❤️exam 2❤️ Flashcards
A nurse is caring for a patient diagnosed with a transudative pleural effusion. Which condition is most likely the underlying cause?
A. Pneumonia
B. Congestive heart failure
C. Lung abscess
D. Tuberculosis
Answer: B. Congestive heart failure
Rationale: Transudative pleural effusions are typically caused by non-inflammatory conditions, such as increased hydrostatic pressure in heart failure or decreased oncotic pressure from hypoalbuminemia. Pneumonia, lung abscess, and TB are associated
A patient undergoing thoracentesis for a pleural effusion asks the nurse why this procedure is necessary. Which response by the nurse is most accurate?
A. “It removes fluid to prevent lung collapse.”
B. “It is a treatment for infection in your lungs.”
C. “It helps your body eliminate the excess protein in the fluid.”
D. “It cures the underlying cause of the fluid accumulation.”
Answer: A. “It removes fluid to prevent lung collapse.”
Rationale: Thoracentesis is performed to remove excess fluid from the pleural space, which relieves pressure on the lungs and prevents respiratory complications. While it is not a cure for the underlying condition, it can alleviate symptoms like dyspnea.
A nurse is monitoring a patient after a chemical pleurodesis procedure. Which of the following findings would be most concerning?
A. Fever of 100.8°F
B. Reports of chest pain
C. Drainage of 200 mL/day from the chest tube
D. New onset shortness of breath
Answer: D. New onset shortness of breath
Rationale: Shortness of breath may indicate complications such as pneumothorax or fluid re-accumulation after pleurodesis. Fever and chest pain are expected side effects. Drainage of 200 mL/day can be normal immediately post-procedure.
A patient with an empyema is prescribed intrapleural fibrinolytic therapy. What is the primary purpose of this treatment?
A. Eradicate the infectious organism
B. Break down fibrous adhesions
C. Prevent fluid re-accumulation
D. Restore normal oncotic pressure
Answer: B. Break down fibrous adhesions
Rationale: Intrapleural fibrinolytic therapy dissolves fibrous adhesions in the pleural space, allowing for effective drainage of purulent fluid. Antibiotics are used to treat the infection, not the fibrinolytics.
Which assessment finding would the nurse expect in a patient with a large pleural effusion?
A. Increased breath sounds over the affected area
B. Decreased chest movement on the affected side
C. Hyperresonance on percussion
D. Tracheal deviation toward the affected side
Answer: B. Decreased chest movement on the affected side
Rationale: Pleural effusion restricts lung expansion, leading to decreased chest movement on the affected side. Breath sounds are typically decreased, and percussion yields dullness. Tracheal deviation occurs away from the affected side if the effusion is massive.
A patient with hypoalbuminemia is at risk for developing which type of pleural effusion?
A. Transudative
B. Exudative
C. Empyema
D. Malignant
Answer: A. Transudative
Rationale: Hypoalbuminemia decreases oncotic pressure, leading to a transudative pleural effusion. Exudative effusions are related to inflammatory processes.
A nurse is preparing to unclamp a chest tube 8 hours after pleurodesis. Which nursing intervention is most appropriate before unclamping?
A. Administer an analgesic
B. Obtain a chest X-ray
C. Record the amount of drainage
D. Flush the chest tube
Answer: A. Administer an analgesic
Rationale: Chest pain is a common side effect after pleurodesis. Administering an analgesic before unclamping the chest tube ensures the patient is comfortable during the procedure.
A patient with a pleural effusion is receiving oxygen therapy. What is the primary goal of this intervention?
A. Treat underlying infection
B. Improve nutritional status
C. Manage hypoxemia
D. Promote lung re-expansion
Answer: C. Manage hypoxemia
Rationale: Oxygen therapy addresses hypoxemia caused by impaired gas exchange due to the fluid compressing the lungs. It does not directly affect infection or lung re-expansion.
Which patient is most likely to develop an exudative pleural effusion?
A. A 45-year-old with chronic kidney disease
B. A 60-year-old with liver cirrhosis
C. A 50-year-old with pneumonia
D. A 70-year-old with congestive heart failure
Answer: C. A 50-year-old with pneumonia
Rationale: Exudative pleural effusions occur due to increased capillary permeability in inflammatory conditions like pneumonia. Kidney disease, liver cirrhosis, and CHF are associated with transudative effusions.
A nurse is teaching a patient about supportive care for pleural effusion. Which statement by the patient indicates a need for further teaching?
A. “I need to stay hydrated and eat a nutritious diet.”
B. “I should avoid turning in bed to keep the fluid from moving.”
C. “I may need oxygen therapy to help with my breathing.”
D. “Taking pain medicine can help me feel more comfortable.”
Answer: B. “I should avoid turning in bed to keep the fluid from moving.”
Rationale: Turning and repositioning are encouraged, especially after procedures like pleurodesis, to ensure even distribution of treatment agents and improve lung expansion. Avoiding movement is incorrect and indicates the need for further education.
A nurse assesses a patient with a suspected pneumothorax. Which clinical manifestation is most indicative of this condition?
A. Crackles over the affected lung
B. Dullness on percussion over the affected lung
C. Absent breath sounds on one side
D. Bilateral wheezing
Answer: C. Absent breath sounds on one side
Rationale: Absent breath sounds on the affected side are a hallmark of pneumothorax due to the collapse of the lung. Crackles, dullness on percussion, and wheezing are not typically associated with pneumothorax.
A patient presents to the emergency department with a tension pneumothorax. Which finding should the nurse prioritize?
A. Decreased breath sounds on the affected side
B. Tracheal deviation toward the unaffected side
C. Mild dyspnea
D. Low-grade fever
Answer: B. Tracheal deviation toward the unaffected side
Rationale: Tracheal deviation toward the unaffected side is a late and critical sign of tension pneumothorax, indicating severe pressure buildup in the chest. This is a medical emergency requiring immediate intervention.
A nurse is caring for a patient with a spontaneous pneumothorax. Which of the following risk factors is most relevant to the patient’s condition?
A. Recent thoracic surgery
B. Smoking history
C. Long-term steroid use
D. Immunosuppression
Answer: B. Smoking history
Rationale: Smoking increases the risk of bleb formation, which can lead to a spontaneous pneumothorax. Recent thoracic surgery and immunosuppression are associated with other types of pneumothoraces or infections.
A patient with a chest wound is receiving pre-hospital care. What is the most appropriate intervention for an open pneumothorax?
A. Removing the object causing the injury
B. Applying an occlusive dressing secured on three sides
C. Performing needle decompression
D. Covering the wound with a dry sterile dressing
Answer: B. Applying an occlusive dressing secured on three sides
Rationale: A vent dressing secured on three sides prevents air from entering the pleural space during inspiration but allows it to escape during expiration. Removing the object may cause further damage.
A patient receiving mechanical ventilation develops sudden respiratory distress. The nurse suspects tension pneumothorax. What is the priority intervention?
A. Administer oxygen via a face mask
B. Notify the healthcare provider immediately
C. Disconnect the ventilator and manually ventilate the patient
D. Perform needle decompression
Answer: D. Perform needle decompression
Rationale: Tension pneumothorax is a medical emergency. Needle decompression should be performed immediately to relieve pressure and prevent cardiovascular collapse.
Which intervention is most appropriate for a patient with a hemothorax?
A. Needle decompression
B. Chest tube insertion
C. Bronchodilator therapy
D. Ventilation with high positive pressure
Answer: B. Chest tube insertion
Rationale: A chest tube is inserted to evacuate blood from the pleural space in cases of hemothorax. Needle decompression is primarily for tension pneumothorax.
A nurse is educating a patient about the risks of recurrent spontaneous pneumothorax. Which factor should the nurse include as a major risk?
A. High altitude travel
B. History of asthma
C. Use of antihypertensive medication
D. Female gender
Answer: A. High altitude travel
Rationale: High altitude can exacerbate the risk of pneumothorax due to pressure changes. Other risk factors include male gender, smoking, and lung disease.
A patient with a pneumothorax reports sudden, sharp chest pain and increasing dyspnea. What should the nurse assess first?
A. Oxygen saturation
B. Breath sounds
C. Heart rate
D. Pain level
Answer: B. Breath sounds
Rationale: Assessing breath sounds can help determine the severity and progression of the pneumothorax, guiding subsequent interventions. Oxygen saturation and other vital signs are also important but secondary.
A nurse is caring for a patient with a chest tube after a traumatic pneumothorax. Which finding indicates the chest tube is functioning properly?
A. Continuous bubbling in the water-seal chamber
B. Fluctuation (tidaling) in the water-seal chamber
C. Absence of drainage
D. Intermittent bubbling in the suction control chamber
Answer: B. Fluctuation (tidaling) in the water-seal chamber
Rationale: Tidaling in the water-seal chamber indicates proper functioning of the chest tube and reflects changes in intrapleural pressure. Continuous bubbling in the water-seal chamber may indicate a leak.
A patient develops pneumothorax after a subclavian catheter insertion. Which type of pneumothorax is this?
A. Spontaneous
B. Iatrogenic
C. Tension
D. Open
Answer: B. Iatrogenic
Rationale: Iatrogenic pneumothorax results from medical procedures, such as subclavian catheter insertion or lung biopsy. It is caused by accidental injury to the pleura or lung.0-
Which of the following findings is most indicative of pulmonary edema?
A. Dullness to percussion over the lungs
B. Frothy, blood-tinged sputum
C. Tracheal deviation
D. Hyperresonance to percussion
Answer: B. Frothy, blood-tinged sputum
Rationale: Frothy, blood-tinged sputum is a hallmark sign of pulmonary edema, caused by fluid leaking into the alveoli. Other options are more indicative of other respiratory conditions (e.g., pleural effusion or pneumothorax).
A nurse is caring for a patient with pulmonary edema secondary to left-sided heart failure. Which intervention should the nurse implement first?
A. Administer IV furosemide
B. Place the patient in a high Fowler’s position
C. Obtain a chest x-ray
D. Monitor urinary output
Answer: B. Place the patient in a high Fowler’s position
Rationale: Positioning the patient in high Fowler’s improves ventilation and decreases the work of breathing. Administering furosemide is critical but not the first action.
The nurse is assessing a patient with a suspected pulmonary embolism (PE). Which symptom is most likely to be reported by the patient?
A. Sudden onset dyspnea
B. Peripheral cyanosis
C. Chronic productive cough
D. Chest tightness after eating
Answer: A. Sudden onset dyspnea
Rationale: Dyspnea is the most common presenting symptom of PE, caused by impaired gas exchange. The other symptoms are not characteristic of PE.
Which laboratory test result is most specific for ruling out a pulmonary embolism?
A. Elevated D-dimer
B. High troponin levels
C. Low PaO2
D. Increased BNP
Answer: A. Elevated D-dimer
Rationale: A D-dimer test measures fibrin degradation products. While an elevated level supports the possibility of a PE, it is not definitive without further imaging.
A patient has been diagnosed with a massive PE. Which finding requires immediate intervention?
A. Tachycardia
B. Hypotension and altered mental status
C. Crackles in the lung bases
D. Mild hypoxemia
Answer: B. Hypotension and altered mental status
Rationale: These findings indicate hemodynamic instability, which can result in cardiopulmonary arrest and requires urgent intervention.
What is the priority nursing action for a patient receiving tissue plasminogen activator (tPA) for a PE?
A. Monitor for signs of bleeding
B. Maintain strict bed rest
C. Assess for deep vein thrombosis
D. Provide education about anticoagulants
Answer: A. Monitor for signs of bleeding
Rationale: The primary risk of tPA is bleeding. Monitoring for signs of hemorrhage is critical during therapy.
A patient with pulmonary edema has an oxygen saturation of 88%. Which intervention should the nurse prioritize?
A. Initiate Bi-PAP therapy
B. Encourage deep breathing exercises
C. Increase the IV infusion rate
D. Obtain a sputum culture
Answer: A. Initiate Bi-PAP therapy
Rationale: Bi-PAP therapy provides non-invasive ventilation to improve oxygenation and decrease the work of breathing.
A nurse caring for a patient with pulmonary hypertension understands which of the following as a primary cause of the condition?
A. Increased pulmonary vascular resistance
B. Pulmonary capillary destruction
C. Alveolar overdistention
D. Bronchospasm
Answer: A. Increased pulmonary vascular resistance
Rationale: Pulmonary hypertension results from increased resistance in the pulmonary circulation, leading to elevated pulmonary artery pressure.
A nurse is caring for a postoperative patient with a high risk for VTE. Which intervention is most appropriate to prevent PE?
A. Place the patient on bed rest until ambulation is possible
B. Apply intermittent pneumatic compression devices
C. Administer warfarin only if symptoms develop
D. Monitor for a low-grade fever
Answer: B. Apply intermittent pneumatic compression devices
Rationale: Compression devices enhance venous return and help prevent the formation of DVT, reducing the risk of PE.
A patient is being treated for acute PE with IV heparin. Which laboratory value is most important to monitor?
A. INR
B. aPTT
C. Platelet count
D. D-dimer
Answer: B. aPTT
Rationale: aPTT is monitored during IV heparin therapy to ensure therapeutic anticoagulation and reduce the risk of bleeding.
A patient with pulmonary edema is prescribed furosemide. Which parameter should the nurse monitor to evaluate effectiveness?
A. Heart rate
B. Oxygen saturation
C. Urine output
D. Hemoglobin level
Answer: C. Urine output
Rationale: Furosemide, a diuretic, promotes fluid excretion. Increased urine output indicates effective preload reduction.
What is the priority diagnostic test for a patient suspected of having a PE?
A. Chest x-ray
B. Spiral CT scan
C. ABG analysis
D. Ventilation-perfusion (V/Q) scan
Answer: B. Spiral CT scan
Rationale: A spiral CT scan (CT angiography) is the most common and effective diagnostic test for PE.
Which clinical finding is most characteristic of pulmonary hypertension?
A. Sudden pleuritic chest pain
B. Elevated central venous pressure
C. Dyspnea on exertion
D. Bilateral leg edema
Answer: C. Dyspnea on exertion
Rationale: Dyspnea on exertion is a hallmark symptom of pulmonary hypertension, caused by reduced oxygen delivery to tissues.
A nurse is educating a patient about warfarin therapy after a PE. Which statement indicates the patient understands the teaching?
A. “I need to have my INR checked regularly.”
B. “I can take over-the-counter aspirin for pain.”
C. “I will need to avoid eating green leafy vegetables.”
D. “I should stop the medication if I notice any bruising.”
Answer: A. “I need to have my INR checked regularly.”
Rationale: Regular INR monitoring ensures warfarin remains within the therapeutic range. Aspirin increases bleeding risk, and patients should manage vitamin K intake rather than avoid it completely.
A patient on anticoagulant therapy for PE has a sudden drop in platelet count. Which condition should the nurse suspect?
A. Hemorrhagic stroke
B. Heparin-induced thrombocytopenia (HIT)
C. Disseminated intravascular coagulation (DIC)
D. Acute hemolytic reaction
Answer: B. Heparin-induced thrombocytopenia (HIT)
Rationale: HIT is a potential complication of heparin therapy, characterized by a significant drop in platelet count.
Which nursing action is a priority when caring for a patient with acute pulmonary edema?
A. Monitor daily weights
B. Restrict fluid intake
C. Assess for peripheral edema
D. Administer oxygen therapy
Answer: D. Administer oxygen therapy
Rationale: Oxygen therapy is essential to improve gas exchange and relieve hypoxemia in pulmonary edema.
A patient with a history of PE reports leg swelling and pain. Which condition should the nurse suspect?
A. Recurrent PE
B. DVT
C. Pulmonary hypertension
D. Hemothorax
Answer: B. DVT
Rationale: Leg swelling and pain are classic signs of DVT, which can lead to PE if untreated.
What is the primary goal of treatment for a patient with acute PE?
A. Lower pulmonary artery pressure
B. Restore adequate perfusion to lung tissue
C. Reduce pulmonary secretions
D. Prevent infection
Answer: B. Restore adequate perfusion to lung tissue
Rationale: Treatment aims to restore blood flow and oxygenation, preventing further complications.
A nurse is caring for a patient with a PE receiving IV fluids for hypotension. Which parameter is most critical to monitor?
A. Blood pressure
B. Urine output
C. Lung sounds
D. Peripheral pulses
Answer: A. Blood pressure
Rationale: Monitoring blood pressure ensures fluid therapy is effective in maintaining hemodynamic stability.
A patient is prescribed LMWH for VTE prophylaxis. What instruction should the nurse provide?
A. “Inject the medication into a muscle.”
B. “Monitor for bleeding or bruising.”
C. “Take this medication at the same time as warfarin.”
D. “Avoid all physical activity while on this medication.”
Answer: B. “Monitor for bleeding or bruising.”
Rationale: Bleeding and bruising are common side effects of LMWH. Proper injection technique and activity levels should be clarified but do not preclude routine activities.
A nurse is caring for a patient with pulmonary edema who reports severe dyspnea. Which intervention should the nurse perform first?
A. Administer IV morphine
B. Place the patient in a high Fowler’s position
C. Start an infusion of IV nitroglycerin
D. Prepare for mechanical ventilation
Answer: B. Place the patient in a high Fowler’s position
Rationale: Positioning the patient in high Fowler’s improves lung expansion and reduces venous return to the heart, which helps relieve dyspnea. Morphine and nitroglycerin are important but are not the first intervention.
Which diagnostic finding is most consistent with a pulmonary embolism (PE)?
A. Low PaO2 and elevated D-dimer
B. High BNP and elevated D-dimer
C. Low pH and elevated serum troponin
D. High PaCO2 and low D-dimer
Answer: A. Low PaO2 and elevated D-dimer
Rationale: PE causes impaired gas exchange, leading to hypoxemia (low PaO2). An elevated D-dimer supports the presence of a clot.
A patient with pulmonary edema is receiving IV furosemide. Which assessment finding indicates that the medication is effective?
A. Decreased blood pressure
B. Increased urine output
C. Lower respiratory rate
D. Improved oxygen saturation
Answer: D. Improved oxygen saturation
Rationale: Improved oxygenation indicates that pulmonary congestion is resolving. While increased urine output is expected, oxygen saturation reflects direct improvement in gas exchange.
A patient with a PE is started on warfarin. Which lab value indicates therapeutic anticoagulation?
A. aPTT of 40 seconds
B. INR of 2.5
C. Platelet count of 150,000/mm³
D. D-dimer of 1.0 µg/mL
Answer: B. INR of 2.5
Rationale: A therapeutic INR range for warfarin is 2.0–3.0. Other values are unrelated or normal.
Which assessment finding would the nurse most likely observe in a patient with pulmonary hypertension?
A. Inspiratory crackles
B. Peripheral edema
C. Frothy sputum
D. Dullness to percussion
Answer: B. Peripheral edema
Rationale: Pulmonary hypertension increases right-sided heart pressure, leading to fluid retention and peripheral edema.
The nurse is caring for a patient with pulmonary edema who is receiving non-invasive Bi-PAP ventilation. Which outcome demonstrates effectiveness of the therapy?
A. Increased heart rate
B. Reduced respiratory rate
C. Elevated BNP levels
D. Persistent hypoxemia
Answer: B. Reduced respiratory rate
Rationale: A reduced respiratory rate indicates improved oxygenation and decreased work of breathing, demonstrating the effectiveness of Bi-PAP therapy.
A patient develops sudden chest pain and shortness of breath after pelvic surgery. What is the priority nursing intervention?
A. Place the patient in a high Fowler’s position
B. Call for immediate chest x-ray
C. Administer prescribed IV heparin
D. Perform a V/Q scan
Answer: A. Place the patient in a high Fowler’s position
Rationale: Elevating the head of the bed optimizes breathing while diagnostic tests and treatment are prepared.
A patient receiving anticoagulation therapy for PE reports bruising and bleeding gums. What is the nurse’s priority action?
A. Assess the patient’s INR
B. Discontinue anticoagulation therapy
C. Apply pressure to the bleeding site
D. Notify the healthcare provider
Answer: A. Assess the patient’s INR
Rationale: Assessing INR determines if the anticoagulation level is within the therapeutic range or excessively high, guiding further interventions.
Which intervention is most important to prevent complications in a patient with pulmonary edema?
A. Monitor fluid intake and output
B. Administer bronchodilators
C. Encourage early ambulation
D. Perform incentive spirometry
Answer: A. Monitor fluid intake and output
Rationale: Fluid balance monitoring is critical to prevent fluid overload and worsening pulmonary edema.
A patient with pulmonary hypertension is started on diuretics and vasodilators. What is the primary goal of this therapy?
A. Improve oxygenation
B. Reduce pulmonary vascular resistance
C. Lower left ventricular preload
D. Prevent blood clots
Answer: B. Reduce pulmonary vascular resistance
Rationale: Diuretics and vasodilators reduce pulmonary vascular resistance, relieving pressure in the pulmonary circulation and improving symptoms.
A patient is admitted with heart failure and presents with pink frothy sputum, dyspnea, and crackles in the lungs. Which is the nurse’s priority intervention?
1 Administer furosemide IV push.
2 Place the patient in high Fowler’s position.
3 Obtain a chest x-ray.
4 Administer a dose of digoxin.
Answer: 2. Place the patient in high Fowler’s position.
Rationale: Positioning the patient in high Fowler’s reduces pulmonary congestion and improves breathing. Administering furosemide is important but comes after ensuring airway stability.
The nurse assesses a patient with tension pneumothorax. Which finding requires immediate intervention?
1 Hyperresonance to percussion.
2 Sudden pleuritic chest pain.
3 Tracheal deviation to the unaffected side.
4 Decreased breath sounds on the affected side.
Answer: 3. Tracheal deviation to the unaffected side.
Rationale: Tracheal deviation is a hallmark of a tension pneumothorax and indicates life-threatening pressure changes that require emergency decompression.
A patient is diagnosed with stable angina. Which statement by the patient indicates understanding of the condition?
1 “I will experience chest pain even at rest.”
2 “Nitroglycerin will relieve my chest pain during episodes.”
3 “This condition is caused by a blood clot.”
4 “I will need surgery to cure this.”
Answer: 2. “Nitroglycerin will relieve my chest pain during episodes.”
Rationale: Stable angina is predictable and usually relieved with rest or nitroglycerin.
A patient with a recent myocardial infarction is prescribed beta-blockers. What is the primary rationale for this treatment?
1 To improve cardiac contractility.
2 To reduce myocardial oxygen demand.
3 To relieve chest pain.
4 To prevent arrhythmias.
Answer: 2. To reduce myocardial oxygen demand.
Rationale: Beta-blockers decrease heart rate and contractility, reducing myocardial oxygen consumption and workload.
A patient with infective endocarditis has new onset petechiae and a murmur. What diagnostic test is most appropriate?
1 Echocardiogram.
2 Electrocardiogram.
3 Chest x-ray.
4 Troponin levels.
Answer: 1. Echocardiogram.
Rationale: Echocardiograms are used to visualize valvular vegetations, a key diagnostic criterion for infective endocarditis.
Which is the priority assessment for a patient post-thoracentesis for a hemothorax?
1 Monitor for infection.
2 Assess for chest tube patency.
3 Check for signs of re-expansion pulmonary edema.
4 Measure fluid output.
Answer: 3. Check for signs of re-expansion pulmonary edema.
Rationale: Re-expansion pulmonary edema is a potential complication of rapid fluid removal.
- What is the hallmark symptom of pericarditis?
1 Chest pain relieved by leaning forward.
2 Sharp pain radiating to the jaw.
3 Pain unrelieved by rest.
4 Substernal pain worsened with exertion.
Answer: 1. Chest pain relieved by leaning forward.
Rationale: Pericarditis pain typically improves when the patient sits up or leans forward.
- A patient presents with Beck’s triad: muffled heart sounds, JVD, and hypotension. What condition does this suggest?
1 Myocarditis.
2 Cardiac tamponade.
3 Valvular disease.
4 Pulmonary embolism.
Answer: 2. Cardiac tamponade.
Rationale: Beck’s triad is a classic presentation of cardiac tamponade.
A nurse notes ST depression on an ECG. Which condition is most likely associated with this finding?
1 Myocardial infarction.
2 Stable angina.
3 Ventricular fibrillation.
4 Pulmonary embolism.
Answer: 2. Stable angina.
Rationale: ST depression typically indicates ischemia, as seen in stable or unstable angina.
A patient with pulmonary embolism (PE) reports sudden dyspnea and chest pain. Which diagnostic test is most definitive?
1 D-dimer test.
2 Spiral CT scan.
3 Chest x-ray.
4 Ventilation-perfusion (V/Q) scan.
Answer: 2. Spiral CT scan.
Rationale: Spiral CT angiography is the gold standard for diagnosing a PE.
A patient with valvular disease presents with atrial fibrillation. Which diagnostic study is most important to confirm valvular dysfunction?
1 Electrocardiogram (ECG).
2 Echocardiogram.
3 Chest x-ray.
4 Cardiac catheterization.
Answer: 2. Echocardiogram.
Rationale: Echocardiograms provide structural and functional data on valves.
In myocarditis, which treatment goal is prioritized?
1 Reducing myocardial inflammation.
2 Preventing heart failure progression.
3 Treating arrhythmias.
4 Alleviating fatigue.
Answer: 1. Reducing myocardial inflammation.
Rationale: Addressing inflammation is key to preventing further myocardial damage.
A patient has acute pulmonary edema. What is the first intervention?
1 Administer morphine IV.
2 Place the patient in a semi-Fowler’s position.
3 Administer a diuretic.
4 Apply high-flow oxygen.
Answer: 4. Apply high-flow oxygen.
Rationale: Oxygen is the priority to improve oxygenation in pulmonary edema.
A patient develops a pleural effusion with empyema. Which symptom is most indicative of infection?
1 Sharp chest pain.
2 Dyspnea.
3 Night sweats.
4 Decreased breath sounds.
Answer: 3. Night sweats.
Rationale: Night sweats, fever, and cough are indicative of infection with empyema.
For a patient with mitral stenosis, which intervention addresses a primary complication?
1 Controlling atrial fibrillation.
2 Reducing pulmonary congestion.
3 Managing fluid overload.
4 Increasing cardiac output.
Answer: 1. Controlling atrial fibrillation.
Rationale: Atrial fibrillation is a common complication due to increased left atrial pressure.
What is the primary goal of care for a patient with stable angina?
1 Alleviate ischemia.
2 Prevent myocardial infarction.
3 Improve quality of life.
4 Increase physical activity tolerance.
Answer: 1. Alleviate ischemia.
Rationale: Stable angina management focuses on relieving ischemia and preventing progression.
A nurse evaluates a chest tube system. Which finding requires immediate intervention?
1 Bubbling in the water seal chamber.
2 Output of 150 mL in 2 hours.
3 Subcutaneous emphysema at the insertion site.
4 Intermittent tidaling.
Answer: 1. Bubbling in the water seal chamber.
Rationale: Continuous bubbling indicates an air leak.
A patient with coronary artery disease (CAD) is prescribed atorvastatin. Which lab value is most important to monitor?
1 Serum potassium.
2 Liver enzymes.
3 Blood glucose.
4 Serum calcium.
Answer: 2. Liver enzymes.
Rationale: Statins can elevate liver enzymes, necessitating monitoring.
A nurse suspects right-sided heart failure. Which symptom supports this diagnosis?
1 Pulmonary crackles.
2 Pink frothy sputum.
3 Peripheral edema.
4 Orthopnea.
Answer: 3. Peripheral edema.
Rationale: Peripheral edema is a hallmark of right-sided heart failure.
A nurse prepares to administer digoxin. What assessment must be completed first?
1 Apical pulse.
2 Respiratory rate.
3 Oxygen saturation.
4 Blood pressure.
Answer: 1. Apical pulse.
Rationale: Digoxin can cause bradycardia, so assessing apical pulse ensures safe administration.
A nurse assesses a patient with pulmonary embolism. Which symptom is the highest priority to address?
1 Tachycardia.
2 Dyspnea.
3 Chest pain.
4 Hemoptysis.
Answer: 2. Dyspnea.
Rationale: Dyspnea indicates impaired oxygenation, the most critical concern in pulmonary embolism.
A patient with pericarditis reports chest pain. What is the best position to alleviate discomfort?
1 Lying flat with legs elevated.
2 Sitting upright and leaning forward.
3 Side-lying on the left side.
4 Semi-Fowler’s position.
Answer: 2. Sitting upright and leaning forward.
Rationale: This position reduces pressure on the pericardium, alleviating pain.
In a patient with a pneumothorax, which diagnostic finding is most expected?
1 Hyperresonance on percussion.
2 Elevated white blood cell count.
3 Bilateral decreased breath sounds.
4 Mediastinal shift toward the affected side.
Answer: 1. Hyperresonance on percussion.
Rationale: Air trapped in the pleural space leads to hyperresonance during assessment.
What is the most common cause of pulmonary edema?
1 Left-sided heart failure.
2 Chronic obstructive pulmonary disease.
3 Pulmonary embolism.
4 Pericarditis.
Answer: 1. Left-sided heart failure.
Rationale: Left-sided heart failure causes fluid backup into the lungs, leading to pulmonary edema.
A patient with acute coronary syndrome has persistent chest pain despite rest. Which type of angina is this?
1 Stable angina.
2 Prinzmetal angina.
3 Unstable angina.
4 Microvascular angina.
Answer: 3. Unstable angina.
Rationale: Unstable angina occurs at rest and is a precursor to myocardial infarction.
A nurse evaluates a patient with tension pneumothorax. Which immediate intervention is required?
1 Administer oxygen via nasal cannula.
2 Prepare for needle decompression.
3 Position the patient in Trendelenburg.
4 Insert a chest tube.
Answer: 2. Prepare for needle decompression.
Rationale: Needle decompression rapidly relieves life-threatening pressure in tension pneumothorax.
A patient with coronary artery disease (CAD) is advised on lifestyle changes. Which patient statement requires clarification?
1 “I will reduce saturated fats in my diet.”
2 “I can smoke occasionally if I feel stressed.”
3 “I will take daily walks to improve my fitness.”
4 “I will reduce my alcohol consumption.”
Answer: 2. “I can smoke occasionally if I feel stressed.”
Rationale: Smoking increases CAD risk and should be completely avoided.
Which lab finding confirms disease progression in heart failure?
1 Elevated b-type natriuretic peptide (BNP).
2 Increased hemoglobin and hematocrit.
3 Elevated liver enzymes.
4 Decreased serum sodium.
Answer: 1. Elevated b-type natriuretic peptide (BNP).
Rationale: BNP levels correlate with the severity of heart failure.
A patient with pleural effusion reports difficulty breathing. What is the priority nursing intervention?
1 Place the patient in high Fowler’s position.
2 Administer diuretics as prescribed.
3 Prepare for thoracentesis.
4 Apply continuous oxygen therapy.
Answer: 1. Place the patient in high Fowler’s position.
Rationale: Positioning optimizes lung expansion and eases breathing.
A patient with myocarditis is at risk for developing which life-threatening complication?
1 Ventricular arrhythmias.
2 Coronary artery spasm.
3 Mitral valve prolapse.
4 Aortic dissection.
Answer: 1. Ventricular arrhythmias.
Rationale: Myocarditis can lead to arrhythmias due to inflammation of the myocardium.
A nurse assesses a patient with valvular disease. Which finding suggests mitral stenosis?
1 Murmur heard during diastole.
2 Murmur heard during systole.
3 Bounding pulses.
4 Narrow pulse pressure.
Answer: 1. Murmur heard during diastole.
Rationale: Mitral stenosis causes a diastolic murmur due to impaired blood flow.
A patient with a hemothorax is receiving a blood transfusion. What is the nurse’s priority assessment?
1 Monitor for signs of transfusion reaction.
2 Measure chest tube output every 8 hours.
3 Assess for worsening pleural effusion.
4 Evaluate pain management effectiveness.
Answer: 1. Monitor for signs of transfusion reaction.
Rationale: Transfusion reactions are life-threatening and require immediate intervention.
A patient with infective endocarditis reports new back pain. What complication should the nurse suspect?
1 Pericarditis.
2 Pulmonary embolism.
3 Systemic embolization.
4 Cardiac tamponade.
Answer: 3. Systemic embolization.
Rationale: Back pain can indicate emboli lodging in the spine or kidneys.
A patient with coronary artery disease is prescribed aspirin. What is the primary purpose of this medication?
1 To reduce cholesterol levels.
2 To prevent platelet aggregation.
3 To relieve chest pain.
4 To lower blood pressure.
Answer: 2. To prevent platelet aggregation.
Rationale: Aspirin inhibits platelet aggregation, reducing the risk of thrombus formation.
- A nurse notes muffled heart sounds and hypotension in a patient with pericardial effusion. What is the next best action?
Administer IV fluids to increase preload.
Prepare for pericardiocentesis.
Monitor vital signs hourly.
Administer a vasopressor.
Answer: 2. Prepare for pericardiocentesis.
Rationale: Pericardiocentesis relieves cardiac tamponade caused by fluid accumulation.
A patient with pulmonary embolism has an SpO2 of 88% on room air. What intervention should the nurse implement first?
1 Administer oxygen therapy.
2 Notify the healthcare provider.
3 Prepare for CT angiography.
4 Obtain an arterial blood gas sample.
Answer: 1. Administer oxygen therapy.
Rationale: Oxygen therapy improves oxygenation, the immediate priority.
A patient with chronic mitral stenosis develops atrial fibrillation. Which complication is the nurse most concerned about?
1 Pulmonary hypertension.
2 Systemic embolization.
3 Heart block.
4 Cardiogenic shock.
Answer: 2. Systemic embolization.
Rationale: Atrial fibrillation increases the risk of embolism due to stasis of blood in the atria.
A patient with a small, asymptomatic pneumothorax is being monitored. What is the expected management?
1 Chest tube insertion.
2 Observation and supplemental oxygen.
3 Needle decompression.
4 Thoracentesis.
Answer: 2. Observation and supplemental oxygen.
Rationale: Small pneumothoraces often resolve with oxygen therapy and monitoring.
A patient is prescribed nitroglycerin for chest pain. Which instruction is most important?
1 “Take the medication before meals.”
2 “Store tablets in a cool, dry place.”
3 “Sit or lie down when taking the medication.”
4 “Avoid taking this with aspirin.”
Answer: 3. “Sit or lie down when taking the medication.”
Rationale: Nitroglycerin can cause hypotension, increasing fall risk.
A patient with acute heart failure is prescribed IV furosemide. What parameter must the nurse monitor closely?
1 Potassium levels.
2 Creatinine levels.
3 Blood glucose.
4 Hemoglobin levels.
Answer: 1. Potassium levels.
Rationale: Furosemide can cause hypokalemia, leading to arrhythmias.
What does cardiac biomarkers consist of?
- troponin 2. BNP 3. myoglobin 4. CKMP
Gold standard for a PE
CTA
Three things to know about endocarditis
One the cause agent is staphylococcus saurus to gold standard is a positive blood culture and three is endocarditis can be caused from dental procedures
Plural effusion transudative
Translucent pale color or clear usually from heart failure, and hypoalbuminia
Plural effusion exudative
Rich in protein and caused by cancer or infection
Pericarditis two things to know
One pericardial friction rub and two muffle heart sounds is known as Beck’s triad
Explain P QRS and T for ECG
P equals atrial contraction
QRS equals ventricle construction (depolarization)
T equals ventricular relaxation (epolarization)
A normal ECG consist of what?
A rate of 60 to 100 bpm, P wave before QRS interval and, less than 0.12 to 0.20 seconds for PR interval
Indication for thorcentisis
Plural effusion
Test to be done for a pneumothorax
CT, chest, x-ray, ultrasound, thoracentesis for a hemothorax
