MSS: Cardiac Practice Questions

Question 1

The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client?

1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white sputum and crackles that clear with cough.
3. The client sleeping with no pillow and eupnea.
4. Radial pulse rate of 90 and capillary refill time <3 seconds.

Answer 1

1. The client with CHF would exhibit tachycardia (apical pulse rate of 110), dependent edema, fatigue, third heart sounds, lung congestion, and change in mental status.
2. The client with CHF usually has pink frothy sputum and crackles that do not clear with coughing.
3. The client with CHF would report sleeping on at least two pillows, if not sleeping in an upright position, and labored breathing, not eupnea, which means normal breathing.
4. In a client diagnosed with heart failure, the apical pulse, not the radial pulse, is the best place to assess the cardiac status.

Question 2

The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of “decreased cardiac output related to inability of the heart to pump effectively” is written. Which short-term goal would be best for the client? The client will:

1. Be able to ambulate in the hall by date of discharge.
2. Have an audible S1 and S2 with no S3 heard by end of shift.
3. Turn, cough, and deep breathe every two (2) hours.
4. Have a pulse oximeter reading of 98% by day two (2) of care.

Answer 2

1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis.
2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure which could be life threatening.
3. This is a nursing intervention, not a short-term goal, for this client.
4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output.

Question 3

The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply.

1. Notify health-care provider of a weight gain of more than one (1) pound in a week.
2. Teach client how to count the radial pulse when taking digoxin, a cardiac glycoside.
3. Instruct client to remove the saltshaker from the dinner table.
4. Encourage client to monitor urine output for change in color to become dark.
5. Discuss the importance of taking the loop diuretic furosemide at bedtime.

Answer 3

1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day.
2. The client should not take digoxin if the radial pulse is less than 60.
3. The client should be on a low-sodium diet to prevent water retention.
4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics.
5. Instruct the client to take the diuretic in the morning to prevent nocturia.

Question 4

The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first?

1. Sponge the client’s forehead.
2. Obtain a pulse oximetry reading.
3. Take the client’s vital signs.
4. Assist the client to a sitting position.

Answer 4

1. Sponging the client’s forehead would be appropriate, but it is not the first intervention.
2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention.
3. Taking the vital signs would be appropriate, but it is not the first intervention.
4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client’s forehead.

Question 5

The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective?

1. The client’s peripheral pitting edema has gone from 3+ to 4+.
2. The client is able to take the radial pulse accurately.
3. The client is able to perform ADLs without dyspnea.
4. The client has minimal jugular vein distention.

Answer 5

1. Pitting edema changing from 3+ to 4+ indi- cates a worsening of the CHF.
2. The client’s ability to take the radial pulse would evaluate teaching, not medical treatment.
3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client’s condition is improving. The client’s heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs.
4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment.

Question 6

The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?

1. An elevated B-type natriuretic peptide (BNP).
2. An elevated creatine kinase (CK-MB).
3. A positive D-dimer.
4. A positive ventilation/perfusion (V/Q) scan.

Answer 6

1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the num- ber, the more severe the CHF.
2. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme.
3. A positive D-dimer would indicate a pul- monary embolus.
4. A positive ventilation/perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus.

Question 7

The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include?

1. Instruct the client to take a cough suppressant if a cough develops.
2. Teach the client how to prevent orthostatic hypotension.
3. Encourage the client to eat bananas to increase potassium level.
4. Explain the importance of taking the medication with food.

Answer 7

1. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discon- tinue the medication.
2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should in- struct the client to rise slowly and sit on the side of the bed until equilibrium is restored.
3. ACE inhibitors may cause the client to re- tain potassium; therefore, the client should not increase potassium intake.
4. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication.

Question 8

The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first?
1. The client diagnosed with myocardial infarction who has an audible S3 heart
sound.
2. The client diagnosed with congestive heart failure who has 4+ sacral pitting
edema.
3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
4. The client with chronic renal failure who has an elevated creatinine level.

Answer 8

1. An S3 heart sound indicates left ventric- ular failure, and the nurse must assess this client first because it is an emergency situation.
2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation.
3. A pulse oximeter reading of greater than 93% is considered normal.
4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure.

Question 9

The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?

1. Assist the client to go down to the smoking area for a cigarette.
2. Transport the client to the intensive care unit via a stretcher.
3. Provide the client going home discharge-teaching instructions.
4. Help position the client who is having a portable x-ray done.

Answer 9

1. Allowing the UAP to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking.
2. The client going to the ICU would be unstable, and the nurse should not dele- gate to a UAP any nursing task that involves an unstable client.
3. The nurse cannot delegate teaching.
4. The UAP can assist the x-ray technician in positioning the client for the portable x-ray. This does not require judgment.

Question 10

The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse?
1. The client diagnosed with congestive heart failure who is being discharged in the
morning.
2. The client who is having frequent incontinent liquid bowel movements and
vomiting.
3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood
pressure of 94/62.
4. The client who is complaining of chest pain with inspiration and a nonproductive
cough.

Answer 10

1. This client is stable because discharge is scheduled for the following day. There- fore, this client does not need to be assigned to the most experienced registered nurse.
2. This client is more in need of custodial nursing care than care from the most experienced registered nurse. Therefore, the charge nurse could assign a less experi- enced nurse to this client.
3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client.
4. These complaints usually indicate muscu- lar or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration.

Question 11

The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented?
1. Check the client for peripheral edema and make sure the client takes a diuretic
early in the day.
2. Monitor the client’s potassium level and assess the client’s intake of bananas and
orange juice.
3. Determine if the client has gained weight and instruct the client to keep the legs
elevated.
4. Instruct the client to ambulate frequently and perform calf-muscle stretching
exercises daily.

Answer 11

1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels.
2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium.
3. Weight gain is monitored in clients with CHF, and elevating the legs would de- crease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps.
4. Ambulating frequently and performing leg-stretching exercises will not be effec- tive in alleviating the leg cramps.

Question 12

The nurse has written an outcome goal “demonstrates tolerance for increased activity” for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?

1. Measure intake and output.
2. Provide two (2)-g sodium diet.
3. Weigh client daily.
4. Plan for frequent rest periods.

Answer 12

1. Measuring the intake and output is an ap- propriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity.
2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity.
3. Daily weighing monitors fluid volume sta- tus, not activity tolerance.
4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome.

Question 13

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction?

1. Creatine kinase (CK-MB).
2. Lactate dehydrogenase (LDH).
3. Troponin.
4. White blood cells (WBCs).

Answer 13

1. CPK-MB elevates in 12 to 24 hours.
2. LDH elevates in 24 to 36 hours.
3. Troponin is the enzyme that elevates within 1 to 2 hours.
4. WBCs elevate as a result of necrotic tis- sue, but this is not a cardiac enzyme.

Question 14

Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction?

1. Midepigastric pain and pyrosis.
2. Diaphoresis and cool clammy skin.
3. Intermittent claudication and pallor.
4. Jugular vein distention and dependent edema.

Answer 14

1. Midepigastric pain would support a diag- nosis of peptic ulcer disease; pyrosis is belching.
2. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasocon- stricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
3. Intermittent claudication is leg pain sec- ondary to decreased oxygen to the muscle, and pallor is paleness of the skin as a result of decreased blood supply. Neither is an early sign of MI.
4. Jugular vein distension (JVD) and depend- ent edema are signs/symptoms of conges- tive heart failure, not of MI.

Question 15

The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first?

1. Administer sublingual nitroglycerin.
2. Obtain a STAT electrocardiogram.
3. Have the client sit down immediately.
4. Assess the client’s vital signs.

Answer 15

1. The nurse must assume the chest pain is secondary to decreased oxygen to the myocardium and administer a sublingual nitroglycerin tablet, which is a coronary vasodilator, but this is not the first action.
2. An ECG should be ordered, but it is not the first intervention.
3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
4. Assessment is often the first nursing inter- vention, but when the client has chest pain and a possible MI, the nurse must first take care of the client. Taking vital signs would not help relieve chest pain.

Question 16

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply.

1. Administer morphine intramuscularly.
2. Administer an aspirin orally.
3. Apply oxygen via a nasal cannula.
4. Place the client in a supine position.
5. Administer nitroglycerin subcutaneously.

Answer 16

1. Morphine should be administered intravenously, not intramuscularly.
2. Aspirin is an antiplatelet medication and should be administered orally.
3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.
4. The supine position will increase respiratory effort, which will increase myocardial oxygen consumption; the client should be in the semi-Fowler’s position.
5. Nitroglycerin, a coronary vasodilator, is administered sublingually, not subcuta- neously.

Question 17

The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client?

1. Social worker.
2. Physical therapy.
3. Cardiac rehabilitation.
4. Occupational therapy.

Answer 17

1. The social worker addresses financial con- cerns or referrals after discharge, which are not indicated for this client.
2. Physical therapy addresses gait problems, lower extremity strength building, and assisting with transfer, which are not required for this client.
3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac reha- bilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.
4. Occupational therapy assists the client in regaining activities of daily living and cov- ers mainly fine motor activities.

Question 18

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first?

1. Medicate the client with intravenous morphine.
2. Assess the client’s chest dressing and vital signs.
3. Encourage the client to turn from side to side.
4. Check the client’s telemetry monitor.

Answer 18

1. The nurse should medicate the client as needed, but it is not the first intervention.
2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postopera- tively or if it is a complication of the surgery.
3. Turning will help decrease complications from immobility, such as pneumonia, but it will not help relieve the client’s pain.
4. The nurse, not a machine, should always take care of the client.

Question 19

The client diagnosed with a myocardial infarction is six (6) hours post–right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse?

1. The client is keeping the affected extremity straight.
2. The pressure dressing to the right femoral area is intact.
3. The client is complaining of numbness in the right foot. 4. The client’s right pedal pulse is 3+ and bounding.

Answer 19

1. After PTCA, the client must keep the right leg straight for at least six (6) to eight (8) hours to prevent any arterial bleeding from the insertion site in the right femoral artery.
2. A pressure dressing is applied to the inser- tion site to help prevent arterial bleeding.
3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.
4. A bounding pedal pulse indicates that ade- quate circulation is getting to the right foot; therefore, this would not require immediate intervention.

Question 20

The intensive care department nurse is assessing the client who is 12 hours post–myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement?

1. Notify the health-care provider immediately.
2. Elevate the head of the client’s bed.
3. Document this as a normal and expected finding.
4. Administer morphine intravenously.

Answer 20

1. An S3 indicates left ventricular failure and should be reported to the health- care provider. It is a potential life- threatening complication of a myocar- dial infarction.
2. Elevating the head of the bed will not do anything to help a failing heart.
3. This is not a normal finding; it indicates heart failure.
4. Morphine is administered for chest pain, not for heart failure, which is suggested by the S3 sound.

Question 21

The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication?

1. The client’s apical pulse is 64.
2. The client’s calcium level is elevated.
3. The client’s telemetry shows occasional PVCs.
4. The client’s blood pressure is 90/62.

Answer 21

1. The apical pulse is within normal limits— 60 to 100 beats per minute.
2. The serum calcium level is not monitored when calcium channel blockers are given.
3. Occasional PVCs would not warrant immediate intervention prior to administering this medication.
4. The client’s blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.

Question 22

The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement?

1. Instruct the UAP to stop encouraging the leg movements.
2. Report this behavior to the charge nurse as soon as possible.
3. Praise the UAP for encouraging the client to move legs.
4. Take no action concerning the UAP’s behavior.

Answer 22

1. Leg movement is an appropriate action, and the UAP should not be told to stop encouraging it.
2. This behavior is not unsafe or dangerous and should not be reported to the charge nurse.
3. The nurse should praise and encourage UAPs to participate in the client’s care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring.
4. The nurse should praise subordinates for appropriate behavior, especially when it is helping to prevent life-threatening complications.

Question 23

The client diagnosed with a myocardial infarction asks the nurse, “Why do I have to rest and take it easy? My chest doesn’t hurt anymore.” Which statement would be the nurse’s best response?

1. “Your heart is damaged and needs about four (4) to six (6) weeks to heal.”
2. “There is necrotic myocardial tissue that puts you at risk for dysrhythmias.”
3. “Your doctor has ordered bedrest. Therefore, you must stay in the bed.”
4. “Just because your chest doesn’t hurt anymore doesn’t mean you are out of
   danger. ”

Answer 23

1. The heart tissue is dead, stress or ac- tivity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.
2. The nurse should talk to the client in layperson’s terms, not medical terms. Medical terminology is a foreign language to most clients.
3. This is not answering the client’s question. The nurse should take any opportunity to teach the client.
4. This is a condescending response, and telling the client that he or she is not out of danger is not an appropriate response.

Question 24

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?

1. The client’s BP is 110/70 and pulse is 90.
2. The client’s groin dressing is dry and intact.
3. The client refuses to keep the leg straight.
4. The client denies any numbness and tingling.

Answer 24

1. These vital signs are within normal limits and would not require any immediate intervention.
2. The groin dressing should be dry and intact.
3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.
4. The nurse must check the neurovascular assessment, and paresthesia would warrant immediate intervention, but no numbness and tingling is a good sign.

Question 25

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching?

1. “I should keep the tablets in the dark-colored bottle they came in.”
2. “If the tablets do not burn under my tongue, they are not effective.”
3. “I should keep the bottle with me in my pocket at all times.”
4. “If my chest pain is not gone with one tablet, I will go to the ER.”

Answer 25

1. If the tablets are not kept in a dark bottle, they will lose their potency.
2. The tablets should burn or sting when put under the tongue.
3. The client should keep the tablets with him in case of chest pain.
4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency depart- ment or call 911.

Question 26

The client with coronary artery disease asks the nurse, “Why do I get chest pain?” Which statement would be the most appropriate response by the nurse?

1. “Chest pain is caused by decreased oxygen to the heart muscle.”
2. “There is ischemia to the myocardium as a result of hypoxemia.”
3. “The heart muscle is unable to pump effectively to perfuse the body.”
4. “Chest pain occurs when the lungs cannot adequately oxygenate the blood.”

Answer 26

1. This is a correct statement presented in layman’s terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.
2. This is the explanation in medical terms that should not be used when explaining medical conditions to a client.
3. This explains congestive heart failure but does not explain why chest pain occurs.
4. Respiratory compromise occurs when the lungs cannot oxygenate the blood, such as occurs with altered level of consciousness, cyanosis, and increased respiratory rate.

Question 27

The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure?

1. Perform passive range-of-motion exercises.
2. Assess the client’s neurovascular status.
3. Keep the client in high Fowler’s position.
4. Assess the gag reflex prior to feeding the client.

Answer 27

1. The client’s right leg should be kept straight to prevent arterial bleeding from the femoral insertion site for the catheter used to perform the catheterization.
2. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthe- sia, paralysis, coldness, and pallor.
3. The head of the bed should be elevated no more than 10 degrees. The client should be kept on bedrest, flat with the affected extremity straight, to help decrease the chance of femoral artery bleeding.
4. The gag reflex is assessed if a scope is in- serted down the trachea (bronchoscopy) or esophagus (endoscopy) because the throat is numbed when inserting the scope. A catheter is inserted in the femoral or brachial artery when performing a cardiac catheterization.

Question 28

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication?

1. The client has a BP of 110/70.
2. The client has an apical pulse of 56.
3. The client is complaining of a headache.
4. The client’s potassium level is 4.5 mEq/L.

Answer 28

1. This blood pressure is normal and the nurse would administer the medication.
2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than- normal heart rate and should make the nurse question administering this med- ication because it will further decrease the heart rate.
3. A headache will not affect administering the medication to the client.
4. The potassium level is within normal lim- its, but it is usually not monitored prior to administering a beta blocker.

Question 29

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?

1. Assess the client’s radial pulse.
2. Assess the client’s serum potassium level.
3. Assess the client’s glucometer reading.
4. Assess the client’s pulse oximeter reading.

Answer 29

1. The nurse should always assess the apical (not radial) pulse, but the pulse is not affected by a loop diuretic.
2. Loop diuretics cause potassium to be lost in the urine output. Therefore,the nurse should assess the client’s potassium level, and if the client is hypokalemic, the nurse should question administering this medication.
3. The glucometer provides a glucose level, which is not affected by a loop diuretic.
4. The pulse oximeter reading evaluates pe- ripheral oxygenation and is not affected by a loop diuretic.

Question 30

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply.

1. Encourage a low-fat, low-cholesterol diet.
2. Instruct client to walk 30 minutes a day.
3. Decrease the salt intake to two (2) g a day.
4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

Answer 30

1. A low-fat, low-cholesterol diet will help decrease the buildup of athero- sclerosis in the arteries.
2. Walking will help increase collateral circulation.
3. Salt should be restricted in the diet of a client with hypertension, not coronary artery disease.
4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle.
5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.

Question 31

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching?

1. “Do you have a daily bowel movement?”
2. “Do you get yearly chest x-rays?”
3. “Are you sexually active?”
4. “Have you had any weight change?”

Answer 31

1. Bowel movements are important, but they are not pertinent to coronary artery disease.
2. Chest x-rays are usually done for respira- tory problems, not for coronary artery disease.
3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client’s being elderly should not affect the nurse’s assess- ment of the client’s concerns about sexual activity.
4. Weight change is not significant in a client with coronary artery disease.

Question 32

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement?

1. Perform isometric exercises daily.
2. Walk for 15 minutes three (3) times a week.
3. Do not walk outside if it is less than 40 ̊F.
4. Wear open-toed shoes when ambulating

Answer 32

1. Isometric exercises are weight lifting–type exercises. A client with CAD should per- form isotonic exercises, which increase muscle tone, not isometric exercises.
2. The client should walk at least 30 minutes a day to increase collateral circulation.
3. When it is cold outside, vasoconstric- tion occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.
4. The client should wear good supportive tennis shoes when ambulating, not sandals or other open-toed shoes.

Question 33

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina?

1. Put a nitroglycerin tablet under the tongue.
2. Stop the activity immediately and rest.
3. Document when and what activity caused angina.
4. Notify the health-care provider immediately.

Answer 33

1. The client should take the coronary vasodilator nitroglycerin sublingually, but it is not the first intervention.
2. Stopping the activity decreases the heart’s need for oxygen and may help decrease the angina (chest pain).
3. The client should keep a diary of when angina occurs, what activity causes it, and how many nitroglycerin tablets are taken before chest pain is relieved.
4. If the chest pain (angina) is not relieved with three (3) nitroglycerin tablets, the client should call 911 or have someone take him to the emergency department. Notifying the HCP may take too long.

Question 34

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement?

1. Instruct client to keep a diary of activity, especially when having chest pain.
2. Discuss the need to remove the Holter monitor during a.m. care and showering.
3. Explain that all medications should be withheld while wearing a Holter monitor.
4. Teach the client the importance of decreasing activity while wearing the monitor.

Answer 34

1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity.
2. The Holter monitor should not be removed for any reason.
3. All medications should be taken as prescribed.
4. The client should perform all activity as usual while wearing the Holter monitor so the HCP can get an accurate account of heart function during a 24-hour period.

Question 35

Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet?

1. “I will not eat more than six (6) eggs a week.”
2. “I should bake or grill any meats I eat.”
3. “I will drink eight (8) ounces of whole milk a day.”
4. “I should not eat any type of pork products.”

Answer 35

1. According to the American Heart Associa- tion, the client should not eat more than three (3) eggs a week, especially the egg yolk.
2. The American Heart Association rec- ommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.
3. The client should drink low-fat milk, not whole milk.
4. Pork products (bacon, sausage, ham) are high in sodium, which is prohibited in a low-salt diet, not a low-cholesterol, low- fat diet.

Question 36

The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?

1. The 44-year-old client diagnosed with a myocardial infarction.
2. The 65-year-old client admitted with unstable angina.
3. The 75-year-old client scheduled for a cardiac catheterization.
4. The 50-year-old client complaining of chest pain.

Answer 36

1. This client is at high risk for complica- tions related to necrotic myocardial tissue and will need extensive teaching, so this client should not be assigned to a new graduate.
2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate.
3. A new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory.
4. Chest pain means this client could be hav- ing a myocardial infarction and should not be assigned to a new graduate.

Question 37

A client is being seen in the clinic to R/O mitral valve stenosis. Which assessment data would be most significant?

1. The client complains of shortness of breath when walking.
2. The client has jugular vein distention and 3+ pedal edema.
3. The client complains of chest pain after eating a large meal.
4. The client’s liver is enlarged and the abdomen is edematous.

Answer 37

1. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis.
2. Jugular vein distention (JVD) and 3+ pedal edema are signs/symptoms of right-sided heart failure and indicate worsening of the mitral valve stenosis. These signs would not be expected in a client with early manifestations of mitral valve stenosis.
3. Chest pain rarely occurs with mitral valve stenosis.
4. An enlarged liver and edematous abdomen are late signs of right-sided heart failure that can occur with long-term untreated mitral valve stenosis.

Question 38

Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?

1. A loud S1, S2 split, and a mitral opening snap.
2. A holosystolic murmur heard best at the cardiac apex.
3. A midsystolic ejection click or murmur heard at the base.
4. A high-pitched sound heard at the third left intercostal space.

Answer 38

1. This would be expected with mitral valve stenosis.
2. The murmur associated with mitral valve insufficiency is loud, high- pitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex.
3. This would be expected with mitral valve prolapse.
4. This would be expected with aortic regurgitation.

Question 39

The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching?

1. The client takes prophylactic antibiotics.
2. The client uses a soft-bristle toothbrush.
3. The client takes an enteric-coated aspirin daily.
4. The client alternates rest with activity.

Answer 39

1. Prophylactic antibiotics before invasive procedures prevent infectious endocarditis.
2. The client is undergoing anticoagulant therapy and should use a soft-bristle toothbrush to help prevent gum trauma and bleeding.
3. Aspirin and nonsteroidal anti- inflammatory drugs (NSAIDs) interfere with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore, the client should not take aspirin daily.
4. The client should alternate rest with activ- ity to prevent fatigue to help decrease the workload of the heart.

Question 40

The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological tissue valve replacement?

1. The client must take lifetime anticoagulant therapy.
2. The client’s infections are easier to treat.
3. There is a low incidence of thromboembolism.
4. The valve has to be replaced frequently.

Answer 40

1. An advantage of having a biological valve replacement is that no anticoagu- lant therapy is needed. Anticoagulant therapy is needed with a mechanical valve replacement.
2. This is an advantage of having a biological valve replacement; infections are harder to treat in clients with mechanical valve replacement.
3. This is an advantage of having a biological valve replacement; there is a high inci- dence of thromboembolism in clients with mechanical valve replacement.
4. Biological valves deteriorate and need to be replaced frequently; this is a dis- advantage of them. Mechanical valves do not deteriorate and do not have to be replaced often.

Question 41

The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client’s international normalized ratio (INR) is 2.7. Which action should the nurse implement?

1. Administer the medication as ordered.
2. Prepare to administer vitamin K (AquaMephyton).
3. Hold the medication and notify the HCP.
4. Assess the client for abnormal bleeding.

Answer 41

1. The therapeutic range for most clients’ INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld.
2. Vitamin K is the antidote for an overdose of warfarin, but 2.7 is within therapeutic range.
3. This laboratory result is within the thera- peutic range, INR 2 to 3, and the medica- tion does not need to be withheld.
4. There is no need for the nurse to assess for bleeding because 2.7 is within therapeutic range.

Question 42

Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.

1. Paroxysmal nocturnal dyspnea.
2. Orthopnea.
3. Cough.
4. Pericardial friction rub. 5. Pulsus paradoxus.

Answer 42

1. Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress, usually occurring at night because of the reclining position, and occurs in valvular disorders.
2. This is an abnormal condition in which a client must sit or stand to breathe comfortably and occurs in valvular disorders.
3. Coughing occurs when the client with long-term valvular disease has difficulty breathing when walking or performing any type of activity.
4. Pericardial friction rub is a sound auscul- tated in clients with pericarditis, not valvular heart disease.
5. Pulsus paradoxus is a marked decrease in amplitude during inspiration. It is a sign of cardiac tamponade, not valvular heart disease.

Question 43

The client is being evaluated for valvular heart disease. Which information would be most significant?

1. The client has a history of coronary artery disease.
2. There is a family history of valvular heart disease.
3. The client has a history of smoking for 10 years.
4. The client has a history of rheumatic heart disease.

Answer 43

1. An acute myocardial infarction can dam- age heart valves, causing tearing, ischemia, or damage to heart muscles that affects valve leaflet function, but coronary heart disease does not cause valvular heart disease.
2. Valvular heart disease does not show a genetic etiology.
3. Smoking can cause coronary artery disease, but it does not cause valvular heart disease.
4. Rheumatic heart disease is the most common cause of valvular heart disease.

Question 44

The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the recovery room nurse implement?

1. Assess the client’s chest tube output.
2. Monitor the client’s chest dressing.
3. Evaluate the client’s endotracheal (ET) lip line.
4. Keep the client’s affected leg straight.

Answer 44

1. Percutaneous balloon valvuloplasty is not an open-heart surgery; therefore, the chest will not be open and the client will not have a chest tube.
2. This is not an open-heart surgery; there- fore, the client will not have a chest dressing.
3. The endotracheal (ET) tube is inserted if the client is on a ventilator, and this surgery does not require putting the client on a ventilator.
4. In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to pre- vent hemorrhaging at the insertion site.

Question 45

The client with a mechanical valve replacement asks the nurse, “Why do I have to take antibiotics before getting my teeth cleaned?” Which response by the nurse is most appropriate?

1. “You are at risk of developing an infection in your heart.”
2. “Your teeth will not bleed as much if you have antibiotics.”
3. “This procedure may cause your valve to malfunction.”
4. “Antibiotics will prevent vegetative growth on your valves.”

Answer 45

1. The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure.
2. Antibiotics have nothing to do with how much the teeth bleed during a cleaning.
3. Teeth cleaning will not cause the valve to malfunction.
4. Vegetation develops on valves secondary to bacteria that cause endocarditis, but the client may not understand “vegetative growth on your valves”; therefore, this is not the most appropriate answer.

Question 46

The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement?

1. Restrict the client’s fluids as ordered.
2. Keep the client in the supine position.
3. Maintain oxygen saturation at 90%.
4. Monitor the total parenteral nutrition.

Answer 46

1. Fluid intake may be restricted to reduce the cardiac workload and pres- sures within the heart and pulmonary circuit.
2. The head of the bed should be elevated to help improve alveolar ventilation.
3. Oxygen saturation should be no less than 93%; 90% indicates an arterial oxygen saturation of around 60 (normal is 80 to 100)
4. Total parenteral nutrition would not be prescribed for a client with mitral valve replacement. It is ordered for clients with malnutrition, gastrointestinal disorders, or conditions in which increased calories are needed, such as burns.

Question 47

Which client would the nurse suspect of having a mitral valve prolapse?

1. A 60-year-old female with congestive heart failure.
2. A 23-year-old male with Marfan’s syndrome.
3. An 80-year-old male with atrial fibrillation.
4. A 33-year-old female with Down syndrome.

Answer 47

1. Congestive heart failure does not predis- pose the female client to having a mitral valve prolapse.
2. Clients with Marfan’s syndrome have life-threatening cardiovascular prob- lems, including mitral valve prolapse, progressive dilation of the aortic valve ring, and weakness of the arterial walls, and they usually do not live past the age of 40 because of dissection and rupture of the aorta.
3. Atrial fibrillation does not predispose a client to mitral valve prolapse.
4. A client with Down syndrome may have congenital heart anomalies but not mitral valve prolapse.

Question 48

The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor?

1. The client admitted for diagnostic tests to rule out valvular heart disease.
2. The client three (3) days post–myocardial infarction being discharged tomorrow.
3. The client exhibiting supraventricular tachycardia (SVT) on telemetry.
4. The client diagnosed with atrial fibrillation who has an INR of five (5).

Answer 48

1. This client requires teaching and an understanding of the preprocedure inter- ventions for diagnostic tests; therefore, a more experienced nurse should be assigned to this client.
2. Because this client is being discharged, it would be an appropriate assignment for the new graduate.
3. Supraventricular tachycardia (SVT) is not life threatening, but the client requires in- travenous medication and close monitor- ing and therefore should be assigned to a more experienced nurse.
4. A client with atrial fibrillation is usually taking the anticoagulant warfarin (Coumadin), and the therapeutic INR is 2 to 3. An INR of 5 is high and the client is at risk for bleeding.

Question 49

The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first?

1. Go to the client’s room to check the client.
2. Instruct the primary nurse to assess the client.
3. Contact the client on the client call system.
4. Request the nursing assistant to take the crash cart to the client’s room.

Answer 49

1. The telemetry nurse should not leave the monitors unattended at any time.
2. The telemetry nurse must have someone go assess the client, but this is not the first intervention.
3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emer- gency. After talking with the client, send a nurse to the room to check the monitor.
4. The crash cart should be taken to a room when the client is experiencing a code.

Question 50

The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first?

1. Administer epinephrine IVP.
2. Prepare to defibrillate the client.
3. Call a STAT code.
4. Start cardiopulmonary resuscitation.

Answer 50

1. There are many interventions that should be implemented prior to administering medication.
2. The treatment of choice for ventricular fibrillation is defibrillation, but it is not the first action.
3. The nurse must call a code that acti- vates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol.
4. The first person at the bedside should start cardiopulmonary resuscitation (CPR), but the telemetry nurse should call a code so that all necessary equipment and personnel are at the bedside.

Question 51

The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to order for this client?

1. Lidocaine.
2. Atropine.
3. Digoxin.
4. Adenosine.

Answer 51

1. Lidocaine suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias.
2. Atropine decreases vagal stimulation and is the drug of choice for asystole.
3. Digoxin slows heart rate and increases car- diac contractility and is the drug of choice for atrial fibrillation.
4. Adenosine is the drug of choice for supraventricular tachycardia.

Question 52

The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented?

1. Administer a thrombolytic medication.
2. Assess the client’s cardiovascular status.
3. Prepare for insertion of a pacemaker.
4. Obtain a permit for synchronized cardioversion.

Answer 52

1. A thrombolytic medication is administered for a client experiencing a myocardial infarction.
2. Assessment is an independent nursing action, not a collaborative treatment.
3. The client is symptomatic and will require a pacemaker.
4. Synchronized cardioversion is used for ventricular tachycardia with a pulse or atrial fibrillation.

Question 53

Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?

1. Defibrillate the client at 50, 100, and 200 joules.
2. Do not remove the oxygen source during defibrillation.
3. Place petroleum jelly on the defibrillator pads.
4. Shout “all clear” prior to defibrillating the client.

Answer 53

1. The adult client should be defibrillated at 360 joules.
2. The oxygen source should be removed to prevent any type of spark during defibrillation.
3. The nurse should use defibrillator pads or defibrillator gel to prevent any type of skin burns while defibrillating the client.
4. If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout “all clear.”

Question 54

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client?

1. Instruct the client to use a soft-bristle toothbrush.
2. Discuss the importance of getting a monthly partial thromboplastin time (PTT).
3. Teach the client about signs of pacemaker malfunction.
4. Explain to the client the procedure for synchronized cardioversion.

Answer 54

1. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush.
2. The client will need a regularly scheduled INR to determine the therapeutic level for the anticoagulant warfarin (Coumadin); PTT levels are monitored for heparin.
3. A client with symptomatic sinus bradycar- dia, not a client with atrial fibrillation, may need a pacemaker.
4. Synchronized cardioversion may be pre- scribed for new-onset atrial fibrillation but not for chronic atrial fibrillation.

Question 55

The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first?

1. Administer lidocaine, an antidysrhythmic, IVP.
2. Prepare to defibrillate the client.
3. Assess the client’s apical pulse and blood pressure.
4. Start basic cardiopulmonary resuscitation.

Answer 55

1. Lidocaine is the drug of choice for ventricular tachycardia, but it is not the first intervention.
2. Defibrillation may be needed, but it is not the first intervention.
3. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. If the client’s heart is beating, the nurse would then administer lidocaine.
4. CPR is only performed on a client who is not breathing and does not have a pulse. The nurse must establish if this is occur- ring first, prior to taking any other action.

Question 56

The client is in complete heart block. Which intervention should the nurse implement first?

1. Prepare to insert a pacemaker.
2. Administer atropine, an antidysrhythmic.
3. Obtain a STAT electrocardiogram (ECG).
4. Notify the health-care provider.

Answer 56

1. A pacemaker will have to be inserted, but it is not the first intervention.
2. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention.
3. A STAT ECG may be done, but the telemetry reading shows complete heart block, which is a life-threatening dys- rhythmia and must be treated.
4. The HCP will need to be notified but not prior to administering a medication. The test taker must assume the nurse has the order to administer medication. Many telemetry departments have standing protocols.

Question 57

The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply.

1. Start cardiopulmonary resuscitation.
2. Prepare to administer the antidysrhythmic adenosine IVP.
3. Prepare to defibrillate the client.
4. Bring the crash cart to the bedside.
5. Prepare to administer the antidysrhythmic amiodarone IVP.

Answer 57

1. Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted.
2. Adenosine, an antidysrhythmic, is the drug of choice for supraventricular tachycardia, not for ventricular fibrillation.
3. Defibrillation is the treatment of choice for ventricular fibrillation.
4. The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation.
5. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias.

Question 58

The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement?

1. Assess the apical heart rate for one (1) full minute.
2. Notify the client’s cardiac surgeon.
3. Prepare the client for synchronized cardioversion.
4. Determine if the client is having pain.

Answer 58

1. The telemetry reading is accurate, and there is no need for the nurse to assess the client’s heart rate.
2. There is no reason to notify the surgeon for a client exhibiting sinus tachycardia.
3. Synchronized cardioversion is prescribed for clients in acute atrial fibrillation or ventricular fibrillation with a pulse.
4. Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appro- priately. There is no specific medica- tion for sinus tachycardia.

Question 59

The client’s telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement?

1. Document this as normal sinus rhythm.
2. Request a 12-lead electrocardiogram.
3. Prepare to administer the cardiotonic digoxin PO.
4. Assess the client’s cardiac enzymes.

Answer 59

1. The P wave represents atrial contrac- tion, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action.
2. A 12-lead ECG should be requested for chest pain or abnormal dysrhythmias.
3. Digoxin is used to treat atrial fibrillation.
4. Cardiac enzymes are monitored to deter- mine if the client has had a myocardial in- farction. Nothing in the stem indicates the client has had an MI.

Question 60

Which client problem has priority for the client with a cardiac dysrhythmia?

1. Alteration in comfort.
2. Decreased cardiac output.
3. Impaired gas exchange.
4. Activity intolerance.

Answer 60

1. Not every cardiac dysrhythmia causes alteration in comfort; angina is caused by decreased oxygen to the myocardium.
2. Any abnormal electrical activity of the heart causes decreased cardiac output.
3. Impaired gas exchange is the result of pulmonary complications, not cardiac dysrhythmias.
4. Not all clients with cardiac dysrhythmias have activity intolerance.

Question 61

The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client?

1. Pulsus paradoxus.
2. Complaints of fatigue and arthralgias.
3. Petechiae and splinter hemorrhages.
4. Increased chest pain with inspiration.

Answer 61

1. Pulsus paradoxus is the hallmark of cardiac tamponade; a paradoxical pulse is markedly decreased in amplitude during inspiration.
2. Fatigue and arthralgias are nonspecific signs/symptoms that usually occur with myocarditis.
3. Petechiae on the trunk, conjunctiva, and mucous membranes and hemorrhagic streaks under the fingernails or toenails occur with endocarditis.
4. Chest pain is the most common symp- tom of pericarditis, usually has an abrupt onset, and is aggravated by res- piratory movements (deep inspiration, coughing), changes in body position, and swallowing.

Question 62

The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse?

1. Muffled heart sounds.
2. Nondistended jugular veins.
3. Bounding peripheral pulses.
4. Pericardial friction rub.

Answer 62

1. Acute pericardial effusion interferes with normal cardiac filling and pump- ing, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider.
2. Distended, not nondistended, jugular veins would warrant immediate intervention.
3. Decreasing quality of peripheral pulses, not bounding peripheral pulses, would warrant immediate intervention.
4. A pericardial friction rub is a classic symp- tom of acute pericarditis, but it would not warrant immediate intervention.

Question 63

The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis?

1. “Have you had a sore throat in the last month?”
2. “Did you have rheumatic fever as a child?”
3. “Do you have a family history of carditis?”
4. “What over-the-counter (OTC) medications do you take?”v

Answer 63

1. A sore throat in the last month would not support the diagnosis of carditis.
2. Rheumatic fever, a systemic inflamma- tory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of people who develop it.
3. Carditis is not a genetic or congenital disease process.
4. This is an appropriate question to ask any client, but OTC medications do not cause carditis.

Question 64

The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client?

1. Explain the importance of tapering off the medication.
2. Discuss that the medication will make the client drowsy.
3. Instruct the client to take the medication with food.
4. Tell the client to take the medication when the pain level is around “8.”

Answer 64

1. Steroids, such as prednisone, not NSAIDs, must be tapered off to prevent adrenal insufficiency.
2. NSAIDs will not make clients drowsy.
3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain.
4. NSAIDs should be taken regularly around the clock to help decrease inflammation, which, in turn, will decrease pain.

Question 65

The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first?

1. Administer oxygen via nasal cannula.
2. Evaluate the client’s urinary output.
3. Assess the client for cardiac complications.
4. Encourage the client to use the incentive spirometer.

Answer 65

1. Oxygen may be needed, but it is not the first intervention.
2. This would be appropriate to determine if the urine output is at least 30 mL/hr, but it is not the first intervention.
3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider.
4. Using the incentive spirometer will increase the client’s alveolar ventilation and help prevent atelectasis, but it is not the first intervention.

Question 66

The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client?

1. Prepare for a pericardiocentesis.
2. Request STAT cardiac enzymes.
3. Perform a 12-lead electrocardiogram.
4. Assess the client’s heart and lung sounds.

Answer 66

1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade.
2. Cardiac enzymes may be slightly elevated because of the inflammatory process, but evaluation of these would not be ordered to treat or evaluate cardiac tamponade.
3. A 12-lead ECG would not help treat the medical emergency of cardiac tamponade.
4. Assessment by the nurse is not collabora- tive; it is an independent nursing action.

Question 67

The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching?

1. “I must take all the prescribed antibiotics.”
2. “I may get a vaginal yeast infection with penicillin.”
3. “I will have no problems as long as I take my medication.”
4. “My throat culture was positive for a streptococcal infection.”

Answer 67

1. The full course of antibiotics must be taken to help ensure complete destruction of streptococcal infection.
2. Antibiotics kill bacteria but also destroy normal body flora in the vagina, bowel, and mouth, leading to a superinfection.
3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur.
4. A throat culture is taken to diagnose group A beta-hemolytic streptococcus and is positive in 25% to 40% of clients with acute rheumatic fever.

Question 68

Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

1. Pulmonary embolus.
2. Cerebrovascular accident.
3. Hemoptysis.
4. Deep vein thrombosis.

Answer 68

1. Pulmonary embolus would occur with an embolization of vegetative lesions from the tricuspid valve on the right side of the heart.
2. Bacteria enter the bloodstream from invasive procedures, and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegeta- tion breaks off, it will go through the left ventricle into the systemic circula- tion and may lodge in the brain, kidneys, or peripheral tissues.
3. Coughing up blood (hemoptysis) occurs when the vegetation breaks off the tricus- pid valve in the right side of the heart and enters the pulmonary artery.
4. Deep vein thrombosis is a complication of immobility, not of a vegetative embolus from the left side of the heart.

Question 69

Which nursing diagnosis would be priority for the client diagnosed with myocarditis?

1. Anxiety related to possible long-term complications.
2. High risk for injury related to antibiotic therapy.
3. Increased cardiac output related to valve regurgitation.
4. Activity intolerance related to impaired cardiac muscle function.

Answer 69

1. Anxiety is a psychosocial nursing diagnosis, which is not a priority over a physiological nursing diagnosis.
2. Antibiotic therapy does not result in injury to the client.
3. Myocarditis does not result in valve dam- age (endocarditis does), and there would be decreased, not increased, cardiac output.
4. Activity intolerance is priority for the client with myocarditis, an inflamma- tion of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output.

Question 70

The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching?

1. Be sure to allow for uninterrupted rest and sleep.
2. Refer client to outpatient occupational therapy.
3. Maintain oxygen via nasal cannula at two (2) L/min.
4. Discuss upcoming valve replacement surgery.

Answer 70

1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health.
2. Occupational therapy addresses activities of daily living.
3. The client should be referred to physical therapy to develop a realistic and progressive plan of activity. The client with pericarditis is not usually prescribed oxygen, and 2 L/min is a low dose of oxygen that is prescribed for a client with chronic obstructive pulmonary disease (COPD).
4. Endocarditis, not pericarditis, may lead to surgery for valve replacement.

Question 71

The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply.

1. Monitor vital signs every 15 minutes for the first hour.
2. Assess the client’s heart and lung sounds.
3. Record the amount of fluid removed as output.
4. Evaluate the client’s cardiac rhythm.
5. Keep the client in the supine position.

Answer 71

1. The nurse should monitor the vital signs for any client who has just undergone surgery.
2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure.
3. The pericardial fluid is documented as output.
4. Evaluating the client’s cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis.
5. The client should be in the semi-Fowler’s position, not in a flat position, which increases the workload of the heart.

Question 72

The client with infective endocarditis is admitted to the medical department. Which health-care provider’s order should be implemented first?

1. Administer intravenous antibiotic.
2. Obtain blood cultures times two (2).
3. Schedule an echocardiogram.
4. Encourage bedrest with bathroom privileges.

Answer 72

1. The nurse must obtain blood cultures prior to administering antibiotics.
2. Blood cultures must be done before administering antibiotics so that an ad- equate number of organisms can be obtained to culture and identify.
3. An echocardiogram allows visualization of vegetations and evaluation of valve function. However, antibiotic therapy is priority before diagnostic tests, and blood cultures must be obtained before administering medication.
4. Bedrest should be implemented, but the first intervention should be obtaining blood cultures so that antibiotic therapy can be started as soon as possible.