Exam 2/Midterm

Question 1

In managing a patient with ADHF and dyspnea, what positioning technique should the nurse use to decrease venous return and improve thoracic capacity?

A. Trendelenburg position
B. Supine position
C. High-Fowler’s position with feet dangling
D. Prone position Correct

Answer 1

C. High-Fowler’s position with feet dangling

Question 2

Which drug is considered the first line of treatment for patients with volume overload in Acute Decompensated Heart Failure (ADHF)?

A. Morphine
B. Vasodilators
C. Diuretics
D. Positive inotropes

Answer 2

C. Diuretics

Rationale: Diuretics are the first line of treatment for patients with volume overload as they help reduce sodium and water reabsorption, thereby decreasing intravascular volume.

Question 3

Which of the following is a selective β-agonist that works mainly on the β1-receptors in the heart?

A. Dopamine
B. Dobutamine
C. Norepinephrine
D. Milrinone

Answer 3

B. Dobutamine

Question 4

What is the primary purpose of prescribing an ACE inhibitor to a patient with heart failure?

A. To decrease cardiac preload and afterload
B. To increase cardiac contractility
C. To reduce the risk of arrhythmias
D. To prevent diuretic resistance

Answer 4

A. To decrease cardiac preload and afterload

Question 5

A patient with ADHF is receiving dobutamine. What is the desired outcome of this treatment?

A. Increased heart rate
B. Decreased systemic vascular resistance
C. Reduced myocardial oxygen demand
D. Improved contractility and cardiac output

Answer 5

D. Improved contractility and cardiac output

Question 6

The expected outcome for a patient with ADHF receiving IV nitroglycerin is:

A. Decreased respiratory rate
B. Reduced preload and afterload
C. Increased peripheral vasoconstriction
D. Improved myocardial oxygen demand

Answer 6

B. Reduced preload and afterload

Rationale: Nitroglycerin reduces preload and afterload through vasodilation.

Question 7

A patient is scheduled for an echocardiogram. What information can this test provide in heart failure?

A. Presence of pulmonary embolism
B. Left ventricular ejection fraction (LVEF)
C. Degree of coronary artery stenosis
D. Arterial blood gas (ABG) results

Answer 7

B. Left ventricular ejection fraction (LVEF)

Question 8

A nurse assesses jugular venous distension (JVD) in a patient with heart failure. What does this finding indicate?

A. Left-sided heart failure
B. Pulmonary hypertension
C. Decreased systemic vascular resistance
D. Increased right atrial pressure

Answer 8

D. Increased right atrial pressure

Question 9

A patient with heart failure reports a dry, hacking cough. Which condition is the most likely cause?

A. Pulmonary embolism
B. Chronic heart failure
C. Acute respiratory infection
D. Pericarditis

Answer 9

B. Chronic heart failure

Question 10

A patient with ADHF has a BP of 80/50 mm Hg, HR 120 bpm, and cool extremities. What is the priority nursing action?

A. Administer IV diuretics
B. Begin dobutamine infusion
C. Obtain a 12-lead ECG
D. Start oxygen therapy

Answer 10

B. Begin dobutamine infusion

Rationale: Dobutamine is indicated to improve cardiac output in hypotensive patients with signs of poor perfusion.

Question 11

Which intervention is most effective for managing fluid overload in a patient with heart failure?

A. Limiting sodium intake to 4 g/day
B. Encouraging increased oral fluid intake
C. Administering diuretics as prescribed
D. Performing daily chest physiotherapy

Answer 11

C. Administering diuretics as prescribed

Question 12

A patient with heart failure is categorized as “wet and warm.” Which findings support this classification?

A. Pulmonary congestion with adequate perfusion
B. Fluid overload with decreased skin perfusion
C. Cool extremities and crackles in the lungs
D. Peripheral vasodilation and low cardiac output

Answer 12

A. Pulmonary congestion with adequate perfusion

Question 13

Which of the following is considered a major risk factor for coronary artery disease (CAD)?

A. High serum LDL levels

B. Low serum HDL levels

C. High serum albumin levels

D. Low serum triglyceride levels

Answer 13

A. High serum LDL levels

Question 14

Obesity often coexists with other CAD risk factors, including:

A. Decreased triglyceride levels

B. Low insulin resistance

C. Hypertension and high LDL levels

D. Increased heart rate and vasodilation

Answer 14

C. Hypertension and high LDL levels

Question 15

A patient with a history of CAD reports episodic chest pain while shopping or performing daily activities. The patient denies any relief with physical rest. What is the most likely diagnosis?

A. Chronic stable angina
B. Prinzmetal’s angina
C. Microvascular angina
D. Unstable angina

Answer 15

C. Microvascular angina

Rationale: Microvascular angina is associated with ischemia in small coronary vessels and is often triggered by activities of daily living rather than physical exertion.

Question 16

A patient reports new-onset angina that occurs at rest and lasts more than 10 minutes. What is the most likely cause?

A. Chronic stable angina
B. Microvascular angina
C. Prinzmetal’s angina
D. Unstable angina

Answer 16

D. Unstable angina

Rationale: Unstable angina is characterized by new-onset or worsening chest pain that occurs at rest or with minimal exertion and persists for over 10 minutes.

Question 17

What distinguishes microvascular angina from chronic stable angina?

A. Microvascular angina is triggered by exertion.
B. Microvascular angina is more common in men.
C. Microvascular angina is triggered by activities of daily living.
D. Microvascular angina is relieved by beta-blockers.

Answer 17

C. Microvascular angina is triggered by activities of daily living.

Rationale: Microvascular angina is caused by ischemia in small coronary vessels and is often triggered by routine activities rather than physical exertion.

Question 18

What factor is commonly associated with triggering Prinzmetal’s angina?

A. Stress
B. Daily activities
C. Smoking
D. Exercise

Answer 18

C. Smoking

Question 19

Which type of angina is associated with rupture of unstable plaque?

A. Chronic stable angina
B. Microvascular angina
C. Prinzmetal’s angina
D. Unstable angina

Answer 19

D. Unstable angina

Question 20

Which diagnostic test should be obtained to evaluate a patient with chest pain?

a) Blood glucose test
b) Abdominal ultrasound
c) Pulmonary function test
d) 12-lead ECG

Answer 20

d) 12-lead ECG

Question 21

What side effect is common with all nitrates and requires monitoring?

a) Hyperglycemia
b) Orthostatic hypotension
c) Hyperthermia
d) Tachycardia

Answer 21

b) Orthostatic hypotension

Question 22

A nurse is assessing a patient with suspected unstable angina. Which symptom is most concerning?

A. Pain lasting less than 5 minutes
B. Pain unrelieved by rest or nitroglycerin
C. Pain triggered by exercise
D. Pain that resolves with nitroglycerin

Answer 22

B. Pain unrelieved by rest or nitroglycerin

Question 23

Which diagnostic test is most commonly used to confirm the presence of angina?

A. Chest X-ray
B. Complete blood count (CBC)
C. Echocardiogram
D. Electrocardiogram (ECG)

Answer 23

D. Electrocardiogram (ECG)

Rationale: An ECG can reveal ischemic changes (e.g., ST depression or T-wave inversion) that occur during episodes of angina.

Question 24

A patient with angina reports nausea and diaphoresis. What should the nurse do first?

A. Assess vital signs.
B. Administer nitroglycerin.
C. Perform an ECG.
D. Notify the healthcare provider.

Answer 24

A. Assess vital signs.

Rationale: Vital signs should be assessed to determine hemodynamic stability and guide subsequent interventions.

Question 25

A patient undergoing a stress test reports chest pain. What is the priority action?

A. Stop the test immediately.
B. Administer oxygen.
C. Call for the crash cart.
D. Encourage the patient to keep walking.

Answer 25

A. Stop the test immediately.

Question 26

Which medication is most appropriate for a patient with unstable angina to prevent platelet aggregation?

A. Morphine
B. Aspirin
C. Metoprolol
D. Atorvastatin

Answer 26

B. Aspirin

Question 27

A patient states, “I have chest pain when I’m stressed, but it stops when I relax.” What is the nurse’s best interpretation?

A. Stable angina
B. Unstable angina
C. Silent ischemia
D. Variant angina

Answer 27

A. Stable angina

Question 28

Which finding during a physical exam of a patient with angina requires immediate action?

A. Heart rate of 88 bpm
B. Oxygen saturation of 95% on room air
C. Patient reports a headache after nitroglycerin
D. Blood pressure of 90/60 mmHg after nitroglycerin

Answer 28

D. Blood pressure of 90/60 mmHg after nitroglycerin

Rationale: Hypotension following nitroglycerin administration can lead to inadequate tissue perfusion and requires prompt attention.

Question 29

A nurse is caring for a young, tall, thin male who is a smoker and has a history of asthma. Which of the following conditions is he at an increased risk for?

A. Spontaneous pneumothorax
B. Pleural effusion
C. Pulmonary embolism
D. Pneumonia

Answer 29

A. Spontaneous pneumothorax

Rationale: The patient’s risk factors, such as being tall and thin, male gender, smoking, and having a history of asthma, increase the likelihood of spontaneous pneumothorax due to the formation of small blebs on the lung surface.

Question 30

A patient with chronic obstructive pulmonary disease (COPD) is diagnosed with a spontaneous pneumothorax. Which of the following is the most likely cause of the pneumothorax?

A. Rupture of small blebs on the lung surface
B. A severe asthma attack
C. An underlying pneumonia infection
D. Pulmonary embolism

Answer 30

A. Rupture of small blebs on the lung surface

Rationale: In COPD patients, spontaneous pneumothorax often occurs due to the rupture of small blebs, which are air-filled sacs that can form on the surface of the lungs.

Question 31

A nurse is teaching a patient with a history of spontaneous pneumothorax about risk factors. Which statement by the patient indicates a need for further education?

A. “I should avoid smoking to prevent bleb formation.”

B. “Being tall and thin can increase my risk for pneumothorax.”

C. “I am at higher risk because I have asthma.”

D. “A previous spontaneous pneumothorax doesn’t increase my risk for future ones.”

Answer 31

D. “A previous spontaneous pneumothorax doesn’t increase my risk for future ones.”

Rationale: Having a previous spontaneous pneumothorax actually increases the risk of having another one, so the statement shows a misunderstanding and requires further education.

Question 32

A 25-year-old male patient with no significant medical history presents with sudden chest pain and shortness of breath. He is tall and thin and has been smoking for several years. What is the most likely diagnosis?

A. Spontaneous pneumothorax
B. Acute asthma exacerbation
C. Myocardial infarction
D. Pulmonary embolism

Answer 32

A. Spontaneous pneumothorax

Rationale: This patient’s sudden chest pain and shortness of breath, combined with risk factors such as being tall and thin, smoking, and male gender, suggest spontaneous pneumothorax, especially since he has no significant medical history.

Question 33

A nurse is monitoring a patient with spontaneous pneumothorax who has been treated with oxygen therapy and observation. Which of the following would indicate that the patient’s condition is worsening?

A. Increase in respiratory rate and effort
B. Decrease in oxygen saturation
C. Sudden onset of sharp, localized chest pain
D. All of the above

Answer 33

D. All of the above

Rationale: Worsening spontaneous pneumothorax is indicated by increased respiratory rate and effort, decreased oxygen saturation, and sharp chest pain, as these signs suggest that the pneumothorax is not resolving and may require further intervention.

Question 34

A nurse is caring for a patient with a tension pneumothorax. Which of the following is the priority intervention for this condition?

A. Administer oxygen therapy

B. Perform needle decompression to relieve pressure

C. Start an intravenous line to administer fluids

D. Insert a chest tube to drain the pleural space

Answer 34

B. Perform needle decompression to relieve pressure

Rationale: Tension pneumothorax is a medical emergency requiring immediate intervention to relieve the pressure in the pleural space. Needle decompression is the first priority to restore pressure balance and prevent cardiovascular collapse.

Question 35

A patient with a tension pneumothorax is exhibiting signs of tracheal deviation and severe respiratory distress. The nurse understands that this is due to:

A. Increased venous return from the unaffected side
B. Pressure on the heart and great vessels from the trapped air
C. Decreased pressure on the unaffected lung
D. Rapid oxygenation of the affected lung

Answer 35

B. Pressure on the heart and great vessels from the trapped air

Rationale: In a tension pneumothorax, air enters the pleural space but cannot escape, causing pressure to build up. This pressure compresses the heart and great vessels, causing the mediastinum to shift and affecting both cardiac and respiratory function.

Question 36

A nurse is assessing a patient with suspected tension pneumothorax. Which of the following signs is the most concerning and requires immediate intervention?

A. Increased neck vein distention
B. Decreased breath sounds on the affected side
C. Severe dyspnea and marked tachycardia
D. Tracheal deviation to the unaffected side

Answer 36

D. Tracheal deviation to the unaffected side

Rationale: Tracheal deviation is a late sign of tension pneumothorax and indicates severe pressure in the pleural space. Immediate intervention is necessary to relieve the pressure and prevent further complications.

Question 37

A nurse is caring for a patient who sustained a trauma and is at risk for developing a tension pneumothorax. Which of the following actions may cause or exacerbate tension pneumothorax in this patient?

A. Clamping a chest tube in place
B. Administering high-flow oxygen
C. Inserting a nasogastric tube
D. Elevating the head of the bed

Answer 37

A. Clamping a chest tube in place

Rationale: Clamping a chest tube can obstruct the pleural drainage, leading to the accumulation of air and causing or exacerbating a tension pneumothorax, which can result in increased pressure and cardiovascular compromise.

Question 38

A patient with a tension pneumothorax is being prepared for needle decompression. The nurse prepares to insert the needle in which location?

A. Above the fifth intercostal space, midaxillary line
B. Second intercostal space, midclavicular line
C. Below the seventh rib, anterior axillary line
D. Fifth intercostal space, anterior axillary line

Answer 38

B. Second intercostal space, midclavicular line

Rationale: The appropriate location for needle decompression in a tension pneumothorax is the second intercostal space, midclavicular line, on the affected side. This allows for effective release of pressure in the pleural space.

Question 39

A nurse is monitoring a patient after successful needle decompression for tension pneumothorax. Which of the following findings would indicate that the patient is stabilizing?

A. Decreased neck vein distention
B. Tracheal deviation to the affected side
C. Increased breath sounds on the affected side
D. Decreased tachycardia and improved oxygenation

Answer 39

D. Decreased tachycardia and improved oxygenation

Rationale: After needle decompression, the reduction in intrapleural pressure should improve the patient’s oxygenation and decrease tachycardia, indicating that cardiovascular and respiratory function is stabilizing.

Question 40

A patient presents with a traumatic hemothorax following a motor vehicle accident. Which of the following is the priority intervention?

A. Administer pain medication
B. Prepare for chest tube insertion
C. Start intravenous fluids for hydration
D. Monitor for signs of infection

Answer 40

B. Prepare for chest tube insertion

Rationale: The priority intervention for a traumatic hemothorax is the insertion of a chest tube to evacuate the blood from the pleural space and prevent complications such as respiratory distress or hypovolemic shock.

Question 41

A patient with hemothorax is receiving autotransfusion of blood drained from the chest tube. What is the nurse’s primary concern during this procedure?

A. Risk of infection from the blood transfusion
B. Proper setup of the autotransfusion equipment
C. Potential for hemolysis of the transfused blood
D. Risk of fluid overload from reinfusion

Answer 41

B. Proper setup of the autotransfusion equipment

Rationale: The nurse’s primary concern is ensuring that the autotransfusion equipment is properly set up to safely reinfuse blood into the patient. Incorrect setup can lead to complications such as contamination or incorrect blood volume being reinfused.

Question 42

A nurse is caring for a patient with hemothorax who has a chest tube in place. Which of the following findings indicates that the patient may be experiencing a complication?

A. Constant bubbling in the chest tube drainage system
B. Decreased drainage of blood from the chest tube
C. Absence of breath sounds on the affected side
D. Increased blood drainage from the chest tube

Answer 42

D. Increased blood drainage from the chest tube

Rationale: Increased blood drainage from the chest tube may indicate ongoing bleeding or re-accumulation of blood in the pleural space, which could lead to hemodynamic instability and requires immediate evaluation.

Question 43

A patient with hemothorax is being monitored after chest tube insertion. Which of the following findings would be most concerning and require immediate intervention?

A. Blood-tinged drainage in the chest tube
B. A drop in hemoglobin and hematocrit levels
C. Mild pain at the chest tube insertion site
D. A decrease in the amount of drainage from the chest tube

Answer 43

B. A drop in hemoglobin and hematocrit levels

Rationale: A significant drop in hemoglobin and hematocrit levels suggests ongoing internal bleeding or insufficient evacuation of blood from the pleural space, which may require further intervention such as surgical evaluation.

Question 44

A patient with a suspected pneumothorax is being assessed. Which of the following findings is most indicative of a pneumothorax?

A. Subcutaneous emphysema
B. Tracheal deviation
C. Absence of breath sounds over the affected area
D. Hyperresonance on percussion

Answer 44

C. Absence of breath sounds over the affected area

Rationale: Breath sounds are absent over the affected area in a pneumothorax due to the presence of air in the pleural space preventing lung expansion.

Question 45

Which of the following would be a likely initial clinical manifestation of a small pneumothorax?

A. Severe chest pain
B. Mild tachycardia and dyspnea
C. Cyanosis
D. Hypotension

Answer 45

B. Mild tachycardia and dyspnea

Rationale: A small pneumothorax may present with mild tachycardia and dyspnea as the initial symptoms.

Question 46

What is the primary cause of a lung collapse in a pneumothorax?

A. Air entering the pleural cavity
B. Infection
C. Accumulation of fluid in the pleural space
D. Increased thoracic pressure from a cough

Answer 46

A. Air entering the pleural cavity

Rationale: A pneumothorax is caused by air entering the pleural cavity, which disrupts the negative pressure needed to keep the lungs inflated, leading to lung collapse.

Question 47

A patient presents with a penetrating chest wound described as a “sucking chest wound.” What is the immediate concern for this patient?

A. Risk of infection
B. Air entering the pleural space during inspiration
C. Fluid accumulation in the pleural space
D. Hypoxia due to decreased alveolar ventilation

Answer 47

B. Air entering the pleural space during inspiration

Rationale: A “sucking chest wound” allows air to enter the pleural space during inspiration, which can cause a pneumothorax and subsequent lung collapse.

Question 48

What diagnostic test is commonly used to confirm the presence of a pneumothorax?

A. MRI
B. CT Scan
C. Chest X-ray
D. Ultrasound

Answer 48

C. Chest X-ray

Rationale: A chest X-ray is commonly used to confirm the presence of a pneumothorax by showing air or fluid in the pleural space and reduced lung volume.

Question 49

A patient with a larger pneumothorax presents with respiratory distress. Which of the following signs would you expect to find upon assessment?

A. Decreased respiratory rate
B. Normal oxygen saturation
C. Eupnea
D. Shallow, rapid respirations

Answer 49

D. Shallow, rapid respirations

Rationale: A larger pneumothorax can cause significant respiratory distress, which often manifests as shallow, rapid respirations.

Question 50

A patient with a pneumothorax is being treated in the emergency department. The healthcare provider has instructed the nurse to apply a three-sided occlusive dressing to the chest wound. What is the purpose of this dressing?

A. To prevent further bleeding from the chest wound

B. To allow air to enter the pleural space during expiration

C. To prevent air from entering the pleural space during inspiration

D. To provide a sterile barrier over the open wound

Answer 50

C. To prevent air from entering the pleural space during inspiration

Rationale: A three-sided occlusive dressing allows air to escape from the wound during expiration but prevents air from entering the pleural space during inspiration, which is important in preventing the pneumothorax from worsening.

Question 51

A patient with a pneumothorax presents with mild dyspnea and stable vital signs. The healthcare provider decides to monitor the patient and not initiate any invasive treatment. Which of the following factors most likely influenced this decision?

A. The size of the pneumothorax is minimal.
B. The patient has a history of COPD.
C. The patient is experiencing severe chest pain.
D. The patient has poor renal function.

Answer 51

A. The size of the pneumothorax is minimal.

Rationale: A minimal pneumothorax with stable vital signs and mild symptoms may resolve on its own without the need for invasive treatment. The decision to monitor is based on the size of the pneumothorax and the patient’s hemodynamic stability.

Question 52

A pre-hospital care provider encounters a patient with a penetrating chest wound. What is the most appropriate action to take before transport to the hospital?

A. Remove the impaled object if it is causing respiratory distress.

B. Apply a non-occlusive dressing to the wound.

C. Secure the chest wound with a sterile bandage and no dressing.

D. Apply an occlusive dressing secured on three sides to the wound.

Answer 52

D. Apply an occlusive dressing secured on three sides to the wound.

Rationale: The occlusive dressing prevents air from entering the pleural space during inspiration, while allowing air to escape during expiration. This helps manage an open chest wound until the patient can be transported to a medical facility for further care.

Question 53

A patient with a pneumothorax is stable and is not experiencing significant symptoms. Which of the following actions should the nurse prioritize?

A. Prepare the patient for chest tube insertion.
B. Administer oxygen to the patient to improve oxygenation.
C. Reassure the patient that no immediate invasive intervention is required.
D. Initiate continuous cardiac monitoring.

Answer 53

C. Reassure the patient that no immediate invasive intervention is required.

Rationale: If the patient is stable and the pneumothorax is minimal, the nurse should reassure the patient that invasive interventions may not be necessary and that the condition may resolve on its own with monitoring.

Question 54

A patient with an open pneumothorax has a large, impaled object in the chest wound. The pre-hospital care provider stabilizes the object with a bulky dressing. What is the rationale for this intervention?

A. To prevent further damage to the lung tissue.
B. To reduce the risk of infection at the wound site.
C. To allow the wound to heal before transport.
D. To prevent the object from moving and causing further injury.

Answer 54

D. To prevent the object from moving and causing further injury.

Rationale: Stabilizing the impaled object with a bulky dressing helps prevent it from shifting, which could cause further damage to the lung or other organs. The object should not be removed in the pre-hospital setting.

Question 55

A nurse is providing education to a patient with a spontaneous pneumothorax. Which statement by the nurse is appropriate regarding the possible resolution of the condition?

A. “The pneumothorax will definitely require chest tube insertion.”

B. “Your condition may resolve on its own without treatment.”

C. “You will need surgery to repair the lung immediately.”

D. “You must remain on a ventilator for at least 24 hours.”

Answer 55

B. “Your condition may resolve on its own without treatment.”

Rationale: In cases of spontaneous pneumothorax, if the patient is stable and the pneumothorax is minimal, it may resolve on its own without the need for invasive treatment. Conservative management and observation are often sufficient.

Question 56

Which early manifestations should the nurse expect in a client with viral myocarditis?

A. Crackles and JVD
B. Fever, fatigue, and myalgias
C. Peripheral edema and syncope
D. Angina and pleuritic chest pain

Answer 56

B. Fever, fatigue, and myalgias

Rationale: Early symptoms of viral myocarditis often mimic those of a viral illness and include fever, fatigue, malaise, and myalgias.

Question 57

The nurse auscultates an S3 heart sound in a client with myocarditis. This finding indicates:

A. Progression to heart failure
B. Early infection
C. Resolution of myocarditis
D. Normal cardiac function

Answer 57

A. Progression to heart failure

Rationale: An S3 heart sound is a late sign of myocarditis and is associated with the development of heart failure due to impaired ventricular function.

Question 58

Which symptom reported by the client suggests a late-stage manifestation of myocarditis?

A. Nausea and vomiting
B. Pleuritic chest pain
C. Syncope
D. Pharyngitis

Answer 58

C. Syncope

Rationale: Syncope is a late manifestation of myocarditis, often related to the development of heart failure or arrhythmias.

Question 59

A nurse is assessing a client with myocarditis. Which finding is most concerning and requires immediate intervention?

A. Fatigue and dyspnea
B. Pleuritic chest pain
C. Lymphadenopathy
D. Peripheral edema and crackles

Answer 59

D. Peripheral edema and crackles

Question 60

The nurse understands that early cardiac signs of myocarditis typically appear:

A. 1 to 3 days after infection
B. 7 to 10 days after viral infection
C. 2 weeks after infection
D. At the time of heart failure development

Answer 60

B. 7 to 10 days after viral infection

Rationale: Early cardiac manifestations, such as chest pain or arrhythmias, usually develop 7 to 10 days after the onset of a viral infection.

Question 61

Which of the following findings is most consistent with pericardial effusion in a client with myocarditis?

A. Increased urine output
B. Bounding pulses
C. Muffled heart sounds
D. Narrow pulse pressure

Answer 61

C. Muffled heart sounds

Rationale: Muffled heart sounds are a common sign of pericardial effusion, which may occur with pericarditis in myocarditis.

Question 62

Which ECG finding is most commonly associated with myocarditis?

A. Diffuse ST-segment changes
B. ST-segment elevation in specific leads
C. Prolonged QT interval
D. Normal sinus rhythm

Answer 62

A. Diffuse ST-segment changes

Rationale: Nonspecific ECG changes in myocarditis often reflect pericardial involvement, such as diffuse ST-segment changes.

Question 63

Which laboratory finding is most indicative of inflammation in myocarditis?

A. Elevated cardiac biomarkers
B. Increased erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels
C. Low white blood cell count
D. Normal viral titers

Answer 63

B. Increased erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels

Rationale: Elevated ESR and CRP indicate systemic inflammation, which is commonly seen in myocarditis.

Question 64

What is the most definitive diagnostic test for myocarditis?

A. Echocardiogram
B. MRI
C. ECG
D. Endomyocardial biopsy

Answer 64

D. Endomyocardial biopsy

Rationale: Endomyocardial biopsy provides histologic confirmation of myocarditis, particularly during the first 6 weeks of acute illness.

Question 65

A nurse caring for a client with myocarditis notes an EF of 30%. Which intervention is most appropriate?

A. Administer anticoagulants
B. Increase IV fluid rate
C. Discontinue ACE inhibitors
D. Promote early ambulation

Answer 65

A. Administer anticoagulants

Rationale: A low ejection fraction increases the risk of clot formation from blood stasis, making anticoagulation necessary.

Question 66

Why must digoxin be used with caution in myocarditis?

A. It causes significant hypotension.
B. Patients are more sensitive to its adverse effects and potential toxicity.
C. It increases the risk of leukocytosis.
D. It reduces cardiac output in these patients.

Answer 66

B. Patients are more sensitive to its adverse effects and potential toxicity.

Question 67

A client with myocarditis is receiving milrinone. The nurse understands that this medication’s primary purpose is to:

A. Increase systemic vascular resistance.
B. Decrease afterload and improve cardiac output.
C. Increase heart rate.
D. Reduce inflammation.

Answer 67

B. Decrease afterload and improve cardiac output.

Rationale: Milrinone is used to reduce afterload by decreasing systemic vascular resistance, thereby improving cardiac output.

Question 68

Which supportive measure is most appropriate for a client with severe heart failure secondary to myocarditis?

A. Intraaortic balloon pump therapy
B. Long-term corticosteroid use
C. Encouraging moderate physical activity
D. Increasing sodium intake

Answer 68

A. Intraaortic balloon pump therapy

Rationale: Intraaortic balloon pump therapy may be required in severe heart failure to assist with cardiac output.

Question 69

What is the primary goal of using ACE inhibitors in myocarditis?

A. Increase heart rate
B. Reduce myocardial workload and treat heart failure
C. Increase sodium and fluid retention
D. Promote clot formation

Answer 69

B. Reduce myocardial workload and treat heart failure

Rationale: ACE inhibitors reduce myocardial workload and improve cardiac output by lowering blood pressure and decreasing afterload.

Question 70

Which client with myocarditis is most likely to benefit from immunosuppressive therapy?

A. A client with bacterial myocarditis

B. A client with mild viral myocarditis

C. A client with normal cardiac function

D. A client with autoimmune myocarditis

Answer 70

D. A client with autoimmune myocarditis

Rationale: Immunosuppressive agents are used to reduce heart inflammation and damage in cases of myocarditis with an autoimmune basis.

Question 71

What is the primary benefit of diuretics in the treatment of myocarditis?

A. Increase afterload
B. Decrease myocardial inflammation
C. Reduce fluid volume and preload
D. Lower heart rate

Answer 71

C. Reduce fluid volume and preload

Rationale: Diuretics help manage heart failure symptoms by reducing fluid volume and preload, alleviating stress on the heart.

Question 72

The nurse is reviewing medications for a client with myocarditis. Which drug combination requires clarification with the provider?

A. Digoxin and diuretics
B. ACE inhibitors and β-blockers
C. Anticoagulants and immunosuppressive agents
D. Digoxin and nitroprusside

Answer 72

D. Digoxin and nitroprusside

Rationale: Caution is required with digoxin due to its potential toxicity. Using it alongside vasodilators like nitroprusside may complicate hemodynamic stability.

Question 73

What is the primary goal of nursing interventions for a patient with myocarditis?

A. Prevent infection and reduce fever

B. Improve cardiac output and manage heart failure symptoms

C. Enhance physical activity and endurance

D. Promote weight gain and nutritional intake

Answer 73

B. Improve cardiac output and manage heart failure symptoms

Rationale: Nursing interventions focus on improving cardiac output and addressing symptoms of heart failure to reduce cardiac workload.

Question 74

Which nursing action best helps to decrease the cardiac workload in a patient with myocarditis?

A. Placing the patient in a semi-Fowler’s position
B. Encouraging frequent ambulation
C. Providing a high-sodium diet
D. Increasing IV fluid intake

Answer 74

A. Placing the patient in a semi-Fowler’s position

Rationale: The semi-Fowler’s position reduces venous return and pulmonary congestion, decreasing cardiac workload.

Question 75

A patient with myocarditis is receiving immunosuppressive therapy. Which nursing intervention is the highest priority?

A. Assessing for signs of infection
B. Monitoring for cardiac dysrhythmias
C. Evaluating therapeutic drug levels
D. Encouraging ambulation to prevent DVT

Answer 75

A. Assessing for signs of infection

Rationale: Immunosuppressive therapy increases infection risk, making infection prevention and monitoring a top priority.

Question 76

A patient with myocarditis is prescribed nitroprusside. What is the nurse’s priority assessment?

A. Monitoring potassium levels
B. Checking for hypotension
C. Assessing for muscle weakness
D. Evaluating fluid intake and output

Answer 76

B. Checking for hypotension

Rationale: Nitroprusside is a vasodilator that reduces afterload but may cause significant hypotension, requiring close monitoring.

Question 77

Which patient statement indicates a need for further education about myocarditis recovery?

A. “I will get plenty of rest and avoid overexertion.”
B. “I need to stay on my medications to manage my symptoms.”
C. “Once I feel better, I can return to full activity immediately.”
D. “I will monitor for signs of infection and notify my provider.”

Answer 77

C. “Once I feel better, I can return to full activity immediately.”

Rationale: Patients recovering from myocarditis should gradually resume activity and avoid sudden increases in exertion to prevent cardiac stress.

Question 78

A nurse is caring for a client diagnosed with viral myocarditis. Which causative agent is most commonly associated with this condition?

A. Streptococcus pneumonia
B. Coxsackie B virus
C. Candida albicans
D. Epstein-Barr virus

Answer 78

B. Coxsackie B virus

Rationale: Coxsackie A and B viruses are the most common causative agents of viral myocarditis. Bacteria, fungi, and other viruses may cause myocarditis but are less common.

Question 79

The nurse understands that which of the following patients is at highest risk for developing myocarditis?

A. A patient with a history of autoimmune disease
B. A patient with controlled hypertension
C. A patient recovering from a hip replacement
D. A patient with a history of peptic ulcer disease

Answer 79

A. A patient with a history of autoimmune disease

Rationale: Autoimmune disorders, such as polymyositis, have been linked with the development of myocarditis due to the autoimmune response targeting the myocardium.

Question 80

Which intervention is most appropriate for managing a patient with myocarditis?

A. Administering antibiotics for bacterial causes
B. Encouraging high-intensity exercise to maintain cardiac output
C. Providing supportive care to reduce myocardial workload
D. Administering anticoagulants to prevent clot formation

Answer 80

C. Providing supportive care to reduce myocardial workload

Rationale: Treatment for myocarditis focuses on supportive care, such as reducing myocardial workload, improving cardiac function, and managing complications like heart failure.

Question 81

A client with myocarditis asks why they are experiencing heart dysfunction. The nurse explains that this is due to:

A. Fluid overload from heart failure
B. Direct cellular invasion and immune-mediated destruction
C. Decreased oxygen supply to the coronary arteries
D. Scarring and calcification of the myocardium

Answer 81

B. Direct cellular invasion and immune-mediated destruction

Rationale: Myocarditis involves cellular damage caused by infectious agents and the immune system, leading to myocardial dysfunction.

Question 82

What complication is most likely to develop in a client with myocarditis?

A. Cardiomyopathy
B. Deep vein thrombosis
C. Pulmonary embolism
D. Chronic obstructive pulmonary disease

Answer 82

A. Cardiomyopathy

Rationale: Myocarditis can lead to cardiomyopathy due to the inflammatory process causing structural and functional abnormalities in the heart muscle.

Question 83

A nurse is assessing a patient with suspected myocarditis. Which symptom is most commonly associated with this condition?

A. Peripheral edema
B. Pleuritic chest pain
C. Bradycardia
D. Fatigue and dyspnea

Answer 83

D. Fatigue and dyspnea

Rationale: Fatigue and dyspnea are common symptoms of myocarditis, often resulting from the heart’s reduced ability to pump effectively. While pleuritic chest pain may occur, it is less frequent. Peripheral edema and bradycardia are not hallmark symptoms of myocarditis.

Question 84

What is the primary treatment goal for a patient diagnosed with myocarditis?

A. Relieve chest pain
B. Prevent progression to heart failure
C. Treat bacterial infection
D. Increase heart rate

Answer 84

B. Prevent progression to heart failure

Rationale: The primary treatment goal for myocarditis is to prevent heart failure by supporting cardiac function and reducing myocardial inflammation.

Question 85

A patient with myocarditis is prescribed an ACE inhibitor. What is the purpose of this medication in treating myocarditis?

A. To reduce myocardial inflammation
B. To improve cardiac output by decreasing afterload
C. To treat the underlying infection
D. To prevent arrhythmias

Answer 85

B. To improve cardiac output by decreasing afterload

Rationale: ACE inhibitors decrease afterload, improving cardiac output and reducing stress on the heart, which is crucial in managing myocarditis-related heart dysfunction.

Question 86

What is the most common cause of myocarditis worldwide?

A. Bacterial infections
B. Fungal infections
C. Autoimmune diseases
D. Viral infections

Answer 86

D. Viral infections

Rationale: Viral infections, particularly Coxsackievirus B, are the most common cause of myocarditis worldwide.

Question 87

A patient with myocarditis reports worsening shortness of breath and orthopnea. What is the nurse’s priority intervention?

A. Administer a diuretic as prescribed
B. Encourage bedrest to decrease cardiac workload
C. Notify the healthcare provider immediately
D. Obtain a 12-lead ECG

Answer 87

C. Notify the healthcare provider immediately

Rationale: Worsening symptoms such as shortness of breath and orthopnea may indicate heart failure or a life-threatening complication. Immediate provider notification is critical.

Question 88

Which medication is contraindicated in a patient with myocarditis due to the risk of worsening myocardial damage?

A. NSAIDs
B. Beta-blockers
C. Diuretics
D. Corticosteroids

Answer 88

A. NSAIDs

Rationale: NSAIDs are contraindicated in myocarditis as they may increase myocardial damage and interfere with healing by promoting inflammation.

Question 89

A nurse is assessing a patient with suspected acute pericarditis. Which clinical manifestation should the nurse expect to find?

A. Pericardial friction rub
B. Crackles in the lungs
C. Pulsus paradoxus
D. Systolic murmur

Answer 89

A. Pericardial friction rub

Rationale: A pericardial friction rub is a hallmark sign of pericarditis, caused by the inflamed pericardial layers rubbing against each other. Crackles in the lungs are associated with pulmonary conditions, pulsus paradoxus is more common in cardiac tamponade, and a systolic murmur is associated with valve disorders.

Question 90

A patient with acute pericarditis reports sharp chest pain that worsens when lying flat. What intervention should the nurse recommend to alleviate this symptom?

A. Administer a beta-blocker
B. Encourage the patient to sit upright and lean forward
C. Provide a warm compress to the chest
D. Restrict oral fluid intake

Answer 90

B. Encourage the patient to sit upright and lean forward

Rationale: Sitting upright and leaning forward reduces pressure on the pericardium, decreasing pain. Beta-blockers are not indicated for symptom relief in pericarditis. Warm compresses and fluid restrictions are unrelated to managing the pain associated with pericarditis.

Question 91

Which diagnostic test result is most indicative of acute pericarditis?

A. ST-segment elevation in all ECG leads
B. Low ejection fraction on echocardiogram
C. Elevated troponin levels
D. Decreased white blood cell count

Answer 91

A. ST-segment elevation in all ECG leads

Rationale: Diffuse ST-segment elevation is a characteristic finding in acute pericarditis. Low ejection fraction is not typically associated with pericarditis. Elevated troponin levels suggest myocardial injury, and a decreased WBC count is not associated with inflammation.

Question 92

A nurse is preparing to discharge a patient diagnosed with acute pericarditis. Which statement by the patient indicates a need for further teaching?

A. “I should avoid strenuous activity until cleared by my doctor.”

B. “I will take my NSAIDs as prescribed to reduce inflammation.”

C. “If I have trouble breathing or feel faint, I should rest and wait for the symptoms to resolve.”

D. “I need to follow up with my healthcare provider regularly.”

Answer 92

C. “If I have trouble breathing or feel faint, I should rest and wait for the symptoms to resolve.”

Rationale: Trouble breathing or feeling faint may indicate complications such as cardiac tamponade, which requires immediate medical attention. This statement reflects a misunderstanding of the seriousness of these symptoms. The other statements demonstrate accurate understanding.

Question 93

Which statement best describes the pathophysiology of acute pericarditis?

A. Rapid bacterial invasion leads to sepsis and necrosis of pericardial tissue.

B. Inflammation of the pericardial sac results in neutrophil influx and fibrin deposition.

C. Chronic immune activation causes myocardial fibrosis.

D. Coronary artery occlusion leads to ischemic pericardial damage.

Answer 93

B. Inflammation of the pericardial sac results in neutrophil influx and fibrin deposition.

Rationale: Acute pericarditis is characterized by an inflammatory process in the pericardial sac, resulting in neutrophil infiltration, increased vascularity, and fibrin deposition. This response may lead to pericardial effusion.

Question 94

A nurse is assessing a patient with suspected acute pericarditis. Which of the following symptoms would most likely confirm the diagnosis?

A. Progressive, sharp chest pain that worsens with lying flat

B. Dull chest pain radiating to the jaw and associated with exertion

C. Chest pain that improves with nitroglycerin administration

D. Sudden, crushing chest pain that resolves with rest

Answer 94

A. Progressive, sharp chest pain that worsens with lying flat

Rationale: Acute pericarditis typically presents with sharp, pleuritic chest pain that worsens with lying flat and improves when sitting up and leaning forward. This pain may radiate to the neck, arms, or shoulder but is distinct from angina or myocardial infarction.

Question 95

The nurse auscultates a high-pitched, scratching sound at the lower left sternal border of a patient suspected of having acute pericarditis. Which action should the nurse take to confirm that this is a pericardial friction rub?

A. Ask the patient to hold their breath and listen for the sound.

B. Reassess the sound while the patient is lying flat.

C. Have the patient cough to see if the sound resolves.

D. Observe for changes in the sound during inspiration and expiration.

Answer 95

A. Ask the patient to hold their breath and listen for the sound.

Rationale: A pericardial friction rub persists when the patient holds their breath, distinguishing it from a pleural friction rub, which disappears when the patient stops breathing.

Question 96

A patient reports chest pain that radiates to the trapezius muscle and worsens with deep breathing. Which condition does the nurse suspect?

A. Stable angina
B. Acute pericarditis
C. Pulmonary embolism
D. Gastroesophageal reflux disease (GERD)

Answer 96

B. Acute pericarditis

Rationale: Chest pain radiating to the trapezius muscle (shoulder and upper back) is a distinguishing feature of acute pericarditis. This pain is often worsened by deep inspiration and lying flat.

Question 97

A patient with acute pericarditis is experiencing dyspnea. What is the most likely cause of this symptom?

A. Decreased cardiac output from pericardial effusion

B. Compression of the airway by the inflamed pericardium

C. Pulmonary congestion due to left-sided heart failure

D. Rapid, shallow breathing to avoid chest pain

Answer 97

D. Rapid, shallow breathing to avoid chest pain

Rationale: Patients with acute pericarditis often breathe in rapid, shallow breaths to minimize movement of the chest wall and reduce pain caused by pericardial inflammation.

Question 98

The nurse is assessing a patient with chest pain caused by acute pericarditis. Which patient position will most likely relieve the pain?

A. Lying on the left side
B. Supine with knees elevated
C. Sitting up and leaning forward
D. Standing with arms crossed

Answer 98

C. Sitting up and leaning forward

Rationale: Sitting up and leaning forward reduces pressure on the pericardium and alleviates chest pain caused by acute pericarditis. Pain typically worsens when lying flat.

Question 99

A patient with acute pericarditis reports progressive, severe chest pain. Which characteristic best differentiates this pain from angina?

A. Pain radiating to the trapezius muscle

B. Pain that improves with rest

C. Pain described as dull and aching

D. Pain that worsens with physical exertion

Answer 99

A. Pain radiating to the trapezius muscle

Rationale: Pain radiating to the trapezius muscle (shoulder or upper back) is specific to pericarditis and helps differentiate it from angina. Angina typically presents with dull, aching pain that resolves with rest.

Question 100

The nurse is auscultating a patient with acute pericarditis. The pericardial friction rub is most likely to be heard during which phase of the cardiac cycle?

A. Systole only
B. Diastole only
C. Early systole
D. Both systole and diastole

Answer 100

D. Both systole and diastole

Rationale: A pericardial friction rub is typically heard during both systole and diastole due to friction between the inflamed pericardial layers.

Question 101

Which diagnostic imaging study is most useful in identifying pericardial effusion or cardiac tamponade?

A. Echocardiogram
B. Chest x-ray
C. CT scan
D. MRI

Answer 101

A. Echocardiogram

Rationale: An echocardiogram is the primary diagnostic tool to detect pericardial effusion or cardiac tamponade, as it provides a clear view of the pericardial space and heart function.

Question 102

Which laboratory finding is commonly associated with acute pericarditis?

A. Decreased CRP
B. Increased ESR
C. Decreased leukocyte count
D. Normal troponin levels

Answer 102

B. Increased ESR

Rationale: Elevated CRP and ESR are common inflammatory markers found in acute pericarditis. Leukocytosis may also be present.

Question 103

A chest x-ray of a patient with acute pericarditis is most likely to reveal:

A. Cardiomegaly in all cases

B. Diffuse calcifications of the pericardium

C. Enlarged pulmonary vessels

D. A large pericardial effusion as cardiomegaly

Answer 103

D. A large pericardial effusion as cardiomegaly

Rationale: In acute pericarditis, a chest x-ray is typically normal unless a large pericardial effusion is present, which can appear as cardiomegaly.

Question 104

A CT scan or MRI is preferred over an echocardiogram in acute pericarditis for which purpose?

A. Visualizing localized myocardial ischemia
B. Diagnosing pericardial effusion
C. Visualizing the pericardium and pericardial space
D. Diagnosing coronary artery blockages

Answer 104

C. Visualizing the pericardium and pericardial space

Rationale: CT scans and MRIs provide detailed images of the pericardium and pericardial space, making them useful for diagnosing structural abnormalities.

Question 105

Which medication is most appropriate for a patient with acute pericarditis due to systemic lupus erythematosus?

A. NSAIDs
B. Colchicine
C. Antibiotics
D. Corticosteroids

Answer 105

D. Corticosteroids

Rationale: Corticosteroids are indicated for patients with pericarditis caused by systemic lupus erythematosus or other autoimmune conditions when NSAIDs are ineffective.

Question 106

What is the primary purpose of pericardiocentesis in acute cardiac tamponade?

A. Prevent recurrent effusion
B. Administer medication directly to the pericardial space
C. Remove fluid to relieve heart pressure
D. Correct dysrhythmias

Answer 106

C. Remove fluid to relieve heart pressure

Rationale: Pericardiocentesis removes excess fluid from the pericardial sac to relieve pressure on the heart, improving cardiac output and hemodynamics.

Question 107

Colchicine is most useful in managing:

A. Recurrent pericarditis or pericarditis lasting more than 10 days
B. Bacterial pericarditis
C. Acute pericarditis with ST elevation
D. Pericarditis caused by trauma

Answer 107

A. Recurrent pericarditis or pericarditis lasting more than 10 days

Rationale: Colchicine is an anti-inflammatory medication beneficial in managing recurrent or persistent pericarditis due to its ability to reduce inflammation.

Question 108

A patient with acute pericarditis reports severe, sharp chest pain that worsens when lying flat. Which intervention should the nurse implement first?

A. Administer prescribed anti-inflammatory medication.
B. Assist the patient into a sitting position, leaning forward.
C. Provide a proton pump inhibitor to prevent GI discomfort.
D. Explain the cause of the chest pain to the patient.

Answer 108

B. Assist the patient into a sitting position, leaning forward.

Rationale: Sitting up and leaning forward can help relieve chest pain associated with acute pericarditis. This intervention provides immediate comfort before other measures are implemented.

Question 109

Which nursing intervention is the priority for a patient at risk for cardiac tamponade?

A. Position the patient flat in bed to monitor for dyspnea.

B. Administer anti-inflammatory medications to reduce inflammation.

C. Monitor for muffled heart sounds, neck vein distention, and pulsus paradoxes.

D. Prepare the patient for a chest x-ray to confirm the diagnosis.

Answer 109

C. Monitor for muffled heart sounds, neck vein distention, and pulsus paradoxes.

Rationale: These are key signs of cardiac tamponade, a life-threatening complication. Prompt recognition allows timely intervention.

Question 110

When managing a patient with acute pericarditis, the nurse should place the patient in which position to provide the greatest comfort?

A. Supine with the head of the bed flat
B. Semi-Fowler’s position with knees flexed
C. Left side-lying with legs elevated
D. Sitting upright with the bed at 45 degrees

Answer 110

D. Sitting upright with the bed at 45 degrees

Rationale: This position helps relieve the sharp chest pain by reducing pressure on the pericardium.

Question 111

A patient with acute pericarditis is prescribed a proton pump inhibitor (PPI). What is the primary reason for this prescription?

A. To prevent GI discomfort associated with NSAID use

B. To reduce inflammation in the pericardium

C. To treat esophageal reflux caused by lying flat

D. To manage anxiety related to chest pain

Answer 111

A. To prevent GI discomfort associated with NSAID use

Rationale: PPIs reduce stomach acid, preventing GI irritation and potential ulcers caused by NSAIDs.

Question 112

The nurse is assessing a patient with acute pericarditis and suspects cardiac tamponade. Which clinical finding supports this suspicion?

A. Widened pulse pressure
B. Loud, bounding heart sounds
C. Jugular vein distention and muffled heart sounds
D. Chest pain relieved by leaning forward

Answer 112

C. Jugular vein distention and muffled heart sounds

Rationale: Jugular vein distention, muffled heart sounds, and pulsus paradoxus are hallmark signs of cardiac tamponade, requiring immediate intervention.

Question 113

A patient is diagnosed with acute pericarditis. Which statement by the nurse accurately explains this condition?

A. “Pericarditis involves inflammation of the sac surrounding the heart.”
B. “Pericarditis is an infection of the inner lining of the heart valves.”
C. “Pericarditis results from thickening of the heart muscle walls.”
D. “Pericarditis is a genetic condition affecting the heart chambers.”

Answer 113

A. “Pericarditis involves inflammation of the sac surrounding the heart.”

Rationale: Pericarditis is the inflammation of the pericardium, the sac that encases the heart.

Question 114

Which clinical finding is most indicative of acute pericarditis?

A. Crushing chest pain radiating to the jaw

B. Chest pain relieved by sitting up and leaning forward

C. Irregular heart rhythms on ECG

D. Dependent edema and ascites

Answer 114

B. Chest pain relieved by sitting up and leaning forward

Rationale: Acute pericarditis typically presents with pleuritic chest pain that improves with sitting up or leaning forward, differentiating it from myocardial infarction pain.

Question 115

Which medication is most commonly prescribed for managing inflammation in acute pericarditis?

A. Furosemide
B. Prednisone
C. Ibuprofen
D. Amiodarone

Answer 115

C. Ibuprofen

Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are the first-line treatment to reduce inflammation and relieve pain in pericarditis.

Question 116

Which of the following is an expected outcome for a patient recovering from pericarditis?

A. Resolution of pericardial friction rub within 48 hours
B. Ability to resume strenuous exercise immediately
C. Decreased peripheral edema
D. Absence of chest pain at rest

Answer 116

D. Absence of chest pain at rest

Rationale: An expected outcome is the resolution of pain at rest, indicating reduced inflammation and healing.

Question 117

Which diagnostic finding is considered a major criterion for infective endocarditis (IE) according to the Duke Criteria?

a. Mild leukocytosis
b. Positive blood cultures from two separate sites
c. Presence of Janeway’s lesions
d. Increased erythrocyte sedimentation rate (ESR)

Answer 117

b. Positive blood cultures from two separate sites

Rationale: Positive blood cultures for a typical microorganism are a major Duke Criterion for diagnosing IE. The other findings are minor criteria or nonspecific.

Question 118

A patient with suspected infective endocarditis (IE) has received antibiotics for a skin infection in the past 2 weeks. What diagnostic challenge might this pose?

a. Negative blood cultures despite active infection
b. False-positive echocardiographic findings
c. Decreased C-reactive protein (CRP) levels
d. Absence of leukocytosis

Answer 118

a. Negative blood cultures despite active infection

Rationale: Recent antibiotic use can lead to culture-negative IE, as it may suppress bacterial growth in blood cultures.

Question 119

Which minor criterion in the Duke Criteria is most likely to be documented in a patient with a history of IV drug use?

a. Vascular phenomena
b. Immunologic phenomena
c. Predisposing heart condition or IV drug use
d. Echocardiographic findings

Answer 119

c. Predisposing heart condition or IV drug use

Rationale: A history of IV drug use is a recognized minor criterion for IE, as it increases the risk of infection.

Question 120

Why is echocardiography crucial in the diagnosis of infective endocarditis (IE)?

a. It identifies the microorganism causing the infection.
b. It confirms the presence of vegetations on the valves.
c. It rules out culture-negative IE.
d. It detects changes in C-reactive protein levels.

Answer 120

b. It confirms the presence of vegetations on the valves.

Rationale: Echocardiography (especially transesophageal) is essential for visualizing vegetations, which is a key diagnostic feature of IE.

Question 121

Which laboratory finding supports the diagnosis of acute IE?

a. Mild leukocytosis
b. Normal ESR and CRP levels
c. Negative blood cultures
d. Decreased platelet count

Answer 121

a. Mild leukocytosis

Rationale: Mild leukocytosis is a common finding in acute IE due to the systemic inflammatory response.

Question 122

Which combination of criteria confirms a diagnosis of IE according to the Duke Criteria?

a. One major and one minor criterion
b. Two major criteria and one minor criterion
c. Five minor criteria
d. Either b or c

Answer 122

d. Either b or c

Question 123

A 35-year-old IV drug user presents with fever, fatigue, and a new-onset heart murmur. Blood cultures confirm the presence of Staphylococcus aureus. Which of the following is a major Duke criterion for diagnosing infective endocarditis?

A. Positive blood cultures for Staphylococcus aureus
B. Presence of Janeway lesions
C. Fever >38°C (100.4°F)
D. Splinter hemorrhages

Answer 123

A. Positive blood cultures for Staphylococcus aureus

Rationale: Positive blood cultures for typical microorganisms, such as Staphylococcus aureus, are a major Duke criterion. The other options are minor criteria or clinical findings associated with infective endocarditis.

Question 124

A nurse is reviewing the diagnostic criteria for infective endocarditis. Which of the following echocardiographic findings meets a major Duke criterion?

A. Vegetation on a prosthetic valve
B. Pericardial effusion
C. Left ventricular hypertrophy
D. Atrial septal defect

Answer 124

A. Vegetation on a prosthetic valve

Rationale: The presence of vegetation on a valve or prosthetic valve is a major Duke criterion. The other findings are not diagnostic features of infective endocarditis

Question 125

A patient with a history of mitral valve prolapse is diagnosed with infective endocarditis caused by Staphylococcus aureus. Which of the following symptoms is classified as a major Duke criterion?

A. Roth spots
B. Osler nodes
C. Positive echocardiogram showing valvular regurgitation
D. Arthralgia

Answer 125

C. Positive echocardiogram showing valvular regurgitation

Rationale: Evidence of valvular dysfunction, such as regurgitation on echocardiography, is a major criterion. Roth spots and Osler nodes are minor criteria.

Question 126

Which of the following patients is at the highest risk of developing infective endocarditis caused by Staphylococcus aureus?

A. A 25-year-old with rheumatic heart disease
B. A 40-year-old with a prosthetic heart valve
C. A 30-year-old IV drug user
D. A 65-year-old with uncontrolled hypertension

Answer 126

C. A 30-year-old IV drug user

Rationale: IV drug use is a significant risk factor for infective endocarditis caused by Staphylococcus aureus. Prosthetic heart valves increase risk but are less specific for this organism.

Question 127

A patient diagnosed with infective endocarditis has persistent bacteremia after appropriate antibiotic therapy for Staphylococcus aureus. What is the next best action?

A. Continue current antibiotics
B. Add antifungal therapy
C. Initiate corticosteroids
D. Evaluate for valvular abscess

Answer 127

D. Evaluate for valvular abscess

Rationale: Persistent bacteremia despite therapy suggests a complication such as a valvular abscess, which must be evaluated and treated promptly.

Question 128

Which of the following best defines a pulmonary embolism (PE)?

A. An infection of the lung tissue caused by bacteria.
B. An obstruction of a pulmonary artery by a blood clot, fat, or air embolism.
C. The collapse of alveoli due to lack of surfactant.
D. A collection of fluid in the pleural space.

Answer 128

B. An obstruction of a pulmonary artery by a blood clot, fat, or air embolism.

Rationale: A PE occurs when a substance (commonly a blood clot) blocks blood flow in a pulmonary artery, reducing oxygenation and leading to respiratory distress.

Question 129

Which of the following is the most common cause of pulmonary embolism?

A. Air embolism.
B. Fat embolism.
C. Deep vein thrombosis (DVT).
D. Foreign body aspiration.

Answer 129

C. Deep vein thrombosis (DVT).

Rationale: DVT is the most frequent cause of PE. Clots formed in the deep veins of the legs travel through the bloodstream to the pulmonary arteries.

Question 130

Which patient is at the highest risk for developing a pulmonary embolism?

A. A 35-year-old marathon runner.
B. A 50-year-old smoker with a history of hypertension.
C. A 70-year-old patient on prolonged bed rest after hip surgery.
D. A 25-year-old with a history of asthma.

Answer 130

C. A 70-year-old patient on prolonged bed rest after hip surgery.

Rationale: Prolonged immobility, surgery, and advanced age significantly increase the risk of venous stasis and DVT, which can lead to PE.

Question 131

Which of the following is the most common clinical manifestation of a pulmonary embolism?

A. Sudden onset of dyspnea and chest pain.
B. Wheezing.
C. Productive cough with green sputum.
D. Hyperactive bowel sounds.

Answer 131

A. Sudden onset of dyspnea and chest pain.

Rationale: Dyspnea and chest pain are hallmark symptoms of PE due to the sudden obstruction of blood flow in the lungs.

Question 132

A patient presents with tachypnea, tachycardia, and sudden onset of pleuritic chest pain. What should the nurse assess for next?

A. Lung auscultation for crackles.
B. Assessment of peripheral pulses.
C. Signs of lower extremity swelling and redness.
D. Evaluation of bowel sounds.

Answer 132

C. Signs of lower extremity swelling and redness.

Rationale: Assessing for signs of DVT (e.g., swelling, redness) can help identify the source of the embolism.

Question 133

Which diagnostic test is most specific for confirming the presence of a pulmonary embolism?

A. Chest X-ray.
B. D-dimer assay.
C. Pulmonary function tests (PFTs).
D. Spiral computed tomography (CT) scan with contrast.

Answer 133

D. Spiral computed tomography (CT) scan with contrast.

Rationale: A spiral CT scan provides direct visualization of the pulmonary vasculature, making it the gold standard for diagnosing PE.

Question 134

A D-dimer test is ordered for a patient suspected of having a pulmonary embolism. What does an elevated D-dimer indicate?

A. Infection is present.
B. Significant clot breakdown is occurring in the body.
C. Lung tissue is inflamed.
D. There is no clot present.

Answer 134

B. Significant clot breakdown is occurring in the body.

Rationale: An elevated D-dimer indicates fibrin degradation products, suggesting the presence of a thrombotic event, but it is not specific to PE.

Question 135

A patient with PE is prescribed IV heparin. What is the primary goal of this therapy?

A. To dissolve the clot.
B. To prevent the formation of new clots.
C. To improve oxygenation.
D. To lower blood pressure.

Answer 135

B. To prevent the formation of new clots.

Rationale: Heparin prevents further clot formation and stabilizes the existing clot, reducing the risk of additional emboli.

Question 136

Which of the following complications is most life-threatening in a patient with PE?

A. Acute respiratory distress syndrome (ARDS).
B. Chronic obstructive pulmonary disease (COPD).
C. Pulmonary hypertension.
D. Right ventricular failure.

Answer 136

D. Right ventricular failure.

Rationale: A PE increases right heart strain, potentially causing acute right ventricular failure, which can lead to hemodynamic collapse.

Question 137

A patient with PE suddenly becomes hypotensive and cyanotic. What should the nurse suspect?

A. Myocardial infarction.
B. Acute massive pulmonary embolism.
C. Pleural effusion.
D. Pneumothorax.

Answer 137

B. Acute massive pulmonary embolism.

Rationale: Massive PE causes obstruction of pulmonary blood flow, leading to decreased cardiac output and shock.

Question 138

A patient with PE is prescribed warfarin. Which lab value is most important for the nurse to monitor?

A. Platelet count.
B. Partial thromboplastin time (PTT).
C. Prothrombin time (PT) and INR.
D. D-dimer levels.

Answer 138

C. Prothrombin time (PT) and INR.

Rationale: PT/INR monitors warfarin’s therapeutic effect to ensure anticoagulation while minimizing bleeding risk.

Question 139

What is the most common source of a pulmonary embolism (PE)?

A) Fat embolism from fractured long bones
B) Deep vein thrombosis (DVT) from the deep veins of the legs
C) Air embolism from improperly administered IV therapy
D) Amniotic fluid embolism

Answer 139

B) Deep vein thrombosis (DVT) from the deep veins of the legs

Rationale: The majority of pulmonary embolisms originate from deep vein thrombosis (DVT) in the deep veins of the legs. Other sources are less common.

Question 140

Which of the following is a risk factor for pulmonary embolism (PE)? (Select all that apply)

A) History of deep vein thrombosis (DVT)
B) Pregnancy
C) Recent hip surgery
D) Use of oral contraceptives
E) Smoking

Answer 140

all of the choices are correct

Question 141

What is a “saddle embolus”?

A) A large thrombus lodged at the arterial bifurcation
B) A small thrombus located in the pulmonary veins
C) A fat embolism from a fractured long bone
D) An air embolism from improper IV therapy

Answer 141

A) A large thrombus lodged at the arterial bifurcation

Rationale: A saddle embolus refers to a large thrombus that becomes lodged at the bifurcation of a pulmonary artery, potentially obstructing blood flow to both lungs.

Question 142

Which of the following is the most likely consequence of a pulmonary embolism (PE)?

A) Increased blood flow to the alveoli
B) Obstruction of perfusion to the alveoli
C) Decreased cardiac output
D) Elevated blood pressure in the lungs

Answer 142

B) Obstruction of perfusion to the alveoli

Rationale: A pulmonary embolism causes a blockage of pulmonary arteries, obstructing the blood flow to the alveoli and impairing oxygen exchange.

Question 143

A patient with a history of pelvic surgery presents with sudden chest pain and shortness of breath. Which of the following is the priority assessment?

A) Auscultate lung sounds
B) Check for signs of deep vein thrombosis (DVT)
C) Administer pain medication
D) Assess for signs of a stroke

Answer 143

A) Auscultate lung sounds

Rationale: A patient presenting with sudden chest pain and shortness of breath may have a pulmonary embolism. Auscultation of lung sounds is a priority to assess for abnormal lung sounds like crackles or decreased breath sounds.

Question 144

Which of the following describes the pathophysiology of pulmonary embolism (PE)?

A) An embolus travels through the pulmonary arteries and obstructs alveolar perfusion

B) A thrombus forms in the pulmonary veins and blocks gas exchange

C) An embolus travels through the left side of the heart and obstructs systemic circulation

D) Fat cells from fractured long bones enter the lungs and obstruct airflow

Answer 144

A) An embolus travels through the pulmonary arteries and obstructs alveolar perfusion

Rationale: The embolus travels through the venous system to the pulmonary circulation, where it lodges in a pulmonary artery, blocking perfusion to the alveoli.

Question 145

Which of the following is the most appropriate intervention for a patient suspected of having a pulmonary embolism (PE)?

A) Encourage deep breathing exercises
B) Provide high-flow oxygen therapy
C) Start IV fluids at a rapid rate
D) Administer anticoagulant therapy as prescribed

Answer 145

D) Administer anticoagulant therapy as prescribed

Rationale: Anticoagulant therapy is a primary intervention to prevent further clot formation and reduce the risk of complications from a PE.

Question 146

Which of the following is the most commonly used diagnostic test for confirming pulmonary embolism (PE)?

A) Chest x-ray
B) Venous ultrasound
C) Spiral CT scan (CT angiography)
D) D-dimer test

Answer 146

C) Spiral CT scan (CT angiography)

Rationale: The spiral CT scan, or CT angiography, is the most common and accurate diagnostic test for confirming pulmonary embolism.

Question 147

A patient presents with symptoms of pulmonary embolism (PE). Which diagnostic test is typically used if the patient cannot receive contrast media for a spiral CT scan?

A) Ventilation-perfusion (V/Q) scan
B) Chest x-ray
C) Pulmonary angiography
D) Serum troponin test

Answer 147

A) Ventilation-perfusion (V/Q) scan

Rationale: If a patient cannot receive contrast media for a CT scan, a ventilation-perfusion (V/Q) scan is used to diagnose PE by assessing lung ventilation and blood flow.

Question 148

Which of the following is a limitation of using the D-dimer test for diagnosing pulmonary embolism (PE)?

A) It is highly specific for PE.
B) It may be falsely negative in patients with large PE.
C) It is not sensitive enough to detect a small PE.
D) It is not useful in patients with cancer.

Answer 148

C) It is not sensitive enough to detect a small PE.

Rationale: D-dimer is not sensitive enough to detect small PEs, as up to 50% of patients with small PE may have a normal D-dimer result.

Question 149

What does an elevated serum troponin level in a patient with pulmonary embolism (PE) typically indicate?

A) Right ventricular strain or injury
B) Renal insufficiency
C) Myocardial infarction
D) Pulmonary hypertension

Answer 149

A) Right ventricular strain or injury

Rationale: Elevated serum troponin levels in a patient with PE indicate right ventricular strain or injury due to increased pressure from the obstruction in the pulmonary circulation.

Question 150

Which of the following is the primary purpose of using a ventilation-perfusion (V/Q) scan in the diagnosis of pulmonary embolism (PE)?

A) To confirm the presence of an embolus in the pulmonary circulation
B) To assess lung tissue damage
C) To identify pre-existing lung disease
D) To evaluate pulmonary blood flow and ventilation distribution

Answer 150

D) To evaluate pulmonary blood flow and ventilation distribution

Rationale: A V/Q scan evaluates both the blood flow (perfusion) and ventilation in the lungs to help identify areas of mismatch, which may indicate a PE.

Question 151

A patient with a suspected pulmonary embolism (PE) is being assessed. Which of the following findings is most likely to be seen on a chest x-ray?

A) Hemoptysis
B) Atelectasis or pleural effusion
C) Enlargement of the heart
D) Pulmonary consolidation

Answer 151

B) Atelectasis or pleural effusion

Rationale: Chest x-rays may show atelectasis or pleural effusion, but these findings are not diagnostic for PE and may be seen in a variety of other conditions.

Question 152

A patient with a pulmonary embolism (PE) is experiencing pain from pleural irritation. Which medication should be administered to manage this pain?

A) Acetaminophen
B) Anticoagulants
C) Aspirin
D) Opioids

Answer 152

D) Opioids

Rationale: Opioids are used to manage pain associated with pleural irritation or reduced coronary blood flow in patients with PE.

Question 153

A patient with suspected pulmonary embolism (PE) is showing signs of shock. What is the most appropriate action to support circulation immediately?

A) Administer IV fluids and vasopressor agents
B) Administer oxygen therapy
C) Start heparin therapy
D) Provide mechanical ventilation

Answer 153

A) Administer IV fluids and vasopressor agents

Rationale: In the presence of shock, IV fluids and vasopressors are used to support circulation and stabilize the patient’s hemodynamic status.

Question 154

What is the goal of interprofessional care when treating a patient with a pulmonary embolism (PE)?

A) To reduce pain and prevent atelectasis
B) To perform early surgery for thrombus removal
C) To prevent further thrombus growth and recurrence
D) To administer antibiotics for infection prevention

Answer 154

C) To prevent further thrombus growth and recurrence

Rationale: The primary goals in treating PE are to prevent further thrombus growth, recurrence, and complications, while maintaining adequate oxygenation and circulation.

Question 155

A patient with pulmonary embolism (PE) is being assessed for mechanical ventilation. In which of the following situations is mechanical ventilation most likely required?

A) If the patient experiences hyperventilation
B) If the patient’s oxygen levels cannot be maintained with a mask or cannula
C) If the patient exhibits signs of deep vein thrombosis (DVT)
D) If the patient develops a fever

Answer 155

B) If the patient’s oxygen levels cannot be maintained with a mask or cannula

Rationale: Mechanical ventilation is needed when a patient cannot maintain adequate oxygenation despite the use of a mask or cannula.

Question 156

A patient with a suspected pulmonary embolism (PE) is receiving respiratory support. Which of the following interventions should be prioritized to help prevent atelectasis?

A) Administering opioid pain medications
B) Starting anticoagulation therapy
C) Increasing fluid intake
D) Initiating incentive spirometry and deep breathing exercises

Answer 156

D) Initiating incentive spirometry and deep breathing exercises

Rationale: Incentive spirometry, turning, and deep breathing exercises are key interventions to help prevent atelectasis in patients with PE.

Question 157

Which medication is the first-line treatment for a patient with acute pulmonary embolism (PE)?

A) Warfarin (Coumadin)
B) Subcutaneous low-molecular-weight heparin (LMWH)
C) Unfractionated IV heparin
D) Direct thrombin inhibitors

Answer 157

B) Subcutaneous low-molecular-weight heparin (LMWH)

Rationale: LMWH is recommended for initial treatment of acute PE because it is safer and more effective than unfractionated heparin and does not require aPTT monitoring.

Question 158

Which laboratory test is required to monitor the effectiveness of unfractionated IV heparin therapy in a patient with PE?

A) Activated Partial Thromboplastin Time (aPTT)
B) International Normalized Ratio (INR)
C) D-dimer
D) Platelet count

Answer 158

A) Activated Partial Thromboplastin Time (aPTT)

Question 159

Which patient is most likely to benefit from a pulmonary embolectomy?

A) A patient with a recurrent PE despite anticoagulation
B) A patient with a small PE and mild hypoxemia
C) A patient with a massive PE and hemodynamic instability who cannot receive thrombolytic therapy
D) A patient with an elevated D-dimer but no confirmed PE

Answer 159

C) A patient with a massive PE and hemodynamic instability who cannot receive thrombolytic therapy

Rationale: Pulmonary embolectomy is reserved for patients with massive PE and hemodynamic instability who cannot tolerate thrombolytic therapy, as it can rapidly remove emboli and reduce right ventricular afterload.

Question 160

Which intervention is most appropriate for a patient with contraindications to anticoagulation therapy and a high risk for pulmonary embolism?

A) Thrombolytic therapy
B) Inferior vena cava (IVC) filter placement
C) Surgical embolectomy
D) Long-term oxygen therapy

Answer 160

B) Inferior vena cava (IVC) filter placement

Rationale: An IVC filter is the treatment of choice for patients at high risk for PE who cannot tolerate anticoagulation, as it prevents large clots from reaching the lungs.

Question 161

What is the primary goal of ultrasound-guided catheter thrombolysis in treating pulmonary embolism?

A) To mechanically remove emboli from the pulmonary arteries
B) To dissolve clots using localized thrombolytic therapy
C) To prevent clot migration to the lungs
D) To avoid the need for anticoagulation therapy

Answer 161

B) To dissolve clots using localized thrombolytic therapy

Rationale: Ultrasound-guided catheter thrombolysis delivers thrombolytic agents directly to the clot, aiding in clot dissolution and minimizing systemic effects.

Question 162

A nurse is assessing a patient with pulmonary edema caused by left-sided heart failure. Which of the following clinical manifestations is most commonly associated with this condition?

A. Frothy, blood-tinged sputum
B. Decreased respiratory rate and shallow breathing
C. Bradycardia and hypotension
D. Decreased jugular vein distention

Answer 162

A. Frothy, blood-tinged sputum

Rationale: Frothy, blood-tinged sputum is a hallmark sign of pulmonary edema, especially in patients with left-sided heart failure, due to fluid leakage into the alveoli.

Question 163

A nurse is administering diuretics to a patient with pulmonary edema. Which of the following is the primary purpose of this intervention?

A. To increase fluid retention
B. To increase cardiac output
C. To reduce afterload by dilating blood vessels
D. To reduce preload by removing excess fluid

Answer 163

D. To reduce preload by removing excess fluid

Rationale: Diuretics, such as furosemide, reduce preload by promoting fluid excretion, which decreases the volume of blood returning to the heart and reduces pulmonary congestion.

Question 164

A patient with pulmonary edema is receiving IV morphine. What is the primary reason for administering this medication?

A. To increase cardiac output
B. To reduce afterload and alleviate dyspnea
C. To promote diuresis
D. To reduce the risk of infection

Answer 164

B. To reduce afterload and alleviate dyspnea

Rationale: Morphine is used to reduce afterload and alleviate dyspnea in patients with pulmonary edema by causing vasodilation, which lowers systemic vascular resistance and decreases the work of the heart.

Question 165

A patient with pulmonary edema is being treated with IV Dobutamine. What is the primary goal of administering this medication?

A. To reduce preload
B. To improve oxygenation
C. To enhance cardiac output
D. To dilate the airways

Answer 165

C. To enhance cardiac output

Rationale: Dobutamine is a positive inotropic agent used to enhance cardiac output by increasing the contractility of the heart in patients with pulmonary edema and heart failure.

Question 166

A nurse is educating a patient about the risk factors for pulmonary edema. Which of the following conditions should the nurse emphasize as a major cause of this condition?

A. Right-sided heart failure
B. Chronic obstructive pulmonary disease (COPD)
C. Left-sided heart failure
D. Pneumonia

Answer 166

C. Left-sided heart failure

Rationale: Left-sided heart failure is the most common cause of pulmonary edema, as it leads to fluid accumulation in the lungs due to inadequate pumping of the left ventricle.

Question 167

A patient with pulmonary edema has been prescribed non-invasive ventilation (BiPAP). What is the purpose of this intervention?

A. To provide continuous positive pressure during exhalation
B. To prevent aspiration of fluid into the lungs
C. To reduce fluid retention in the body
D. To improve the patient’s ability to sleep

Answer 167

A. To provide continuous positive pressure during exhalation

Rationale: BiPAP provides positive pressure during exhalation, which helps to improve oxygenation and ventilation by preventing the collapse of the alveoli and improving gas exchange in patients with pulmonary edema.

Question 168

A nurse is caring for a patient with pulmonary edema and is monitoring urinary output. Why is this an important parameter to assess?

A. To monitor for signs of dehydration
B. To assess for complications related to mechanical ventilation
C. To track the progression of heart failure
D. To evaluate kidney function related to diuretic therapy

Answer 168

D. To evaluate kidney function related to diuretic therapy

Rationale: Urinary output is monitored to assess the effectiveness of diuretic therapy, which helps remove excess fluid from the body in patients with pulmonary edema.

Question 169

A patient with pulmonary edema has been receiving furosemide (a diuretic). The nurse notes that the patient’s serum potassium level is 3.2 mEq/L. What action should the nurse take?

A. Administer potassium supplements as ordered
B. Withhold the diuretic and notify the healthcare provider
C. Continue monitoring the potassium level, as it is within normal limits
D. Administer a potassium-sparing diuretic instead of furosemide

Answer 169

A. Administer potassium supplements as ordered

Rationale: A potassium level of 3.2 mEq/L is below the normal range, indicating hypokalemia. Potassium supplements are necessary to prevent complications associated with low potassium levels, especially after diuretic therapy.

Question 170

A patient is admitted with pulmonary edema secondary to left-sided heart failure. Which of the following nursing interventions is a priority in managing this patient?

A. Administer a sedative to reduce anxiety
B. Position the patient in a high Fowler’s position
C. Restrict fluid intake to less than 1 liter per day
D. Encourage deep breathing and coughing exercises

Answer 170

B. Position the patient in a high Fowler’s position

Rationale: Positioning the patient in high Fowler’s position improves lung expansion, reduces venous return to the heart, and eases breathing in patients with pulmonary edema

Question 171

A patient develops pulmonary edema after an allergic reaction. Which of the following mechanisms is most likely responsible for the pulmonary edema in this patient?

A. Increased capillary permeability due to histamine release
B. Increased hydrostatic pressure from the heart’s inability to pump
C. Decreased oxygenation in the blood due to airway obstruction
D. Decreased lymphatic drainage from the lungs

Answer 171

A. Increased capillary permeability due to histamine release

Rationale: Anaphylactic reactions release histamines and other mediators that increase the permeability of blood vessels, allowing fluid to leak into the lungs and causing pulmonary edema.

Question 172

A patient with pulmonary edema after a near-drowning incident is receiving treatment. Which of the following factors most likely caused the pulmonary edema in this patient?

A. Increased hydrostatic pressure from right-sided heart failure

B. Hypoxemia leading to constriction of the pulmonary vasculature

C. Fluid overload due to intravenous rehydration therapy

D. Aspiration of water leading to increased lung permeability

Answer 172

D. Aspiration of water leading to increased lung permeability

Rationale: Near-drowning incidents can cause aspiration of water into the lungs, which leads to increased capillary permeability, allowing fluid to leak into the alveoli and cause pulmonary edema.

Question 173

A nurse is educating a patient about potential causes of pulmonary edema. Which of the following conditions should the nurse emphasize as a common cause due to altered capillary permeability?

A. Pneumonia
B. Liver cirrhosis
C. Left-sided heart failure
D. Chronic kidney disease

Answer 173

A. Pneumonia

Rationale: Pneumonia is a common cause of pulmonary edema due to increased capillary permeability resulting from inflammation in the lungs. This leads to fluid leakage into the alveoli, causing pulmonary edema.

Question 174

Which assessment finding requires immediate intervention in a client with pulmonary edema?

a. Oxygen saturation of 92%
b. Respiratory rate of 28 breaths/min
c. Use of accessory muscles to breathe
d. Bilateral 2+ pitting edema in the lower extremities

Answer 174

c. Use of accessory muscles to breathe

Rationale: Use of accessory muscles indicates significant respiratory distress and impaired oxygenation, requiring immediate intervention.

Question 175

What diagnostic study would confirm pulmonary edema in a client with worsening dyspnea?

a. Chest X-ray
b. Arterial blood gas analysis
c. Pulmonary function test
d. Echocardiogram

Answer 175

a. Chest X-ray

Rationale: A chest X-ray reveals fluid accumulation in the lungs, characteristic of pulmonary edema, confirming the diagnosis.

Question 176

The nurse is caring for a client with acute pulmonary edema. Which medication is most important to administer first?

a. Morphine sulfate
b. Nitroglycerin IV
c. Furosemide IV
d. Albuterol nebulizer

Answer 176

c. Furosemide IV

Rationale: Furosemide rapidly reduces fluid overload by promoting diuresis, addressing the primary issue of pulmonary edema.

Question 177

Which client is at the highest risk for developing pulmonary edema?

a. A client with chronic kidney disease and fluid retention
b. A client with mild hypertension on diuretics
c. A client with a history of asthma and recent steroid use
d. A client with hypovolemia after surgery

Answer 177

a. A client with chronic kidney disease and fluid retention

Rationale: Fluid retention increases the risk of pulmonary edema due to volume overload and increased hydrostatic pressure in the pulmonary vasculature.

Question 178

A client with mitral stenosis reports worsening dyspnea and fatigue. What is the most likely underlying cause of these symptoms?

a. Left ventricular hypertrophy
b. Pulmonary congestion from elevated left atrial pressure
c. Coronary artery disease
d. Systemic hypertension

Answer 178

b. Pulmonary congestion from elevated left atrial pressure

Rationale: In mitral stenosis, blood flow obstruction increases left atrial pressure, leading to pulmonary venous congestion and symptoms like dyspnea and fatigue.

Question 179

The nurse is educating a client about mitral stenosis and its diagnostic process. Which statement by the client indicates the need for further teaching?

a. “A transesophageal echocardiogram gives detailed images of my heart valves.”
b. “I may need a chest X-ray to look for an enlarged heart.”
c. “A cardiac catheterization is the best way to diagnose mitral stenosis.”
d. “The echocardiogram will help measure the severity of my valve disease.”

Answer 179

c. “A cardiac catheterization is the best way to diagnose mitral stenosis.”

Rationale: While cardiac catheterization can assess pressures and gradients, the gold standard for diagnosing mitral stenosis is echocardiography, specifically TEE.

Question 180

Which of the following best describes a pleural effusion?

A. A disease of the pleural membrane
B. An abnormal collection of fluid in the pleural space
C. A condition caused by decreased pulmonary capillary pressure
D. A disease primarily affecting the lymphatic system

Answer 180

B. An abnormal collection of fluid in the pleural space

Rationale: A pleural effusion is not a disease but a sign of another condition, characterized by the abnormal accumulation of fluid in the pleural space.

Question 181

A nurse is caring for a patient with a pleural effusion. Which factor is most likely to cause the fluid accumulation in the pleural space?

A. Decreased pulmonary capillary pressure
B. Increased oncotic pressure
C. Decreased capillary membrane permeability
D. Obstruction of lymphatic flow

Answer 181

D. Obstruction of lymphatic flow

Rationale: Fluid accumulation in the pleural space can occur due to obstruction of lymphatic flow, which impairs the drainage of fluid from the pleural space.

Question 182

A pleural effusion occurs when there is an imbalance in which of the following pressures?

A. Hydrostatic pressure and interstitial pressure
B. Oncotic pressure and pulmonary capillary pressure
C. Hydrostatic pressure, oncotic pressure, and capillary membrane permeability
D. Pulmonary capillary pressure and lymphatic flow

Answer 182

C. Hydrostatic pressure, oncotic pressure, and capillary membrane permeability

Rationale: The balance between hydrostatic pressure, oncotic pressure, and capillary membrane permeability governs fluid movement in and out of the pleural space. An imbalance leads to fluid accumulation.

Question 183

A nurse is educating a patient about pleural effusion. The nurse should explain that pleural effusion is often a sign of:

A. A primary lung disease
B. An underlying condition affecting fluid balance
C. A bacterial infection of the lungs
D. A problem with airway obstruction

Answer 183

B. An underlying condition affecting fluid balance

Rationale: Pleural effusion is not a primary lung disease but a sign of an underlying condition, often one that disrupts fluid balance in the pleural space.

Question 184

A nurse is caring for a patient with a transudative pleural effusion. Which of the following characteristics is most likely to be seen in the fluid?

A. High protein content
B. Cell-rich fluid
C. Clear, pale yellow fluid
D. Purulent fluid

Answer 184

C. Clear, pale yellow fluid

Rationale: A transudative pleural effusion typically consists of protein-poor, cell-poor fluid, which is usually clear and pale yellow.

Question 185

Which of the following conditions is most commonly associated with the development of a transudative pleural effusion?

A. Pneumonia
B. Lung cancer
C. Tuberculosis
D. Heart failure

Answer 185

D. Heart failure

Rationale: Transudative pleural effusions often occur in non-inflammatory conditions, such as heart failure, where there is increased hydrostatic pressure that promotes fluid accumulation.

Question 186

A patient has a transudative pleural effusion caused by hypoalbuminemia. Which condition is most likely to be the underlying cause of the effusion?

A. Chronic liver disease
B. Pneumonia
C. Lung abscess
D. Malignant tumor

Answer 186

A. Chronic liver disease

Rationale: Hypoalbuminemia, which causes decreased oncotic pressure, is commonly associated with conditions like chronic liver disease or renal disease, leading to transudative pleural effusion.

Question 187

Which of the following is characteristic of an exudative pleural effusion?

A. Protein-poor fluid
B. Clear, pale yellow fluid
C. Rich in protein
D. Associated with heart failure

Answer 187

C. Rich in protein

Rationale: Exudative pleural effusions are characterized by fluid that is rich in protein and typically occurs due to an inflammatory response, often caused by infections or cancer.

Question 188

Which of the following conditions is a common cause of empyema?

A. Tuberculosis
B. Heart failure
C. Pneumonia
D. Chronic liver disease

Answer 188

C. Pneumonia

Rationale: Empyema, a collection of purulent fluid in the pleural space, is commonly caused by infections such as pneumonia, tuberculosis, lung abscesses, or infected chest wounds.

Question 189

A nurse is educating a patient with a pleural effusion about the difference between transudative and exudative types. Which statement should the nurse include in the teaching?

A. “Transudative effusions are typically associated with infections, while exudative effusions occur due to conditions like heart failure.”

B. “Exudative effusions have high protein content, while transudative effusions have low protein content.”

C. “Transudative effusions occur due to inflammation, while exudative effusions are caused by a reduction in hydrostatic pressure.”

D. “Exudative effusions are generally clear and pale yellow, while transudative effusions are purulent.”

Answer 189

B. “Exudative effusions have high protein content, while transudative effusions have low protein content.”

Question 190

Which clinical manifestation is most commonly associated with a pleural effusion?

a. Bilateral wheezing
b. Decreased breath sounds on the affected side
c. Stridor during inspiration
d. Hyperresonance to percussion over the affected area

Answer 190

b. Decreased breath sounds on the affected side

Rationale: Pleural effusion reduces lung expansion, leading to decreased or absent breath sounds over the affected area.

Question 191

A nurse is assessing a client with a suspected pleural effusion. Which finding is most likely on physical examination?

a. Tracheal deviation toward the affected side
b. Increased tactile fremitus over the affected area
c. High-pitched crackles on the affected side
d. Dullness to percussion over the lower lobes

Answer 191

d. Dullness to percussion over the lower lobes

Rationale: Pleural effusion causes fluid accumulation, leading to dullness on percussion over the area of fluid collection.

Question 192

A client with a large pleural effusion reports shortness of breath. What is the primary cause of this symptom?

a. Collapse of alveoli in the affected lung
b. Bronchospasm and airway narrowing
c. Decreased oxygen-carrying capacity of the blood
d. Reduced chest wall compliance due to pleuritic pain

Answer 192

a. Collapse of alveoli in the affected lung

Rationale: Pleural effusion compresses the lung, reducing alveolar expansion and leading to dyspnea.

Question 193

Which clinical symptom might suggest that a pleural effusion is progressing and requires immediate intervention?

a. Dry, nonproductive cough
b. Low-grade fever and chills
c. Gradual increase in dyspnea and fatigue
d. Sudden onset of severe chest pain and cyanosis

Answer 193

d. Sudden onset of severe chest pain and cyanosis

Rationale: Severe chest pain and cyanosis may indicate tension pneumothorax or other complications of pleural effusion, requiring immediate evaluation.

Question 194

During assessment, the nurse notes asymmetrical chest expansion in a client with pleural effusion. What is the best explanation for this finding?

a. Air trapping in the affected lung
b. Reduced movement of the affected lung due to fluid accumulation
c. Bronchial obstruction on the affected side
d. Overcompensation by the unaffected lung

Answer 194

b. Reduced movement of the affected lung due to fluid accumulation

Rationale: Fluid in the pleural space restricts lung expansion on the affected side, resulting in asymmetrical chest movement.