Exam One - Practice Q's Flashcards
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse
take first?
A. Encourage the client to increase fluid intake.
B. Assess the clients level of consciousness.
C. Raise the head of the bed to at least 45 degrees.
D. Provide the client with humidified oxygen.
B. Assess the clients level of consciousness
A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires
immediate action?
A. Increase temperature
B. Absent breath sounds
C. Productive cough
D. Incisional discomfort
B. Absent breath sounds
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?
A. Measure oxygen saturation before and after a 12-minute walk.
B. Verify that the client understands all possible complications
C. Explain the procedure in detail to the client and the family.
D. Validate that informed consent has been given by the client.
D. Validate that informed consent has been given by the client
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?
A. The client rates pain as a 5/10 at the site of the procedure.
B. A small amount of drainage from the site is noted.
C. Pulse oximetry is 93% on 2 liters of oxygen.
D. The trachea is deviated toward the opposite side of the neck.
D. The trachea is deviated toward the opposite side of the neck
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a
flight of stairs. Which intervention should the nurse include in this clients plan of care?
A. Assistance with activities of daily living
B. Physical therapy activities every day
C. Oxygen therapy at 2 liters per nasal cannula
D. Complete bedrest with frequent repositioning
A. Assistance with activities of daily living
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the
nurse include in this clients plan of care? (Select all that apply.)
A. Encourage deep breathing and coughing
B. Implement an air mattress overlay
C. Ambulate the client three times each day
D. Provide a diet high in protein and vitamins
E. Administer acetaminophen (Tylenol) twice daily.
A. Encourage deep breathing and coughing
C. Ambulate the client three times each day
D. Provide a diet high in protein and vitamins
A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing
what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
B. 21%
A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?
A. Administer prescribed anxiolytic medication
B. Ensure informed consent is on the chart
C. Reinforce any teaching done previously
D. Start the preoperative antibiotic infusion.
B. Ensure informed consent is on the chart
A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and
the eyelids are swollen. What action by the nurse takes priority?
A. Assess the clients oxygen saturation
B. Notify the Rapid Response Team
C. Oxygenate the client with a bag-valve-mask
D. Palpate the skin of the upper chest.
A. Assess the clients oxygen saturation
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?
A. Elevate the head of the clients bed
B. Measure and compare cuff pressures.
C. Place the client on NPO status
D. Request that the client have a swallow study.
B. Measure and compare cuff pressures
An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the
UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?
a. Assess the clients lung sounds.
B. Assign a different UAP to the client.
C. Report the UAP to the manager.
D. Request thicker liquids for meals.
A. Assess the clients lung sounds
A student nurse is providing tracheostomy care. What action by the student requires intervention by the
instructor?
A. Holding the device securely when changing ties
B. Suctioning the client first if secretions are present
C. Tying a square knot at the back of the neck
D. Using half-strength peroxide for cleansing
C. Tying a square not at the back of the neck
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student
demonstrates that more teaching is needed?
A. Applying suction while inserting the catheter
B. Preoxygenating the client prior to suctioning
C. Suctioning for a total of three times if needed
D. Suctioning for only 10 to 15 seconds each time
A. Applying suction while inserting the catheter
A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that
goals for a priority diagnosis are being met?
A. 100% of meals being eaten by the client
B. Intact skin behind the ears
C. The client understanding the need for oxygen
D. Unchanged weight for the past 3 days
B. Intact skin behind the ears
Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity
A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing
with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the
nurse is most appropriate?
A. Call the operating room to inform them of a pending emergency case.
B. No action is needed at this time; this is a normal finding in some clients.
C. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
D. Stay with the client and have someone else call the provider immediately.
D. Stay with the client and have someone else call the provider immediately
A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best
indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
A. The client demonstrates good understanding of stoma care.
B. The client has joined a book club that meets at the library.
C. Family members take turns assisting with stoma care.
D. Skin around the stoma is intact without signs of infection.
B. The client has joined a book club that meets at the library
A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?
A. Apply water-soluble ointment to nares and lips.
B. Periodically turn the oxygen down or off.
C. Remove the tubing from the clients nose.
D. Turn the client every 2 hours or as needed.
A. Apply water-soluble ointment to nares and lips
A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)
A. The client does not allow smoking in the house.
B. Electrical cords are in good working order.
C. Flammable liquids are stored in the garage.
D. Household light bulbs are the fluorescent type.
E. The client does not have pets inside the home.
A. The client does not allow smoking in the house.
B. Electrical cords are in good working order.
C. Flammable liquids are stored in the garage.
A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to
unlicensed assistive personnel (UAP)? (Select all that apply.)
A. Applying water-soluble lip balm to the clients lips
B. Ensuring the humidification provided is adequate
C. Performing oral care with alcohol-based mouthwash
D. Reminding the client to cough and deep breathe often
E. Suctioning excess secretions through the tracheostomy
A. Applying water-soluble lip balm to the clients lips
D. Reminding the client to cough and deep breathe often
A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse
offer to help the client maintain self-esteem? (Select all that apply.)
A. Create a communication system.
B. Dont go out in public alone.
C. Find hobbies to enjoy at home.
D. Try loose-fitting shirts with collars.
E. Wear fashionable scarves.
A. Create a communication system.
D. Try loose-fitting shirts with collars.
E. Wear fashionable scarves.
A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)
a. Cognition
b. Dexterity
c. Hydration
d. Range of motion
e. Vision
a. Cognition
b. Dexterity
d. Range of motion
e. Vision
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
a. Contact the provider and prepare for intubation.
b. Administer prescribed albuterol nebulizer therapy.
c. Place the client in high-Fowlers position.
d. Ask the client to perform deep-breathing exercises.
a. Contact the provider and prepare for intubation.
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the clients understanding. Which action demonstrates that the client correctly understands the teaching?
a. The client lays on his or her side with his or her knees bent.
b. The client places his or her hands on his or her abdomen.
c. The client lays in a prone position with his or her legs straight.
d. The client places his or her hands above his or her head.
b. The client places his or her hands on his or her abdomen
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the provider and obtain a suture kit.
d. Reinsert the tube using sterile technique.
B. Cover the insertion site with sterile gauze
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?
a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the clients anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.
d. Administer pain medication and encourage the client to take deep breaths.
A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?
a. When the insertion site becomes red and warm to the touch
b. When the tube drainage decreases and becomes sanguineous
c. When the client experiences pain at the insertion site
d. When the tube becomes disconnected from the drainage system
d. When the tube becomes disconnected from the drainage system
A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this clients history and clinical
manifestations?
a. Increased pulmonary pressure creating a higher workload on the right side of the heart
b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles
c. Increased number and size of mucus glands producing large amounts of thick mucus
d. Left ventricular hypertrophy creating a decrease in cardiac output
A. increased pulmonary pressure creating a higher workload on the right side of the heart
A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):
Arterial Blood Gas Results Vital Signs
pH = 7.32
PaCO2 = 62 mm Hg
PaO2 = 46 mm Hg
HCO3 = 28 mEq/L Heart rate = 110 beats/min
Respiratory rate = 12 breaths/min
Blood pressure = 145/65 mm Hg
Oxygen saturation = 76%
Which action should the nurse take first?
a. Administer a short-acting beta2 agonist inhaler.
b. Document the findings as normal for a client with COPD.
c. Teach the client diaphragmatic breathing techniques.
d. Initiate oxygenation therapy to increase saturation to 92%.
d. Initiate oxygenation therapy to increase saturation to 92%.
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurses immediate
intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Pain at insertion site
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
b. Tracheal deviation
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Sudden onset of shortness of breath
d. Pain at insertion site
e. Drainage of 75 mL/hr
b. Tracheal deviation
c. Sudden onset of shortness of breath
A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What
response by the nurse is best?
a. Breathing so quickly can be dehydrating.
b. Everyone with pneumonia is dehydrated.
c. This is really just to administer your
antibiotics.
d. Why do you think you are so dehydrated?
a. Breathing so quickly can be dehydrating.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a
blood pressure of 88/52 mmHg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the clients lung sounds.
b. Notify the Rapid Response Team
c. Provide reassurance to the client.
d. Take a full set of vital signs.
B. notify the rapid response
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is
found.
c. Teach the client about factor V Leiden testing.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen
saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
d. The client needs immediate intubation and mechanical ventilation.
c. The blood clot interferes with perfusion in the lungs.
A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial
thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin
(Coumadin).
B. Increase the heparin rate
For clients on heparin, a PTT of 1.5 - 2.5 times the normal value is needed to demonstrate the heparin is working
Normal PTT is 25 to 35 seconds
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals
the client has an alteration in the gene CYP2C19. What action by the nurse is best?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC)
filter.
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush.
B. prepare preoperative teaching for an inferior vena cava (IVC) filter
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates
that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count:
8.7/mm3
B. platelet count: 82,000 / L
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central
supply.
d. Tell the client to take slow, deep breaths.
A. assess for other manifestations of hypoxia
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to
intubate for 40 seconds. What action by the nurse takes priority?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the clients oxygen saturation.
C. interrupt the procedure to give oxygen
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the clients lung sounds.
d. Suction the endotracheal tube.
C. listen to the clients lung sounds
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per
protocol.
d. Use nonverbal pain assessment tools
C. provide frequent oral care per protocol
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with
the respiratory therapist, what should the nurse ensure as a priority?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate
humidification.
c. The upper peak airway pressure limit alarm is
off.
d. The upper peak airway pressure limit alarm is on.
D. the upper peak airway pressure limit alarm is on
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is
safe.
c. Restrain the clients hands.
d. Sedate the client immediately.
A. assess the cause of the agitation
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the
room
B. ensuring there is a bag-valve-mask in the room
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the
room
C. Ensure a patent airway
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the
client needs more education regarding this medication?
a. Hamburger and French fries
b. Large chefs salad and muffin
c. No selection; spouse brings
pizza
d. Tuna salad sandwich and chips
B. large chefs salad and muffin
A client in the emergency department has several broken ribs. What care measure will best promote comfort?
a. Allowing the client to choose the position in bed
b. Humidifying the supplemental oxygen
c. Offering frequent, small drinks of water
d. Providing warmed blankets
A. allowing the client to choose the position in bed
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
a. Alteplase (Activase)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium
(Coumadin)
A. alteplase (activase)
Clot-busting agent
A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is
cyanotic. What action by the nurse is the priority?
a. Administer oxygen and reassess.
b. Auscultate the clients lung
sounds.
c. Facilitate a portable chest x-ray.
d. Prepare to assist with intubation.
D. prepare to assist with intubation
A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?
a. It is chronic hypoxemia that accompanies restrictive airway disease.
b. It is hypoxemia from lung damage due to mechanical ventilation.
c. It is hypoxemia that continues even after the client is weaned from
oxygen.
d. It is hypoxemia that persists even with 100% oxygen administration.
D. it is hypoxemia that persist even with 100% oxygen administration
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement
surgery
e. Young obese client with a fractured femur
B. client with a new spinal injury on a rotation bed
D. older client who is 1-day post hip replacement surgery
E. young obese client with fractured femur
When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty
acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
C. exercise on a regular basis
D. maintain a healthy weight
E. stop smoking cigarettes
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate?
(Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel
(UAP).
c. Give simple explanations of what is happening.
d. Request a prescription for anti-anxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel
(UAP).
c. Give simple explanations of what is happening.
e. Stay with the client and speak in a quiet, calm voice.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular
schedule
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
a. Allow visitors at the clients bedside.
b. Ensure the client can communicate if awake.
c. Keep the television tuned to a favorite channel.
d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
a. Allow visitors at the clients bedside.
b. Ensure the client can communicate if awake.
d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle
strength
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
a. Chest wall stiffness
b. Decreased muscle
strength
d. Less lung elasticity
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
A. heart rate of 120 beats/minute
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min
d. pulse decreased from 100 beats/min to 80 beats/min
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma
b. A 32-year-old Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy
C. a 45-year-old American Indian woman with diabetes mellitus
The incidence of coronary artery disease and HTN is higher in American Indians, DM increases the risk for HTN and CAD
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the clients medications.
d. Administer 1 mg of atropine.
C. assess the clients medications
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?
a. I get short of breath when I climb stairs.
b. I see halos floating around my head.
c. I have trouble remembering things.
d. I have lost weight over the past month.
A. i get short of breath when i climb stairs
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm
C. disorientation and confusion
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as left pedal pulse of +1/4.
C. assess the color and temperature of the left leg
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
C. slurred speech and confusion
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse
complete prior to this procedure?
a. Clients level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents
D. allergies to iodine-based agents
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the
nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the health care provider before scheduling the MRI.
c. Call the physician and request a laboratory draw for cardiac enzymes.
d. Instruct the client to increase fluid intake the day before the MRI.
B. notify the health care provider before scheduling the MRI
The magnetic fields of the MRI can deactivate the pacemaker!!
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for
surgery?
a. Administration of IV furosemide (Lasix)
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
B. initiation of an external pacemaker
The RCA supplies the right atrium, right ventricle, the inferior portion of the left ventricle, and the AV node. It also supplies the SA node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would go into heart block, so emergency pacing should be available for the client.
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?
a. The best way to lose weight is a high-protein, low-carbohydrate diet.
b. You should balance weight loss with consuming necessary nutrients.
c. A nutritionist will provide you with information about your new diet.
d. If you exercise more frequently, you wont need to change your diet.
B. you should balance weight loss with consuming necessary nutrients
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?
a. I will consult the provider to prescribe a sleep study to determine the problem.
b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.
d. Use pillows to elevate your head and chest while you are sleeping.
D. use pillows to elevate your head and chest while you are sleeping
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond?
a. Chili is high in fat and calories; it would be a good idea to stop eating it.
b. The provider has prescribed an antacid for you to take every morning.
c. What do you understand about what happened to you?
d. When did you start experiencing this indigestion?
C. what do you understand about what happened to you?
Clients who experience MI often respond with denial, which is a defense mechanism
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
a. This is a routine surgery and the risk of death is very low.
b. Would you like to speak with a chaplain prior to surgery?
c. Tell me more about your concerns about the surgery.
d. What support systems do you have to assist you?
C. tell me more about your concerns about the surgery
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?
a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers
b. A 49-year-old male who reports moderate pain that is worse on inspiration
c. A 53-year-old female who reports substernal pain that radiates to her abdomen
d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
D. a 58-year-old male who describes his pain as intense stabbing that spreads across his chest
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac
catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.)
a. Assess for allergies to iodine.
b. Administer intravenous fluids.
c. Assess blood urea nitrogen (BUN) and creatinine results.
d. Insert a Foley catheter.
e. Administer a prophylactic antibiotic.
f. Insert a central venous catheter.
A. assess for allergies to iodine
B. administer IV fluids
C. assess BUN and creatinine results
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
a. Hypertension
b. Fatigue despite adequate rest
c. Indigestion
d. Abdominal pain
e. Shortness of breath
B. fatigue despite adequate rest
C. indigestion
E. shortness of breath
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in
the first few hours after the procedure require immediate action by the nurse? (Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
B. serum potassium of 2.9 mEq/L
D. expanding groin hematoma
E. rhythm changes on the cardiac monitor
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take
when preparing this client for the procedure? (Select all that apply.)
a. Assist the provider to place a central venous access device.
b. Prepare for continuous blood pressure and pulse monitoring.
c. Administer the clients prescribed beta blocker.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this examination.
b. Prepare for continuous blood pressure and pulse monitoring.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which
complications of this procedure should the nurse assess? (Select all that apply.)
a. Thrombophlebitis
b. Stroke
c. Pulmonary embolism
d. Myocardial infarction
e. Cardiac tamponade
a. Thrombophlebitis
c. Pulmonary embolism
e. Cardiac tamponade
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded
by a P wave. How should the nurse interpret this observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The clients chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.
D. ventricular and atrial depolarization are initiated from different sites
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which
activity modification should the nurse suggest to avoid further slowing of the heart rate?
a. Make certain that your bath water is warm.
b. Avoid straining while having a bowel movement.
c. Limit your intake of caffeinated drinks to one a day.
d. Avoid strenuous exercise such as running.
B. avoid straining while having a bowel movement
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily
b. A 50-year-old who is post coronary artery bypass graft surgery
c. A 78-year-old who had a carotid endarterectomy
d. An 80-year-old with chronic obstructive pulmonary disease
b. A 50-year-old who is post coronary artery bypass graft surgery
Afib occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility
of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity
B. speech alterations
clients with afib are at risk for embolic stroke
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the
nurse expect to find on this clients medication administration record to prevent a common complication of this condition?
a. Sotalol (Betapace)
b. Warfarin (Coumadin)
c. Atropine (Sal-Tropine)
d. Lidocaine (Xylocaine)
B. warfarin
Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin or warfarin
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis
C. short period of asystole
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart
rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability
C. level of consciousness
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the
presence of a pacing spike but no QRS complex on the clients electrocardiogram. Which action should the
nurse take next?
a. Administer intravenous diltiazem (Cardizem).
b. Assess vital signs and level of consciousness.
c. Administer sublingual nitroglycerin.
d. Assess capillary refill and temperature.
B. assess vital signs and level of consciousness
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should
the nurse perform prior to defibrillating this client?
a. Make sure the defibrillator is set to the synchronous mode.
b. Administer 1 mg of intravenous epinephrine.
c. Test the equipment by delivering a smaller shock at 100 joules.
d. Ensure that everyone is clear of contact with the client and the bed.
D. ensure that everyone is clear of contact with the client and the bed
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
a. I should wear a snug-fitting shirt over the ICD.
b. I will avoid sources of strong electromagnetic fields.
c. I should participate in a strenuous exercise program.
d. Now I can discontinue my antidysrhythmic medication
B. I will avoid sources of strong electromagnetic fields
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns?
a. Administer oxygen therapy at 2 liters per nasal cannula.
b. Provide the client with a sleeping pill to stimulate rest.
c. Schedule periods of exercise and rest during the day.
d. Ask unlicensed assistive personnel to help bathe the client.
C. schedule periods of exercise and rest during the day
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should
the nurse take prior to the initiation of cardioversion?
a. Administer intravenous adenosine.
b. Turn off oxygen therapy.
c. Ensure a tongue blade is available.
d. Position the client on the left side
B. turn off oxygen therapy
For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire
A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?
a. Medication reconciliation
b. Immunization history
c. Religious beliefs
d. Nutrition preferences
A. medication reconciliation
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by
the nurse?
a. Mid-sternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave
A. mid-sternal chest pain
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by
palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients teaching?
a. Minimize or abstain from caffeine.
b. Lie on your side until the attack subsides.
c. Use your oxygen when you experience PACs.
d. Take amiodarone (Cordarone) daily to prevent PACs.
A. minimize or abstain from caffeine
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, Why do you want to know if I use cocaine? How should the nurse respond?
a. Substance abuse puts clients at risk for many health issues.
b. The hospital requires that I ask you about cocaine use.
c. Clients who use cocaine are at risk for fatal dysrhythmias.
d. We can provide services for cessation of substance abuse.
C. Clients who use cocaine are at risk for fatal dysrhythmias
A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?
a. Clean the skin and clip hairs if needed.
b. Add gel to the electrodes prior to applying them.
c. Place the electrodes on the posterior chest.
d. Turn off oxygen prior to monitoring the client.
A. clean the skin and clip hairs if needed
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)
a. Decrease in cardiac output
b. Increase in cardiac output
c. Decrease in blood pressure
d. Increase in blood pressure
e. Decrease in urine output
f. Increase in urine output
a. Decrease in cardiac output
d. Increase in blood pressure
e. Decrease in urine output
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (Select all that apply.)
a. Until your incision is healed, do not submerge your pacemaker. Only take showers.
b. Report any pulse rates lower than your pacemaker settings.
c. If you feel weak, apply pressure over your generator.
d. Have your pacemaker turned off before having magnetic resonance imaging (MRI).
e. Do not lift your left arm above the level of your shoulder for 8 weeks.
a. Until your incision is healed, do not submerge your pacemaker. Only take showers.
b. Report any pulse rates lower than your pacemaker settings
e. Do not lift your left arm above the level of your shoulder for 8 weeks.
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for
the development of left-sided heart failure?
a. A 36-year-old woman with aortic stenosis
b. A 42-year-old man with pulmonary hypertension
c. A 59-year-old woman who smokes cigarettes daily
d. A 70-year-old man who had a cerebral vascular accident
A. a 36-year-old woman with aortic stenosis
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left- sided heart failure?
a. I have been drinking more water than usual.
b. I am awakened by the need to urinate at night.
c. I must stop halfway up the stairs to catch my breath.
d. I have experienced blurred vision on several occasions.
C. i must stop halfway up the stairs to catch my breath
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the
possibility of right-sided heart failure?
a. I sleep with four pillows at night.
b. My shoes fit really tight lately.
c. I wake up coughing every night.
d. I have trouble catching my breath.
B. my shoes fit really tight lately
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the health care provider immediately.
d. Transfer the client to the intensive care unit.
A. assess for symptoms of left-sided HF
A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?
a. Weight is the best indication that you are gaining or losing fluid.
b. Daily weights will help us make sure that you’re eating properly.
c. The hospital requires that all
inpatients be weighed daily.
d. You need to lose weight to decrease the incidence of heart failure.
a. Weight is the best indication that you are gaining or losing fluid.
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
a. Initiate oxygen therapy.
b. Hold the next dose of Imdur.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen.
d. Administer PRN acetaminophen.
A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this
clients discharge teaching?
a. Avoid drinking more than 3 quarts of liquids each day.
b. Eat six small meals daily instead of three larger meals.
c. When you feel short of breath, take an additional diuretic.
d. Weigh yourself daily while wearing the same amount of clothing.
d. Weigh yourself daily while wearing the same amount of clothing.
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
a. Assess the clients respiratory status.
b. Draw blood to assess the clients serum electrolytes.
c. Administer intravenous furosemide (Lasix).
d. Ask the client about current medications.
a. Assess the clients respiratory status.
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to
the possibility that the clients stenosis has progressed?
a. Oxygen saturation of 92%
b. Dyspnea on exertion
c. Muted systolic murmur
d. Upper extremity weakness
b. dyspnea on exertion
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond?
a. The prosthetic valve places you at greater risk for a heart attack.
b. Blood clots form more easily in artificial replacement valves.
c. The vein taken from your leg reduces circulation in the leg.
d. The surgery left a lot of small clots in your heart and lungs.
b. Blood clots form more easily in artificial replacement valves.
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse
assesses the clients understanding. Which client statement indicates a need for additional teaching?
a. I’ll be able to carry heavy loads after 6 months of rest.
b. I will have my teeth cleaned by my dentist in 2 weeks.
c. I must avoid eating foods high in vitamin K, like spinach.
d. I must use an electric razor instead of a straight razor to shave
b. I will have my teeth cleaned by my dentist in 2 weeks.
A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse
use?
a. Standard Precautions
b. Bleeding precautions
c. Reverse isolation
d. Contact isolation
A. standard precautions
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
a. Heart rate that speeds up and slows down
b. Friction rub at the left lower sternal border
c. Presence of a regular gallop rhythm
d. Coarse crackles in bilateral lung bases
B. friction rub at the left lower sternal border
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond?
a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular
sutures.
b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular
pressure and dizziness.
c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood
pressure caused by position changes.
d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke
c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood
pressure caused by position changes.
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess
the extent of the clients heart failure?
a. Do you have trouble breathing or chest pain?
b. Are you able to walk upstairs without fatigue?
c. Do you awake with breathlessness during the night?
d. Do you have new-onset heaviness in your legs?
b. Are you able to walk upstairs without fatigue?
A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse
include in this clients teaching?
a. Walk until you become short of breath, and then walk back home.
b. Gather everything you need for a chore before you begin.
c. Pull rather than push or carry items heavier than 5 pounds.
d. Take a walk after dinner every day to build up your strength.
b. Gather everything you need for a chore before you begin.
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?
a. Preventricular contractions
b. Atrial fibrillation
c. Symptomatic bradycardia
d. Sinus tachycardia
b. Atrial fibrillation
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)
a. Pulmonary crackles
b. Confusion, restlessness
c. Pulmonary hypertension
d. Dependent edema
e. Cough that worsens at night
a. Pulmonary crackles
b. Confusion, restlessness
e. Cough that worsens at night
A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect?
(Select all that apply.)
a. Hematocrit: 32.8%
b. Serum sodium: 130 mEq/L
c. Serum potassium: 4.0 mEq/L
d. Serum creatinine: 1.0 mg/dL
e. Proteinuria
f. Microalbuminuria
a. Hematocrit: 32.8%
b. Serum sodium: 130 mEq/L
e. Proteinuria
f. Microalbuminuria
After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)
a. I’ll read the nutritional labels on food items for salt content.
b. I will drink at least 3 liters of water each day.
c. Using salt in moderation will reduce the workload of my heart.
d. I will eat oatmeal for breakfast instead of ham and eggs.
e. Substituting fresh vegetables for canned ones will lower my salt intake.
a. I’ll read the nutritional labels on food items for salt content.
d. I will eat oatmeal for breakfast instead of ham and eggs.
e. Substituting fresh vegetables
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this
client? (Select all that apply.)
a. Reposition the client every 2 hours.
b. Teach the client to perform deep-breathing exercises.
c. Accurately record intake and output.
d. Use the same scale to weigh the client each morning.
e. Place the client on oxygen if the client becomes short of breath.
a. Reposition the client every 2 hours.
c. Accurately record intake and output.
d. Use the same scale to weigh the client each morning.
A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure
this clients safety prior to discharging home? (Select all that apply.)
a. Are your bedroom and bathroom on the first floor?
b. What social support do you have at home?
c. Will you be able to afford your oxygen therapy?
d. What spiritual beliefs may impact your recovery?
e. Are you able to accurately weigh yourself at home?
a. Are your bedroom and bathroom on the first floor?
b. What social support do you have at home?
d. What spiritual beliefs may impact your recovery?
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert
the nurse to the possibility of heart transplant rejection? (Select all that apply.)
a. Shortness of breath
b. Abdominal bloating
c. New-onset bradycardia
d. Increased ejection fraction
e. Hypertension
a. Shortness of breath
b. Abdominal bloating
c. New-onset bradycardia
A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)
a. Weight gain
b. Night sweats
c. Cardiac murmur
d. Abdominal bloating
e. Oslers nodes
b. Night sweats
c. Cardiac murmur
e. Oslers nodes
A client has been diagnosed with hypertension but does not take the antihypertensive medications because
of a lack of symptoms. What response by the nurse is best?
a. Do you have trouble affording your medications?
b. Most people with hypertension do not have symptoms.
c. You are lucky; most people get severe morning headaches.
d. You need to take your medicine or you will get kidney failure.
b. Most people with hypertension do not have symptoms.
A student nurse asks what essential hypertension is. What response by the registered nurse is best?
a. It means it is caused by another disease.
b. It means it is essential that it be treated.
c. It is hypertension with no specific cause.
d. It refers to severe and life-threatening hypertension.
c. It is hypertension with no specific cause.
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with
the recommended lifestyle changes. What action by the nurse is best?
a. Assess the clients support system.
b. Assist in finding one change the client can control.
c. Determine what stressors the client faces in daily life.
d. Inquire about delegating some of the clients obligations.
b. Assist in finding one change the client can control.
A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
a. Assess the clients neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
d. Turn down the infusion rate.
b. Notify the Rapid Response Team.
A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
b. Oxygen saturation of 98%
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the clients leg.
d. Provide an ice pack.
b. Apply a warm moist pack.
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.
c. Measure for new compression stockings.
A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.)
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
d. Use an IV pump for the infusion.
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
b. Lower blood volume lowers MAP.
A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18
breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the clients tissue perfusion further.
c. Document the findings in the clients chart.
d. Increase the rate of the clients IV infusion.
b. Assess the clients tissue perfusion further.
The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her.
b. Measure urine output from the catheter.
A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
a. High glucose is common in shock and needs to be treated.
b. Some of the medications we are giving are to raise blood sugar.
c. The IV solution has lots of glucose, which raises blood sugar.
d. The stress of this illness has made your spouse a diabetic.
a. High glucose is common in shock and needs to be treated.
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority?
a. Document the findings in the clients chart.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.
c. Notify the health care provider immediately
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?
a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.
b. Drink fluids on a regular schedule.
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
b. Ensure the client has a patent airway.
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denial of chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
a. Alert and oriented, answering questions
A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first?
a. Apply personal protective equipment.
b. Notify local law enforcement officials.
c. Obtain universal donor blood.
d. Prepare the client for emergency surgery.
a. Apply personal protective equipment.
A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?
a. Creatinine: 0.9 mg/dL
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3
b. Lactate: 6 mmol/L
A client in shock is apprehensive and slightly confused. What action by the nurse is best?
a. Offer to remain with the client for awhile.
b. Prepare to administer antianxiety medication.
c. Raise all four siderails on the clients bed.
d. Tell the client everything possible is being done.
a. Offer to remain with the client for awhile.
A client is being discharged home after a large myocardial infarction and subsequent coronary artery
bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?
a. All my friends and neighbors are planning a party for me.
b. I hope I can get my water turned back on when I get home.
c. I am going to have my daughter scoop the cat litter box.
d. My grandkids are so excited to have me coming home!
b. I hope I can get my water turned back on when I get home.
A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr
c. Report of chest heaviness
The student nurse studying shock understands that the common manifestations of this condition are directly
related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased perfusion
a. Anaerobic metabolism
c. Hypotension
The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility
of the clients developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
a. Assessing and identifying clients at risk
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.)
a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
e. Overhydration
a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)
a. Bringing the client warm blankets
b. Giving the client hot tea to drink
c. Massaging the clients painful legs
d. Reorienting the client as needed
e. Sitting with the client for reassurance
a. Bringing the client warm blankets
d. Reorienting the client as needed
e. Sitting with the client for reassurance
The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)
a. Administer antibiotics.
b. Draw serum lactate levels.
c. Infuse vasopressors.
d. Measure central venous pressure.
e. Obtain blood cultures.
a. Administer antibiotics.
b. Draw serum lactate levels.
e. Obtain blood cultures.
A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?
a. Assess the clients pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.
c. Stop the infusion and call the provider.
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response
by the nurse is best?
a. The t-PA didnt dissolve the entire coronary clot.
b. The heparin keeps that artery from getting blocked again.
c. Heparin keeps the blood as thin as possible for a longer time.
d. The heparin prevents a stroke from occurring as the t-PA wears off.
b. The heparin keeps that artery from getting blocked again.
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.
b. Allow continued bathroom privileges.
A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best?
a. Continue to educate the client on possible healthy changes.
b. Emphasize complications that can occur with noncompliance.
c. Tell the client that denial is normal and will soon go away.
d. You need to make sure the client understands this illness.
a. Continue to educate the client on possible healthy changes.
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to
100/60 mm Hg. What action by the nurse is most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
b. Assess the client for bleeding.
A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The
client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the clients stress levels.
d. Tell the client that anxiety is common and that you can help.
d. Tell the client that anxiety is common and that you can help.
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?
a. Do you have any concerns about sexuality?
b. Im glad to hear you are sleeping well now.
c. Sleep near your spouse in case of emergency.
d. Why would you move into the guest room?
a. Do you have any concerns about sexuality?
Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if
this is the issue
A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider.
c. Maintain airway patency.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequentdysrhythmias. What action by the nurse is most appropriate?
a. Assess for any hemodynamic effects of the rhythm.
b. Prepare to administer antidysrhythmic medication.
c. Notify the provider or call the Rapid Response Team.
d. Turn the alarms off on the cardiac monitor.
a. Assess for any hemodynamic effects of the rhythm.
A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first?
a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
c. Client who is 1 day post percutaneous coronary intervention, going home this morning
d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking
b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg
Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on
the suture lines and can cause bleeding
A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes?
a. Obtain an electrocardiogram (ECG) now and in the morning.
b. Give the client an aspirin.
c. Notify the Rapid Response Team.
d. Prepare to administer thrombolytics.
b. Give the client an aspirin.
A nurse is caring for four clients. Which client should the nurse assess first?
a. Client with an acute myocardial infarction, pulse 102 beats/min
b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr
d. Client who is post coronary artery bypass, potassium 4.2 mEq/L
b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort?
a. Allow family members to remain at the bedside.
b. Ask the family if the client would like a fan in the room.
c. Keep the television tuned to the clients favorite channel.
d. Speak loudly to the client in case of hearing problems.
a. Allow family members to remain at the bedside.
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?
a. Increase the setting on the suction.
b. Notify the provider immediately.
c. Re-position the chest tube.
d. Take the tubing apart to assess for clots.
b. Notify the provider immediately.
A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals?
a. Dirty carpets in need of vacuuming
b. Expired food in the refrigerator
c. Old medications in the kitchen
d. Several cats present in the home
b. Expired food in the refrigerator
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly.
b. Monitor the pedal pulses.
c. Monitor the clients vital signs.
d. Obtain consent for a central line.
a. Assess the IV site hourly.
Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours
c. Poor peripheral pulses and cool skin
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures
set, by what time should the client have a percutaneous coronary intervention performed?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM)
c. 1630 (4:30 PM)
The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction
The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse?
a. It constricts vessels, improving blood flow.
b. It dilates vessels, which lessens the work of the heart.
c. It increases the force of the hearts contractions.
d. It slows the heart rate down for better filling.
c. It increases the force of the hearts contractions.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this
include? (Select all that apply.)
a. Age
b. Hypertension
c. Obesity
d. Smoking
e. Stress
b. Hypertension
c. Obesity
d. Smoking
e. Stress
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol.
a. Assist the client to the chair for meals and to the bathroom.
c. Ensure the client wears TED hose or sequential compression devices.
e. Take and record a full set of vital signs per hospital protocol.
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.)
a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing
b. Assist the client into a position of comfort in bed.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing
A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.)
a. Advanced age
b. Diabetes
c. Ethnic background
d. Medication use
e. Smoking
a. Advanced age
b. Diabetes
c. Ethnic background
e. Smoking
