiocyanate poisoning, which can occur if the infusion is longer than 72 hours. Confusion, dizziness, and tachycardia are adverse reactions that the nurse should report immediately to the healthcare provider. Gastrointestinal bleeding is not an adverse effect of this medication.

Question 165

A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as: A) Class I B) Class II C) Class III D) Class IV

Answer 165

C) Class III Rationale: This client is in Class III (moderate) hemorrhagic shock, which is defined as a loss of 1,500-2,000mL, or 30-40% of blood volume.

Question 166

A nurse working in the intensive care unit (ICU) is caring for a client in progressive hemorrhagic shock. What does the nurse understand about the physiology of progressive shock? A) It involves a sustained decrease of 10 mmHg of the client's mean arterial pressure (MAP). B) It involves a blood loss of 25%. C) It involves a change from aerobic to anaerobic metabolism. D) It involves a decrease in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.

Answer 166

C) It involves a change from aerobic to anaerobic metabolism. Rationale: In decompensated or progressive hemorrhagic shock, there is a change from aerobic to anaerobic metabolism due to cellular hypoxia from decreased perfusion. This stage of shock occurs when there is sustained decrease of 20 mmHg or more of the client's MAP and a blood loss of 35-50%. The acid by-products of anaerobic metabolism causes an increase, not decrease, in hydrostatic pressure within the capillary, shifting fluid into the interstitial space.

Question 167

A client with hemophilia is at increased risk for what type of shock? A) Cardiogenic shock B) Hemorrhagic shock C) Anaphylactic shock D) Distributive shock

Answer 167

B) Hemorrhagic shock Rationale: Because clients with hemophilia have a decreased ability to form clots, they are at high risk for hemorrhagic shock. They are not at higher risk for cardiogenic, anaphylactic, or distributive shock unless they also have other underlying conditions, such as advanced cardiac disease or severe allergies.

Question 168

What type of shock is characterized by increased pulse and respirations, normal blood pressure, elevated body temperature, and warm and flushed skin? A) Hypovolemic shock B) Cardiogenic shock C) Neurogenic shock D) Septic shock

Answer 168

D) Septic shock Rationale: Early septic shock is characterized by normal to slightly decreased blood pressure; increased pulse and respirations; warm, flushed skin; and chills, among other symptoms. In hypovolemic and cardiogenic shock, the skin will typically be pale and cool rather than warm and flushed. In neurogenic shock, the pulse will be slow and bounding rather than rapid.

Question 169

What is the purpose of using warm IV fluids to help resuscitate clients in shock? A) To increase vasodilation B) To prevent hypothermia C) To prevent hyperthermia D) To increase vasoconstriction

Answer 169

B) To prevent hypothermia Rationale: Using room-temperature fluids can cause hypothermia, which may hinder the effectiveness of treatment. Therefore, warmed IV fluids should be used to help resuscitate clients in shock. Use of warm IV fluids does not cause vasodilation or vasoconstriction, and it does not prevent hyperthermia.

Question 170

The nurse is caring for a child who was burned in a house fire. The child has burns on 30% of his body, particularly his legs. The child suddenly goes into shock and needs CPR. What is the first step the nurse should take based on pediatric advanced life support (PALS) guidelines? A) Begin ventilations B) Begin chest compressions C) Obtain a defibrillator D) Establish vascular access

Answer 170

B) Begin chest compressions Rationale: Based on PALS guidelines, the first step in providing life support to a child is to immediately begin chest compressions. This is the first step because no equipment is needed, so compressions can begin immediately. A second healthcare provider should begin ventilations with a bag and mask. A monitor and defibrillator should be obtained as the third step. Establishing vascular access should be the fourth step. The final step is calculating and preparing anticipated medications based on the child's weight.

Question 171

A 67-year-old client with a history of type II diabetes mellitus and chronic hypertension is admitted to the emergency department after a myocardial infarction. Which type of shock should the nurse be prepared to treat in this client? A) Cardiogenic shock B) Hypovolemic shock C) Neurogenic shock D) Septic shock

Answer 171

A) Cardiogenic shock Rationale: Older adults who have a heart attack, especially those with a history of heart failure, diabetes, or hypertension, have an increased risk of cardiogenic shock. Therefore, the nurse should be monitoring the client for signs and symptoms of cardiogenic shock and be prepared to respond immediately to any warning signs of shock. Older adults are also at higher risk for progressing to other types of shock, but this client is at highest risk for cardiogenic shock.

Question 172

While completing a health history with an older adult client, the nurse learns that the client experienced a transient ischemic attack (TIA) several months ago. The nurse should recognize that: A) the client is at risk for an ischemic thrombotic stroke. B) the client will have minimal symptoms should a stroke occur. C) the client will not experience a stroke in the future. D) the client is at high risk for a hemorrhagic stroke.

Answer 172

A) the client is at risk for an ischemic thrombotic stroke. Rationale: TIAs are often warning signs of an ischemic thrombotic stroke. There is no way to predict the symptoms the client will experience after a stroke. One or many TIAs may precede a stroke, with the time between the attack and the stroke ranging from hours to months. A hemorrhagic stroke is caused by the rupture of a cerebral blood vessel and is not related to a TIA.

Question 173

While teaching a wellness class on the warning signs of stroke, a participant asks the nurse, "What's the most important thing for me to remember?" What is an appropriate response by the nurse? A) "Be alert for sudden weakness or numbness." B) "Know your family history." C) "Keep a list of your medications." D) "Call 911 if you notice a gradual onset of paralysis or confusion."

Answer 173

A) "Be alert for sudden weakness or numbness." Rationale: Warning signs of stroke include sudden weakness, numbness, paralysis, loss of speech, confusion, dizziness, unsteadiness, and loss of balance—the key word is sudden. Family history and past medical history can be indicators for risk, but they are not warning signs of stroke. Gradual onset of symptoms is not indicative of a stroke.

Question 174

The nurse is planning care for a client admitted with a stroke. Which intervention would support the client's sensorimotor needs? A) Encourage use of nonaffected arm to feed self, bathe, and dress. B) Speak in normal conversational pattern and tones. C) Provide complete care. D) Talk loudly and distinctly.

Answer 174

A) Encourage use of nonaffected arm to feed self, bathe, and dress. Rationale: To address the client's alteration in sensory and motor statuses, the nurse should encourage the client to use the nonaffected arm to feed self, bathe, and dress. The nurse should not provide all care for the client. The nurse should not talk loudly to the client but should articulate slower and face the client when speaking. Speaking in normal conversational patterns and tones may not be adequate when communicating with the client.

Question 175

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase (rt-PA). Which information should the nurse include when performing medication teaching for the client's family? A) Used to treat thrombotic and hemorrhagic strokes B) Not associated with serious complications C) Indicated if the stroke symptoms have occurred within the last 6 hours D) Administered to break up existing clots and increase cerebral blood flow

Answer 175

D) Administered to break up existing clots and increase cerebral blood flow Rationale: Thrombolytic therapy using rt-PA is used to dissolve the clot formed with a thrombotic stroke. Dissolving the clot reestablishes cerebral circulation. The treatment is only used with ischemic strokes. Bleeding is a complication associated with the treatment, which may result in cerebral hemorrhage, causing extensive brain damage and disability. The treatment can be used if the symptoms have occurred within the last 3 hours.

Question 176

The nurse is instructing the spouse of a client with a stroke on how to do passive range-of-motion exercises to the affected limbs. Which rationale for this intervention will the nurse include in the teaching session? A) Improve muscle strength B) Maintain cardiopulmonary function C) Improve endurance D) Maintain joint flexibility

Answer 176

D) Maintain joint flexibility Rationale: The nurse should instruct the spouse that the exercises will help with joint flexibility. Passive range-of-motion exercises help maintain joint flexibility. Active range-of-motion exercises improve muscle strength, can help maintain cardiopulmonary functioning. And improve endurance.

Question 177

A client with a suspected transient ischemic attack (TIA) presents to the emergency department with aphasia. Based on this data, the nurse plans care based on ischemia to which portion of the brain? A) Anterior cerebral artery B) Vertebral artery C) Left hemisphere of the brain D) Right hemisphere of the brain

Answer 177

C) Left hemisphere of the brain Rationale: Aphasia occurs due to ischemia of the left hemisphere. The other choices may be involved in a TIA, but are not the causative pathology of aphasia.

Question 178

The community nurse is teaching a class at the community center regarding the cultural and ethnic risk factors for stroke. Which statement should nurse include in this presentation? A) Caucasians have an increased incidence of intracerebral hemorrhage. B) African Americans have almost twice the number of first-ever strokes compared with Whites. C) Asian Americans are more likely to die following a stroke than Whites. D) The prevalence of hypertension among Hispanics is the highest in the world.

Answer 178

B) African Americans have almost twice the number of first-ever strokes compared with Whites. Rationale: African Americans have almost twice the number of first-ever strokes compared with Caucasians and have the highest rate of hypertension compared to other races/ethnicities. Hispanics have an increased incidence of intracerebral hemorrhage. Individuals living in the Southeastern United States have the highest stroke mortality rate.

Question 179

) What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis? A) Intracerebral stroke B) Subarachnoid stroke C) Hemorrhagic stroke D) Ischemic stroke

Answer 179

D) Ischemic stroke Rationale: Strokes may be ischemic, occurring when the blood supply to a part of the brain is suddenly interrupted by a thrombus (blood clot), embolus (foreign matter traveling through the circulation), or stenosis (narrowing); or they may be hemorrhagic, occurring when a blood vessel breaks open and spills blood into spaces surrounding neurons. Intracerebral and subarachnoid are two types of hemorrhagic stroke.

Question 180

After a stroke, sensory-perceptual changes increase the client's risk for what? A) Aspiration B) Injury C) Bleeding D) Infection

Answer 180

B) Injury Rationale: Strokes often alter the ability to integrate, interpret, and attend to sensory data. The client may experience deficits in vision, hearing, equilibrium, taste, and smell. The ability to perceive vibration, pain, warmth, cold, and pressure may be impaired, as may proprioception (the body's sense of its position). The loss of these sensory abilities increases the risk for injury. Sensory-perceptual changes do not increase the risk for aspiration, bleeding, or infection, although stroke may cause these other complications.

Question 181

The medication clopidogrel (Plavix) is most commonly given during which stage of treatment for a stroke? A) Stroke prevention B) Acute care immediately after a stroke C) Recovery care after a stroke D) Rehabilitation after a stroke

Answer 181

A) Stroke prevention Rationale: Antiplatelet and anticoagulant drugs, including aspirin, clopidogrel, dipyridamole, and ticlopidine, are often used as preventive drugs in clients with a history of previous transient ischemic attacks or stroke. Recombinant tissue plasminogen activator alteplase is the gold standard for the treatment of acute ischemic stroke. The rehabilitation phase of treatment usually involves physical, occupational, and/or speech therapy rather than medication.

Question 182

During a 6-month well-baby check up, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as a newborn, and she seems to do everything with her left hand. The nurse recognizes that these are warning signs of stroke that occurred early in life. What other question should the nurse ask to assess for signs of stroke? A) "Have you noticed your baby jerking any muscles of the face, arms, or legs?" B) "Have you noticed your baby having trouble forming words?" C) "Does your baby vomit frequently after feeding?" D) "Does your baby frequently seem to lose her balance?"

Answer 182

A) "Have you noticed your baby jerking any muscles of the face, arms, or legs?" Rationale: Stroke warning signs in infants include seizures, extreme sleepiness, and favoring the use of only one side of the body. Signs of seizure in neonates include repetitive facial movements, staring, apnea, and jerking of the muscles of the face, arms, or legs. Questions related to balance or forming words are not age appropriate, as most normal 6-month-old infants do not have steady balance or the ability to form words. The question related to vomiting is also not appropriate, as vomiting at this age is more frequently related to food intolerances/allergies or gastrointestinal problems rather than stroke.

Question 183

The nurse is providing community health teaching on stroke in children and adolescents. Which risk factors for this population should the nurse identify? A) Hypertension B) Dysrhythmias C) Arteriosclerosis D) Head trauma

Answer 183

D) Head trauma Rationale: Common causes of adult strokes such as hypertension, dysrhythmias, and arteriosclerosis are rare in children, whose risk factors for stroke include congenital heart defects, sickle-cell disease, immune disorders, arterial diseases, abnormal blood clotting, trauma to the head or neck, and maternal history of infertility.