exam 2 Flashcards
Which group would most benefit from statins?
Those with a low density lipoprotein-cholesterol greater than 100 mg/dL
Individuals with clinical arteriosclerotic cardiovascular disease
Individuals with a 10-year risk greater than 10%
Individuals of all ages with diabetes mellitus (DM)
Individuals with clinical arteriosclerotic cardiovascular disease
If chest pain can be alleviated with time, analgesics, and heat applications, what might the differential diagnosis be?
Peptic ulcer
Hiatal hernia
Costochondritis
Pericarditis
Costochondritis
Sandra has palpitations that occur with muscle twitching, paresthesia, and fatigue. What specific diagnostic test might help determine the cause?
Serum calcium
Electrocardiogram (ECG)
Thyroid-stimulating hormone test
Complete blood cell count
Serum calcium
A blood pressure (BP) of 150/90 is considered:
Stage 2 hypertension
Hypertensive
Normal in healthy older adults
Acceptable if the patient has DM
Normal in healthy older adults
Lifestyle modifications to manage hypertension (HTN) include
Maintaining a body mass index of 17
Restricting dietary sodium to 2 grams per day
Engaging in exercise or physical activity for 90 minutes a day
Limiting beer intake to 24 ounces per day
Limiting beer intake to 24 ounces per day
Mary has hypertension and previously had a stroke. Which hypertensive drug would you order for her?
Angiotensin converting enzyme inhibitor
Calcium channel blocker
Angiotensin II receptor blocker
Beta blocker
Angiotensin converting enzyme inhibitor
Which high-density lipoprotein (HDL) level is considered cardioprotective?
Greater than 30
Greater than 40
Greater than 50
Greater than 60
Greater than 60
You are assessing Sigred for metabolic syndrome. Which of her parameters is indicative of this syndrome?
Her waist is 36 inches.
Her triglyceride level is 140 mg/dL.
Her BP is 128/84.
Her fasting blood sugar (BS) is 108 mg/dL
Her waist is 36 inches.
Which type of angina do you suspect in Harvey, who complains of chest pain that occurs during sleep and most often in the early morning hours?
Stable angina
Unstable angina
Variant (Prinzmetal‘s angina)
Probably not angina but hiatal hernia
Variant (Prinzmetal‘s angina)
Which ECG change is typical of cardiac ischemia?
T-wave inversion
ST-segment elevation
Significant Q wave
U-wave
T-wave inversion
In which type of arterioventricular (AV) block does the pulse rate (PR) interval lengthen until a beat is dropped?
First-degree AV block
Second-degree Mobitz I AV block
Second-degree Mobitz II AV block
Third-degree AV block
Second-degree Mobitz I AV block
A Delta wave on the ECG maybe present in which condition?
Prinzmetal‘s angina
Bundle branch block
Wolff-Parkinson-White syndrome
Aortic stenosis
Wolff-Parkinson-White syndrome
Which heart sound may be heard with poorly controlled hypertension, angina, and ischemic heart disease?
Aphysiologic split S2
Afixed split S2
S3
S4
S4
Samuel is going to the dentist for some work and must take endocarditis prophylaxis because of his history of:
Severe asthma
Acommonvalvular lesion
Severe hypertension
Aprosthetic heart valve
Aprosthetic heart valve
George, age 64, has cardiovascular disease (CVD), a total cholesterol of 280 mg/dL,and a systolic BP of 158. He is being treated for hypertension. You are doing a Framingham Risk. Assessment on him. Which assessment factor would give him the highest number of points on the scale?
His age
His cholesterol level
His systolic BP
The fact that he is on antihypertensive medication
His cholesterol level
Which pain characteristic is usually indicative of cardiac pathology?
Fleeting
Moving
Diffuse
Localized
Diffuse
What percentage of patients with angina pectoris will have simultaneous dyspnea, caused by transient increase in pulmonary venous pressures that accompany ventricular stiffening during an episode of myocardial ischemia?
About 20%
About 30%
About 50%
Almost all
About 30%
Nitroglycerine (NTG) is given for a patient having ischemic chest pain. One tablet or one spray should be used under the tongue every 5 minutes for three doses. What should be done if the pain has not been relieved after three doses?
911 should be called, and the patient should be transported immediately to the emergency
department.
One more dose of NTG maybe tried.
The person should be given two aspirin to chew.
Aportable defibrillator should be located to ascertain the cardiac rhythm.
911 should be called, and the patient should be transported immediately to the emergency
department.
For the best therapeutic effect after a myocardial infarction (MI), thrombolytics should be administered within the first 3 hours (ideally 30 minutes) of symptom onset. Studies have shown, however, that thrombolytic therapy can be of benefit up to how many hours after the initial presentation of MI symptoms?
6 hours
8 hours
10 hours
12 hours
12 hours
When teaching post MI patients about their NTG tablets, the clinician should stress that the tablets should remain in the light-resistant bottle in which they are packaged and should not be put in another pill box or remain in areas that are or could become warm and humid. Once opened, the bottle must be dated and discarded after how many months?
1 month
3 months
6 months
As long as the tablets are kept in this special bottle, they will last forever.
6 months
There are four stages of heart failure, classified as A to D, that describe the evolution and progression of disease. In which stage are patients hospitalized or treated with specialized interventions or hospice care for refractory symptoms of heart failure despite medical therapy?
Stage A
Stage B
Stage C
Stage D
Stage D
Which of the following is abundant in the heart and rapidly rises in the bloodstream in the presence of heart failure, making it a good diagnostic test?
B-type natriuretic peptide
C-reactive protein
Serum albumin
Erythrocyte sedimentation rate
B-type natriuretic peptide
Which test has long been considered the gold standard for a diagnosis of venous thromboembolism?
Ultrasound
Magnetic resonance imaging (MRI)
Ascending venogram
D-dimer
Ascending venogram
Statins are approved for which age group?
Children over the age of 2
Children over the age of 6
Children over the age of 10
Only adolescents and adults
Children over the age of 10
The American College of Cardiology/American Heart Association states which of the following regarding the use of non-statin lipid-lowering agents?
Nicotinic acid derivatives are effective for lowering LDL and triglycerides (TGs).
Bile acid sequestrates increase HDL.
Cholesterol absorption inhibitors decrease LDL.
There is no sufficient evidence to use non-statin lipid-drugs.
There is no sufficient evidence to use non-statin lipid-drugs.
Which of the following medications can cause hyperlipidemia?
Diuretics
NSAIDs
Opioids
Insulin
Diuretics
** Jamie, age 55, has just started on a statin after having his liver function tests (LFTs)
come back normal. He now asks you how often he has to have the LFTs repeated. What do you
tell him?**
Initially in 6 weeks
Every 3 months
Every 6 months
It‘s no longer necessary for his statin regimen.
It‘s no longer necessary for his statin regimen.
In the CHADS2 Index for the stroke risk score for AF, the ‗A‘ stands for:
Anticoagulation
Autoimmune disease
Age
Antihypertension
Age
Which murmurs are usually ‗watch and wait‘?
Systolic murmurs
Diastolic murmurs\
They both are dangerous and need immediate attention.
You can watch and wait‘ for both of them.
Systolic murmurs
Which of the following statements about dabigatran is true?
It is difficult to keep the patient in therapeutic range.
Anticoagulation cannot be immediately reversed.
It allows for the use of tPA if the patient has a stroke despite anticoagulation.
None of the statements are true
Anticoagulation cannot be immediately reversed.
What value on the ankle-brachial index diagnoses peripheral artery disease?
Less than 0.25
Less than 0.50
Less than 0.90
Greater than 1
Less than 0.90
Your patient with permanent afib asks when he can discontinue his warfarin. You tell him:
When your internalized normalized ratio reaches 3.0, you can stop taking your warfarin permanently
When you no longer feel ill
One month after your symptoms dissipate
You‘ll probably be on it indefinitely..
You‘ll probably be on it indefinitely..
You just started Martha on HTN therapy. The Eighth Joint National Committee recommends that if her goal BP is not reached in what length of time, you should increase the initial drug or add a second drug to it?
1 month
3 months
6 months
1 year
1 month
Meds are offered to anyone with CAD or increased risks:
Patients with an LDL >____
Patients with a 10-year ASCVD risk of > ____%
LDL >190
ASCVD risk of > 7.5%
are the main component of fat molecules in the blood
Triglycerides
1.The nurse suspects a clients heart is failing when which of the following heart sounds is
assessed?
S1
S2
S3
S4
S3
An auscultated S3 is a sign that increased blood volume remains in the ventricle with each beat
and that the heart is beginning to fail. S1 and S2 sounds are the first and second sounds heard
when auscultating the heart. An S4 sound may indicate increased resistance to ventricular filling.
A client is diagnosed with heart failure. Which of the following diagnostic tests is useful to determine the degree of the failure?
1.Brain natriuretic peptide level
2..Blood cultures
3.Sedimentation rate
4.Arterial blood gas
1.Brain natriuretic peptide level
Brain natriuretic peptide is a hormone found in the left ventricle; it is used to help diagnose and
grade the severity of heart failure. Blood cultures are used to diagnose carditis. Sedimentation
rate is used to diagnose pericarditis. Arterial blood gasses are not used to determine the degree of
heart failure.
A nurse is instructing a client regarding medications and substances contraindicated for the client with heart failure. Which of the following would not be contraindicated?
1.Alcohol
2..Furosemide
3.Metformin
4.Pioglitazone
.Furosemide
Loop diuretics (e.g., furosemide) are part of the recommended medications for heart failure.
Alcohol, metformin, and pioglitazone (a thiazolidinedione) are contraindicated.
The nurse is determining nursing diagnoses appropriate for a client demonstrating productive
cough with pink frothy sputum, shortness of breath, and crackles. Which of the following
nursing diagnoses is of the most importance?
1.Activity intolerance
2.Anxiety
Impaired gas exchange
Risk for ineffective respiratory function
Impaired gas exchange
The first priority is to maintain adequate oxygenation. The next diagnoses in priority would be
risk for ineffective respiratory function. Activity intolerance would be the third diagnosis.
Anxiety would be the last diagnosis in order of priority.
In planning the care for a client diagnosed with heart failure, which of the following
would be an appropriate goal?
1.Reduce myocardial contractility.
2.Increase cardiac workload.
3.Decrease ejection fraction.
4.Increase activity levels
4.Increase activity levels
An increase in activity levels would be an appropriate goal for the client diagnosed with heart
failure. The other options would be a decrease in ability, function, or management of the heart
failure patient.
The nurse is instructing a client diagnosed with mild heart failure on dietary modifications.Which of the following client statements indicates that the instruction has been effective?
1.I will avoid green beans.
2..I will avoid orange juice.
3.I will avoid soy sauce.
4.I will avoid apple sauce.
I will avoid soy sauce.
Soy sauce is a high-sodium food choice; all the other choices are low sodium. Treatment for mild
symptoms of heart failure includes dietary restriction of salt.
A client is undergoing diagnostic testing for infective endocarditis. Which of the following laboratory tests would be most useful in diagnosis?
1.Basic metabolic panel
2.Blood cultures
3.Reticulocyte count
4.Prothrombin time
2.Blood cultures
Blood cultures identify the causative organisms. A basic metabolic panel gives the current status
of the clients acid/base balance and electrolytes. The reticulocyte count determines bone marrow
function and evaluates erythropoietic activity. The prothrombin time is useful in monitoring
anticoagulant therapy.
.Which of the following would the nurse most likely assess in a client diagnosed with right sided heart failure?
1.Distended neck veins
2.Oliguria
3.Cough with frothy blood-tinged sputum 4.Syncope
1.Distended neck veins
An assessment finding in a client diagnosed with right-sided heart failure is distended neck
veins. Oliguria, cough with frothy blood-tinged sputum, and syncope are all clinical
manifestations of left- sided heart failure.
Which of the following diagnostic tests is useful to diagnose mitral valve prolapse?
1.Electrocardiogram
2.Echocardiogram
3.Cardiac angiography
4.Transesophageal echocardiography
Transesophageal echocardiography
Transesophageal echocardiography is useful in the assessment of cardiac murmurs, stenosis, and
regurgitation of all four cardiac valves. An electrocardiogram, echocardiogram, and cardiac
angiography may or may not be useful when diagnosing mitral valve prolapse.
A client diagnosed with mitral valve prolapse is experiencing palpitations. Which of the
following should the nurse instruct this client?
Avoid tobacco
Ingest alcohol in moderation
3.Avoid weight loss
4.Limit caffeine intake
Avoid tobacco
Clients with palpitations associated with mitral valve prolapse should be instructed to avoid caffeine, alcohol, and tobacco. Weight loss should be encouraged in overweight clients
.A client tells the nurse that she had rheumatic heart disease as a child. For which of the
following valvular disorders should this client be assessed?
1.Mitral valve prolapse
2.Mitral stenosis
3.Aortic regurgitation
4.Aortic stenosis
2.Mitral stenosis
Mitral stenosis is most commonly caused by rheumatic heart disease. Rheumatic heart disease
has not been linked to mitral valve prolapse, aortic regurgitation, or aortic stenosis.
.A client, recovering from surgery to replace a calcified aortic valve with a mechanical valve,
should be instructed that which of the following medications will be needed long term?
1.ACE inhibitor
2.Beta-blocker
3.Antibiotic
4.Anticoagulant
Anticoagulant
The mechanical valve requires long-term anticoagulation therapy to prevent the risk of
thromboembolism. ACE inhibitors, beta-blockers, and antibiotics are not indicated as long-term
therapy for this surgery.
A client is scheduled for annuloplasty surgery to the aortic valve. Which of the following will
most likely occur during this clients procedure?
1.A catheter will be inserted through the femoral vein.
2.A heart bypass machine will be used.
3.Local anesthesia will be provided.
4.A balloon will inflate and stretch the valve open
.A heart bypass machine will be used.
For an annuloplasty, the client will receive general anesthesia and a heart bypass machine will be
used. A balloon valvuloplasty is done by inserting a catheter through the femoral vein or artery
and stretching the valve open with a balloon. The client needs general anesthesia for an annuloplasty and not a local anesthetic.
1.The nurse suspects a client is experiencing left-sided heart failure when which of the following
is assessed? (Select all that apply.)
1.Decreased basilar lung sounds
2.Distended neck veins
3.Extra heart sounds
4.Lung crackles
5.Tachycardia
6.Weight gain
1.Decreased basilar lung sounds
3.Extra heart sounds
4.Lung crackles
5.Tachycardia
Signs of left-sided heart failure are dysrhythmic heart rate, tachycardia, heart murmurs, extra
heart sounds, lung crackles, and decreased basilar lung sounds. Distended neck veins and weight
gain are symptoms of right-sided heart failure.
A client diagnosed with heart failure is prescribed furosemide (Lasix). Which of the following
should this client be monitored for because of this medication? (Select all that apply.)
Dehydration
Rebound fluid volume overload
Hyponatremia
Hypokalemia
Hypernatremia
Hyperkalemia
Dehydration
Hyponatremia
Hypokalemia
Any client prescribed diuretics should be monitored for dehydration, hyponatremia, and hypokalemia. Rebound fluid volume overload is not possible with diuretic therapy.Hypernatremia and hyperkalemia are also not possible with diuretic therapy.
The nurse is reviewing the medications prescribed for a client diagnosed with dilated cardiomyopathy. Which of the following medications are commonly prescribed for this disease process? (Select all that apply.)
1.ACE Inhibitor
2.Beta-blocker
3.Diuretic
4.Anticoagulant
5.Antiarrhythmic
6.Antibiotic
1.ACE Inhibitor
2.Beta-blocker
3.Diuretic
4.Anticoagulant
5.Antiarrhythmic
Pharmacological management of dilated cardiomyopathy includes ACE inhibitor to prevent
further dilation of the heart, beta-blocker to reduce the strain that heart failure produces on the
heart muscle, diuretics to decrease the amount of circulating fluid, anticoagulants to decrease
blood clots, and antiarrhythmics to maintain the normal electrical stimulation of the heart.
Antibiotics are not routinely prescribed for a client diagnosed with dilated cardiomyopathy
.Which of the following should the nurse instruct a client diagnosed with hypertrophic cardiomyopathy? (Select all that apply.)
1.Follow recommended activity level
2.Avoid all alcohol
3.Take hot tub baths routinely
4.Avoid overexertion
5.Avoid dehydration
6.Unexplained breathlessness is a common symptom
1.Follow recommended activity level
4.Avoid overexertion
5.Avoid dehydration
The nurse should instruct the client diagnosed with hypertrophic cardiomyopathy to follow the
recommended activity level, avoid overexertion, and avoid dehydration. The client should be instructed to use alcohol in moderation, to avoid hot tub baths or showers, and to report unexplained breathlessness to a health care provider
.The nurse determines that a client diagnosed with pericarditis is demonstrating the classic signs
of the Beck triad. What are the signs of the Beck triad? (Select all that apply.)
1.Fever
2.Dyspnea
3.Muffled heart sounds
4.Elevated jugular vein pressure
5.Hypotension
6.Abdominal pain
3.Muffled heart sounds
4.Elevated jugular vein pressure
5.Hypotension
The symptoms of Beck triad include muffled heart sounds, elevated jugular vein pressure, and
hypotension. Fever, dyspnea, and abdominal pain are not considered findings within the Beck
triad
A client is experiencing an alteration in heart rate. The nurse realizes this client is experiencing
a disorder of which part of the heart?
1.Atrioventricular node
2.Bundle branches
3.Purkinje fibers
4..Sinoatrial node
4..Sinoatrial node
The sinoatrial node is the dominant pacemaker of the heart. The sinoatrial node has an inherent
rate of 60 to 100 bpm. The atrioventricular node has an intrinsic rate of 40 to 60 bpm. The
impulse enters the right and left bundle branches and then enters the Purkinje fibers. Impulses at
this level are at 15 to 40 times per minute.
A client is suspected of having cardiac damage. The nurse realizes that which of the following
diagnostic tests is most commonly used to help diagnose this clients possible cardiac damage or
disease?
1.12-lead electrocardiogram
2..Arterial blood gases
3.Cardiac angiogram
4.Cardiac enzymes
1.12-lead electrocardiogram
A12-lead electrocardiogram is a quick and accurate diagnostic tool used to evaluate heart damage and disease. The other diagnostic tests require a longer time for results and/or are invasive procedures requiring some preparation.
The nurse is analyzing a clients electrocardiogram tracing. Which of the following complexes is not normally seen on an electrocardiogram tracing?
1.P wave
2..QRS complex
3.T wave
4.U wave
4.U wave
AUwaveis not always seen and can be very small. It can indicate electrolyte imbalance, medication effects, and ischemia. The P wave, QRS complex, and T wave are normally seen in the electrocardiogram tracing.
The nurse is analyzing a clients electrocardiogram tracing and realizes that each small square on the paper is equal to:
1.0.04 second.
2.0.12 second.
3.0.20 second.
4.0.40 second
.0.04 second.
The small square on the ECG graph paper equals 0.04 second. The large square equals 0.20 second. The PR interval is 0.12 to 0.20 second. Two large squares would be equal to 0.40 second.
The nurse is reading an ECG rhythm strip and notes that there are nine QRS complexes in a 6- second strip. The heart rate is
1.36.
2.54.
3.81
4.90.
90
Aheart rate can be determined by multiplying the QRS complexes in a 6-second strip by 10. The
heart rate is 90. This method of calculating the heart rate is the most common method used
because it is quick and can be used when the heart rate is irregular.
The nurse notes that on a clients electrocardiogram tracing, there is one P wave for every QRScomplex and a delay in the impulse transmission at the AV node. This regular rhythm is identified as:
1.first-degree AV block.
2..second-degree AV block type I.
3.second-degree AV block type II.
4.complete heart block
1.first-degree AV block
First-degree atrioventricular (AV) block occurs when there is a delay in the impulse transmission at the AV node. This delay occurs with every impulse and can be seen on every beat on the recorded rhythm strip. Second-degree and complete heart block have differences with the P wave and the associated QRS complexes.
A client is unresponsive and has no pulse. The nurse notes that the electrocardiogram tracing
shows continuous large and bizarre QRS complexes measured greater than 0.12 each. This
rhythm is identified as:
1.premature ventricular complexes.
2.torsades de pointes.
ventricular fibrillation.
ventricular tachycardia
ventricular tachycardia.
Ventricular tachycardia occurs when the patient experiences sustained consecutive premature
ventricular complexes. Torsades de pointes is characterized by a wide-to-narrow pattern of the
QRScomplexes. Ventricular fibrillation shows a coarse wavy baseline.
An elderly client is demonstrating a change in heart rate that occurs with respirations. When planning care for the client, the nurse knows that treatment may include:
1.Oxygen therapy
2..Analgesics
3..Antibiotics
4.Pacemaker insertion
4.Pacemaker insertion
Achange in heart rate that occurs with respirations defines a sinus arrhythmia. If the client becomes symptomatic during periods of bradycardia, treatment will include atropine sulfate or pacemaker insertion. Treatment for sinus arrhythmia might include oxygen if the client is symptomatic. Treatment for this arrhythmia does not include analgesics or antibiotics.
.A clients electrocardiogram tracing shows a sawtooth pattern with F waves. The nurse realizes
this client is demonstrating:
atrial flutter.
atrial fibrillation.
premature atrial contractions.
atrial tachycardia
atrial flutter.
Atrial flutter is characterized by F waves that occur in a characteristic sawtooth pattern. Atrial fibrillation is characterized by coarse waves with the baseline between the QRS complexes as being rough and uneven. Premature atrial contractions occur when an electrical impulse is generated in an area of the atria outside of the SA node. Atrial tachycardia is three or more premature atrial contractions. Neither premature atrial contractions or atrial tachycardia have an F wave on the tracing.
The electrocardiogram tracing for a client shows premature junctional complexes. Which of
the following should the nurse do to assist this client?
1.Administer oxygen
2..Increase intravenous fluids
3.Check on the serum digoxin level
4..Assist the client to a side-lying position
.Check on the serum digoxin level
The most common cause of premature junctional complexes is digitalis toxicity. The nurse should check on the clients serum digoxin level. Oxygen, intravenous fluids, or position changes will not help treat this rhythm.
.Which of the following should the nurse instruct a client who has been diagnosed with an arrhythmia?
Exercise level
Avoidance of calorie-dense foods
How to take his own pulse
Reasons why fatigue is expected
How to take his own pulse
Instructions for a client diagnosed with an arrhythmia include symptom management, how to
take own pulse, and substances to avoid the onset of an arrhythmia. The nurse may or may not
instruct on exercise level. The client does not need to avoid calorie-dense foods. Fatigue is a symptom that should be reported to a health care provider.
A client is diagnosed with supraventricular tachycardia. The nurse should prepare to
administer which of the following medications?
1.Procainamide
2..Amiodarone
3..Verapamil
4.Adenosine
4.Adenosine
Adenosine has a short half-life, is given intravenous push, and is used to abruptly stop supraventricular tachycardia. Procainamide is used for tachyarrhythmias and ventricular ectopy.
Amiodarone is helpful to treat ventricular fibrillation. Verapamil helps slow the heart rate with
atrial fibrillation.
.A client is recovering from insertion of a pacemaker to pace the activity of the ventricles. At which point on the electrocardiogram tracing will the nurse assess pacer spikes?
1.Before the QRS complex
2..Before the P wave
3.After the QRS complex
4.After the P wave
Before the QRS complex
If the ventricles are being paced, there will be a pacer spike just prior to the QRS complex. If the
atria are being paced, there will be a pacer spike just before the P wave. Pacer spikes that occur
after the QRS complex or P wave would indicate pacemaker malfunction and should be
addressed immediately.
.A client with a heart rate of 40 who is experiencing shortness of breath and nausea is diagnosed
with second-degree AV block type II. Which of the following will be included in this clients
treatment? (Select all that apply.
1.Administer digoxin
2.Administer antiemetic
3..Administer atropine sulfate
4.Insert external pacemaker
Decrease intravenous fluids
Lower the head of the bed
..Administer atropine sulfate
4.Insert external pacemaker
For second-degree AV block type II, treatment will almost always consist of external pacemaker
insertion. Atropine sulfate may be used to increase the heart rate until the pacemaker can be
inserted. Digitalis toxicity can cause this heart rhythm so digoxin should not be administered to
this client. An antiemetic will not solve the clients underlying problem. The client may or may
not need additional fluids. Lowering the head of the bed could compromise this clients
respiratory status and should not be done.
A clients electrocardiogram rhythm strip is a straight line. Which of the following should the
nurse do to help this client? (Select all that apply.)
Assess for loose leads.
Assess for power to the monitor.
Assess the strip for possible fine vfib
Begin CPR once verified the client has no pulse.
.Raise the head of the bed.
.Stop intravenous fluid infusion.
Assess for loose leads.
Assess for power to the monitor.
Assess the strip for possible fine vfib
Begin CPR once verified the client has no pulse.
The absence of electrical activity will create the rhythm of asystole. The rhythm strip is a straight
line. The nurse should confirm that the straight line is not due to another reason such as loose leads, lack of power to the monitor, or fine ventricular fibrillation. Once it is confirmed that the client has no pulse, cardiopulmonary resuscitation should be implemented. Raising the head of the bed or stopping intravenous fluid infusions is not going to help the client experiencing
asystole
The nurse is assessing a client who is diagnosed with pulseless electrical activity. Which of the
following will the nurse include in this assessment? (Select all that apply.)
1.Hypovolemia
2..Hypoxia
3.Hypothermia
4.Tamponade
5.Thrombosis
6.Throat pain
1.Hypovolemia
2..Hypoxia
3.Hypothermia
4.Tamponade
5.Thrombosis
Assessment of pulseless electrical activity includes a review of the 5 Hs and the 5 Ts. The 5 Hs
are: hypovolemia, hypoxia, hydrogen ion status, hyperkalemia/hypokalemia, and hypothermia.
The 5 Ts include tablets, tamponade, tension pneumothorax, thrombosis coronary, and
thrombosis pulmonary. Throat pain does not cause pulseless electrical activity.
.Which of the following should be implemented to ensure the safe use of a defibrillator? (Select
all that apply.)
1.Do not place over monitoring electrodes.
2..Do not place over an implanted pacemaker.
3.Place the paddles at inch from the implanted pacemaker site.
4.Apply transdermal medication to the chest before using the paddles.
5.Insert an oral airway before using the paddles.
6.Have another person hold the clients airway open while using the paddles
1.Do not place over monitoring electrodes.
2..Do not place over an implanted pacemaker
The safe use of defibrillator paddles include: do not place over monitoring electrodes or implanted devices. Paddles should be at least 1 inch away from an implanted device.Transdermal medication should be removed from the clients chest before using the paddles. An oral airway is not needed before using the paddles. No one should be touching the client when using the paddles
Which of the following interventions would be appropriate for a client recovering from a
pacemaker insertion? (Select all that apply.)\
1.Monitor vital signs every 15 minutes until stable.
- 2.Assess for chest pain.
3.Restrict movement of affected extremity.
4.Monitor electrocardiogram every 8 hours.
.Beginintravenous fluid infusion at 150 mL/hr.
6.Reinforce dressing with excessive bleeding
1.Monitor vital signs every 15 minutes until stable.
- 2.Assess for chest pain.
3.Restrict movement of affected extremity.
Interventions appropriate for a client recovering from a pacemaker insertion include monitoring
vital signs every 15 minutes until stable, assessing for chest pain, restricting movement of the
affected extremity, monitoring electrocardiogram ongoing and post a strip every 4 hours, and
report excessive bleeding from the surgical site to the health care provider. Intravenous fluids at
the rate of 150 mL/hr may or may not be needed.
Which of the following should the nurse instruct a client in order to reduce the risk factors for
developing arteriosclerosis?
1.Limit diet to contain less than 40% fat
2.Restrict exercise
Stop smoking
Avoid prescription medications
stop smoking.
To reduce the risk for arteriosclerosis, the nurse should instruct the client to stop smoking. The
diet should be limited to less than 30% of fat. Exercise should be encouraged. Prescription
medications are often prescribed for clients with symptoms of arteriosclerosis.
The nurse is concerned that an elderly client has evidence of arteriosclerosis since the clients capillary refill is greater than:
3 seconds.
4 seconds.
5 seconds.
6 seconds
5 seconds
Elderly patients have a greater capillary refill time due to aging. Capillary refill greater than 5
seconds is significant. Capillary refill in non-elderly clients should be 3 seconds. Capillary refill
in a non-elderly client of 4 seconds would be an abnormal finding. Capillary refill of 6 seconds
for all clients is an abnormal assessment finding.
When instructing a client on ways to lower his cholesterol levels, which of the following
should the nurse include?
1.Eat more meat and eggs.
2.Consume less meat and eggs.
3.Incorporate more vegetables.
4..Limit fruits.
2.Consume less meat and eggs.
Cholesterol is located in animal sources, so decreasing meat and eggs will lower cholesterol
levels. The client should not be instructed to eat more meat and eggs. Vegetables and fruits do
not impact the cholesterol level.
A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the
following should the nurse assess in this client?
1.Respiratory distress
2..Skin breakdown
3.Decreased urine output
4..Bruising and bleeding
Bruising and bleeding
Aclient who is prescribed blood-thinning medication is at a greater risk of bleeding and bruising.
Anticoagulant therapy does not increase a clients risk for developing respiratory distress, skin
breakdown, or decreased urine output.
The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the
following sounds did the nurse auscultate during the assessment?
Pleural rub
Hyperactive bowel sounds
Crackles
4.Bruit
.Bruit
The nurse may auscultate a bruit at the site of the aneurysm. Pleural rib and crackles are
adventitious sounds heard during the assessment of the lungs. Hyperactive bowel sounds may be
heard when assessing the abdomen.
A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?
Hypotension
.Cardiac arrhythmias
.Aneurysm rupture
.Loss of bowel sounds
.Aneurysm rupture
Aneurysm rupture is a life-threatening occurrence and the highest risk for the client until it can
be repaired. Hypotension, cardiac arrhythmias, and loss of bowel sounds are all significant potential complications; however, they are not life threatening.
A client who has experienced signs of Virchows triad has developed a deep vein thrombosis. Which of the following is not a part of this triad?
1.Venous stasis
2.Vessel wall injury
3.Alteration in blood clotting
4..Pregnancy
Pregnancy
Pregnancy is a risk factor for thrombus, but it is not part of Virchows triad.Virchows triad includes venous stasis, vessel wall injury, and alteration of blood coagulation.
A client is diagnosed with Buergers disease. Which of the following should the nurse instruct the client regarding this disorder?
It is a common disorder.
It appears in women more than in men.
.Smoking exacerbates the disease.
4.It is more common in African Americans
.Smoking exacerbates the disease
Smoking cessation halts the disease progress, but continuation of smoking exacerbates the progression of the disease. Buergers disease is a rare disorder. It is more common in men than
women. It is more common in Asians and rare among African Americans
A client is diagnosed with Raynauds disease. Which of the following will the nurse most likely assess in this client?
Elevated blood pressure
Pain, cyanosis, and numb, cold extremities
.Absent peripheral pulses
4.Increase in varicose veins
Pain, cyanosis, and numb, cold extremities
Clinical manifestations of Raynauds disease include venospasms; pain; cyanosis; redness; numb,
cold extremities; and swelling. Elevated blood pressure, absent peripheral pulses, and varicose
veins are not associated with this disorder
.A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client?
Administer oxygen.
Assist with ambulation.
Administer heparin as prescribed.
Restrict fluids
Administer heparin as prescribed.
In the treatment of acute peripheral arterial occlusion, intravenous heparin therapy is usually the
first intervention. Oxygen is not the first intervention for this client. The client will most likely be on bed rest and will not ambulate. Restricting fluids would not be indicated for acute peripheral arterial occlusion.
.A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the
following should the nurse prepare to administer to this client?
1.Aspirin
2. 2.Vitamin K
3.Protamine sulfate
4.Narcan
.Protamine sulfate
Protamine sulfate is the heparin antagonist used for excessive bleeding. Vitamin K is the antagonist for warfarin. Aspirin and narcan are not used for bleeding associated with a heparin
infusion.
A clients blood pressure measurements have a 20 mmHg difference between the upper extremity readings. Which of the following does this assessment finding suggest to the nurse?
1.Arteriosclerosis
2.Aortic aneurysm
3.Deep vein thrombosis
4.Subclavian steal syndrome
Subclavian steal syndrome
Adifference of greater than 20 mmHg when assessing bilateral blood pressure measurements is
considered a significant finding in the diagnosis of subclavian steal syndrome. This blood pressure discrepancy is not a finding with arteriosclerosis, aortic aneurysm, or deep vein thrombosis.
.The nurse is assessing a client for risks in the development of varicose veins. Which of the
following findings would increase this clients risk?
1.Normal weight
2.Prolonged standing
Engages in golf three times a week
Eats several servings of fruits &vegetables each day
Prolonged standing
Risk factors for the development of varicose veins include thrombophlebitis, obesity, prolonged
standing, pregnancy, and liver or pancreas dysfunction. Normal weight, activity, and balanced
diet are not risk factors for the development of varicose veins
.A client is having laboratory tests conducted to confirm a diagnosis of arteriosclerosis. Which
of the following laboratory values would support this clients medical diagnosis? (Select all that
apply.)
1.Serum cholesterol 300 mg/dL
2.LDL 125 mg/dL
3.Blood glucose 90 mg/dL
4.HDL 45 mg/dL
5.Triglycerides 400 mg/dL
6.Serum potassium 4.0 mEq/L
1.Serum cholesterol 300 mg/dL
2.LDL 125 mg/dL
4.HDL 45 mg/dL
5.Triglycerides 400 mg/dL
Diagnostic tests used to support the medical diagnosis of arteriosclerosis include cholesterol,
LDL, HDL, and triglycerides. A serum cholesterol of 300 mg/dL, LDL of 125 mg/dL, HDL of 45 mg/dL, and triglycerides of 400 mg/dL all support the diagnosis of arteriosclerosis. Blood glucose and potassium levels are not used to diagnose arteriosclerosis.
The nurse is assessing a client diagnosed with a peripheral arterial occlusion. Which of the
following will the nurse assess in this client? (Select all that apply.)
1.Pulselessness
2..Pain
3.Pallor
4.Paresthesia
5.Paralysis
6.Petechiae
1.Pulselessness
2..Pain
3.Pallor
4.Paresthesia
5.Paralysis
The nurse would assess a client diagnosed with peripheral arterial disease for the six Ps:
pulseless, pain, pallor, paresthesia, paralysis, and poikilocythemia. Petechiae is not a part of the
six Ps assessment
.The nurse is instructing a client recovering from arterial aneurysm repair. Which of the following should be included in these instructions? (Select all that apply.)
Do not lift anything heavier than 15 to 20 lbs.
Limit activity for up to 8 weeks after surgery.
Use a pillow to splint when coughing.
Driving is permitted 1 week after surgery.
Notify MD of pain, redness, swelling around incision.
Avoid pain medication.
Do not lift anything heavier than 15 to 20 lbs.
Limit activity for up to 8 weeks after surgery.
Use a pillow to splint when coughing.
Notify MD of pain, redness, swelling around incision.
Instructions appropriate after surgery to repair an arterial aneurysm include limit lifting to 15 to
20 lbs; limit activity for up to 8 weeks after the surgery; use a pillow to splint when coughing;
and notify the physician for pain, redness, or swelling around the incision. Driving may be restricted for several weeks. Pain medication will be prescribed and encouraged to be used.
The nurse is utilizing the Wells Scale to assess a client for deep vein thrombosis. Which of the
following is assessed when using this scale? (Select all that apply.)
Treatment for cancer
Recent immobility for greater than 3 days
Recovery from surgery with general anesthesia within 12 weeks
4.Entire leg edematous
5.Pitting edema of the symptomatic leg
6.Blood pressure 130/86 mmHg
Treatment for cancer
Recent immobility for greater than 3 days
Recovery from surgery with general anesthesia within 12 weeks
4.Entire leg edematous
5.Pitting edema of the symptomatic leg
The Wells Scale is a tool used to assess a client for the presence of a deep vein thrombosis. Areas
assessed include treatment or diagnosis of cancer, recent immobility for greater than 3 days recovery from surgery during which the client received general or regional anesthesia within 12 weeks, entire leg swollen, and pitting edema confined to the symptomatic leg. Blood pressure is not a criteria used on this scale.
A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this clients plan of care? (Select all that apply.)
Administer oral antibiotics if infection is present.
Keep the foot open to the air.
Cover the foot with a hydrocolloidal dressing.
Provide pain medication with debridement.
Restrict fluids.
Instruct the client to ambulate without shoes.
Administer oral antibiotics if infection is present.
Cover the foot with a hydrocolloidal dressing.
Provide pain medication with debridement.
Nursing care of a client diagnosed with a venous stasis ulcer includes provide with oral antibiotics if infection is present, cover the wound with hydrocolloidal dressing if indicated to promote the formation of granulation tissue, provide pain medication with debridement. The
wound should not be kept open to the air. The client does not need a fluid restriction. The client
should be instructed to never ambulate without appropriate foot protection.
