TEST 1: The Client with Cardiac Health Problems

Question 1

The Client with Acute Coronary Syndromes
1. A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead
electrocardiogram reveals ST elevation in the inferior leads and troponin levels are elevated. What is
the highest priority for nursing management of this client at this time?
1. Monitor daily weights and urine output.
2. Permit unrestricted visitation by family and friends.
3. Provide client education on medications and diet.
4. Reduce pain and myocardial oxygen demand.

Answer 1

1. 4. Nursing management for a client with a myocardial infarction should focus on pain
      management and decreasing myocardial oxygen demand. Fluid status should be closely monitored.
      Client education should begin once the client is stable and amenable to teaching. Visitation should be
      based on client comfort and maintaining a calm environment.
      CN: Physiological adaptation; CL: Synthesize

Question 2

2. A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of
   greatest concern for the nurse initiating the nitroglycerin drip?
3. Serum potassium is 3.5 mEq/L (3.5 mmol/L).
4. Blood pressure is 88/46.
5. ST elevation is present on the electrocardiogram.
6. Heart rate is 61.

Answer 2

2. 2. Nitroglycerin is a vasodilator that will lower blood pressure. The client is having chest pain
      and the ST elevation indicates injury to the myocardium, which may benefit from nitroglycerin. The
      potassium and heart rate are within normal range.
      CN: Pharmacological and parenteral therapies; CL: Analyze

Question 3

3. The nurse is caring for a client diagnosed with an anterior myocardial infarction 2 days ago.
   Upon assessment, the nurse identifies a systolic murmur at the apex. The nurse should first:
4. Assess for changes in vital signs.
5. Draw an arterial blood gas.
6. Evaluate heart sounds with the client leaning forward.
7. Obtain a 12-lead electrocardiogram.

Answer 3

3. 1. Infarction of the papillary muscles is a potential complication of an MI causing ineffective
      closure of the mitral valve during systole. Mitral regurgitation results when the left ventricle contracts
      and blood flows backward into the left atrium, which is heard at the fifth intercostal space, left
      midclavicular line. The murmur worsens during expiration and in the supine or left-side position.
      Vital sign changes will reflect the severity of the sudden drop in cardiac output: decrease in blood
      pressure, increase in heart rate, and increase in respirations. A 12-lead ECG views the electrical
      activity of the heart; an echocardiogram views valve function.
      CN: Physiological adaptation; CL: Synthesize

Question 4

4. A client with acute chest pain is receiving IV morphine sulfate. Which of the following results
   are intended effects of morphine? Select all that apply.
5. Reduces myocardial oxygen consumption.
6. Promotes reduction in respiratory rate.
7. Prevents ventricular remodeling.
8. Reduces blood pressure and heart rate.
9. Reduces anxiety and fear.

Answer 4

4. 1, 4, 5. Morphine sulfate acts as an analgesic and sedative. It also reduces myocardial oxygen
   consumption, blood pressure, and heart rate. Morphine also reduces anxiety and fear due to its
   sedative effects and by slowing the heart rate. It can depress respirations; however, such an effect
   may lead to hypoxia, which should be avoided in the treatment of chest pain. Angiotensin-converting
   enzyme–inhibitor drugs, not morphine, may help to prevent ventricular remodeling.
   CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 5

5. A client is receiving an IV infusion of heparin sodium at 1,200 units/h. The dilution is 25,000
   units/500 mL. How many milliliters per hour will this client receive?
   _________________ mL/h.

Answer 5

5. 24 mL/h

CN: Pharmacological and parenteral therapies; CL: Apply

Question 6

6. An older adult has chest pain and shortness of breath. The health care provider prescribes
   nitroglycerin tablets. What should the nurse instruct the client to do?
7. Put the tablet under the tongue until it is absorbed.
8. Swallow the tablet with 120 mL of water.
9. Chew the tablet until it is dissolved.
10. Place the tablet between the cheek and gums until it disappears.

Answer 6

6. 1. The client is having symptoms of a myocardial infarction. The first action is to prevent
      platelet formation and block prostaglandin synthesis. The client should place the tablet under the
      tongue and wait until it is absorbed. Nitroglycerin tablets are not effective if chewed, swallowed, or
      placed between the cheek and gums.
      CN: Physiological adaptation; CL: Apply

Question 7

7. The nurse has completed an assessment on a client with a decreased cardiac output. Which
   findings should receive the highest priority?
8. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
9. Confusion, urine output 15 mL over the last 2 hours, orthopnea.3. SpO 2 92 on 2 L nasal cannula, respirations 20, 1+ edema of lower extremities.
10. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.

Answer 7

7. 2. A low urine output and confusion are signs of decreased tissue perfusion. Orthopnea is a sign
      of left-sided heart failure. Crackles, edema, and weight gain should be monitored closely, but the
      levels are not as high a priority. With atrial fibrillation, there is a loss of atrial kick, but the blood
      pressure and heart rate are stable.
      CN: Physiological adaptation; CL: Analyze

Question 8

8. The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The
nurse should first:
1. Administer atropine 0.5 mg IV push.
2. Auscultate for abnormal heart sounds.
3. Prepare for transcutaneous pacing.
4. Take the client's blood pressure.

Answer 8

8. 4. The nurse should first assess the client’s tolerance to the drop in heart rate by checking the
      blood pressure and level of consciousness and determine if Atropine is needed. If the client is
      symptomatic, Atropine and transcutaneous pacing are interventions for symptomatic bradycardia.
      Once the client is stable, further physical assessments can be done.
      CN: Physiological adaptation; CL: Synthesize

Question 9

9. A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the
   heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that
   remains constant throughout the respiratory cycle. The nurse should document these findings as:
10. Heart rate irregular with S3.
11. Heart rate irregular with S4.
12. Heart rate irregular with aortic regurgitation.
13. Heart rate irregular with mitral stenosis.

Answer 9

9. 1. An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood
      rushes into the ventricles. To distinguish an S3 from a physiologic S2 split, a split S2 occurs during
      inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with
      the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard
      in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle. An S4 is
      not heard in a client with atrial fibrillation because there is no atrial contraction. Murmurs are sounds
      created by turbulent blood flow through an incompetent or stenotic valve.
      CN: Physiological adaptation; CL: Analyze

Question 10

10. A 60-year-old comes into the emergency department with crushing substernal chest pain that
    radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infarction (MI).
    Admission prescriptions include oxygen by nasal cannula at 4 L/min, complete blood count (CBC), a
    chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. The
    nurse should first:
11. Administer the morphine.
12. Obtain a 12-lead ECG.
13. Obtain the blood work.
14. Prescribe the chest radiograph.

Answer 10

10. 1. Although obtaining the ECG, chest radiograph, and blood work are all important, the
       nurse’s priority action should be to relieve the crushing chest pain. Therefore, administering morphine
       sulfate is the priority action.
       CN: Physiological adaptation; CL: Synthesize

Question 11

11. An older adult had a myocardial infarction (MI) 4 days ago. At 9:30 AM , the client’s blood
    pressure is 102/64. After reviewing the client’s progress notes (see chart), the nurse should first:
    1/10/14 12:30 am
    Urinary Output for the last 4 hours - 90 ml
    Capillary Refill >3 seconds
    BP 128/82
    Extremities Cool
    D. Smith, RN
12. Give a fluid challenge/bolus.
13. Notify the health care provider.3. Assist the client to walk.
14. Administer Lasix as prescribed.

Answer 11

11. 2. All of the 12 PM assessments are signs of decreased cardiac output and can be an ominous
       sign in a client who has recently experienced an MI; the nurse should notify the health care provider
       of these changes. Cardiac output and blood pressure may continue to fall to dangerous levels, which
       can induce further coronary ischemia and extension of the infarct. While the client is currently
       hypotensive, giving a fluid challenge/bolus can precipitate increased workload on a damaged heart
       and extend the myocardial infarction. Exercise or walking for this client will increase both the heartrate and stroke volume, both of which will increase cardiac output, but the increased cardiac output
       will increase oxygen needs especially in the heart muscle and can induce further coronary ischemia
       and extension of the infarct. The client is hypotensive. Although the client has decreased urinary
       output, this is the body’s response to a decreasing cardiac output, and it is not appropriate to
       administer Lasix.
       CN: Physiological adaptation; CL: Synthesize

Question 12

12. When administering a thrombolytic drug to the client who is experiencing a myocardial
    infarction (MI) and who has premature ventricular contractions, the expected outcome of the drug is
    to:
13. Promote hydration.
14. Dissolve clots.
15. Prevent kidney failure.
16. Treat dysrhythmias.

Answer 12

12. 2. Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse
       clots and reduce the extent of myocardial damage.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 13

13. The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the
    cardiac rhythm on the monitor (see the electrocardiogram strip below). The nurse should:
14. Notify the physician.
15. Call the rapid response team.
16. Assess the client for changes in the rhythm.
17. Administer lidocaine as prescribed.

Answer 13

13. 3. The client is experiencing a single PVC. PVCs are characterized by a QRS of longer than
       0.12 second and by a wide, notched, or slurred QRS complex. There is no P wave related to the QRS
       complex, and the T wave is usually inverted. PVCs are potentially serious and can lead to ventricular
       fibrillation or cardiac arrest when they occur more than 6 to 10 in an hour in clients with myocardial
       infarction. The nurse should continue to monitor the client and note if the PVCs are increasing. It is
       not necessary to notify the physician or call the rapid response team at this point. Lidocaine is not
       indicated from the data on this ECG.
       CN: Reduction of risk potential; CL: Synthesize

Question 14

14. A client admitted for a myocardial infarction (MI) develops cardiogenic shock. An arterial
    line is inserted. Which of the following prescriptions from the health care provider should the nurse
    verify before implementing?
15. Call for urine output less than 30 mL/h for 2 consecutive hours.
16. Metoprolol (Lopressor) 5 mg IV push.
17. Prepare for a pulmonary artery catheter insertion.
18. Titrate dobutamine (Dobutrex) to keep systolic BP greater than 100.

Answer 14

14. 2. Metoprolol is indicated in the treatment of hemodynamically stable clients with an acute MI
       to reduce cardiovascular mortality. Cardiogenic shock causes severe hemodynamic instability and a
       beta blocker will further depress myocardial contractility. The metoprolol should be discontinued.
       The decrease in cardiac output will impair perfusion to the kidneys. Cardiac output, hemodynamic
       measurements, and appropriate interventions can be determined with a PA catheter. Dobutamine will
       improve contractility and increase the cardiac output that is depressed in cardiogenic shock.
       CN: Physiological adaptation; CL: Synthesize

Question 15

15. The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for
    cardiogenic shock. The nurse should report which of the following changes on the client’s chart to the
    physician?

1 PM 
BP  110/70
T  98.7
HR 70
RR  20
Urine Output  90 ml/h

3 PM
BP  100/65
T  99
HR 75
RR  26
Urine Output  20 ml/h

1. Urine output.
2. Heart rate.
3. Blood pressure.
4. Respiratory rate.

Answer 15

15. 1. Oliguria occurs during cardiogenic shock because there is reduced blood flow to the
       kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse,
       decreased urine output, and signs of diminished blood flow to the brain, such as confusion and
       restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching
       90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client’s
       chart are not as significant as the decreased urinary output.
       CN: Reduction of risk potential; CL: Analyze

Question 16

16. The physician prescribes continuous IV nitroglycerin infusion for the client with myocardial
    infarction. The nurse should:
17. Obtain an infusion pump for the medication.
18. Take the blood pressure every 4 hours.
19. Monitor urine output hourly.
20. Obtain serum potassium levels daily.

Answer 16

lood pressure monitoring would be done with a continuous system, and more frequently than every 4
hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not
associated with nitroglycerin infusion.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 17

17. The client is admitted to the telemetry unit due to chest pain. The client has polysubstance
    abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. The nurse
    should do the following in which order from first to last?
18. Obtain a history of which drugs the client has used recently.
19. Administer the prescribed dose of morphine.
20. Position electrodes on the chest.
21. Take vital signs.

Answer 17

17.
3. Position electrodes on the chest.
4. Take vital signs.
2. Administer the prescribed dose of morphine.
1. Obtain a history of which drugs the client has used recently.
The nurse should first connect the client to the monitor by attaching the electrodes.
Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and
conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the
client’s heart. The nurse next obtains vital signs to establish a baseline. Next, the nurse should
administer the morphine; morphine is the drug of choice in relieving myocardial infarction (MI) pain;
it may cause a transient decrease in blood pressure. When the client is stable, the nurse can obtain a
history of the client’s drug use.
CN: Reduction of risk potential; CL: Synthesize

Question 18

18. The nurse is assessing a client who has had a myocardial infarction. The nurse notes the
    cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as:
19. Atrial fibrillation.
20. Ventricular tachycardia.
21. Premature ventricular contractions.
22. Sinus tachycardia.

Answer 18

18. 4. Sinus tachycardia is characterized by normal conduction and a regular rhythm, but with a
       rate exceeding 100 bpm. A P wave precedes each QRS, and the QRS is usually normal.
       CN: Reduction of risk potential; CL: Analyze

Question 19

19. While caring for a client who has sustained a myocardial infarction (MI), the nurse notes
    eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is
    receiving an IV infusion of 5% dextrose in water (D 5 W) and oxygen at 2 L/min. The nurse’s first
    course of action should be to:
20. Increase the IV infusion rate.
21. Notify the physician promptly.
22. Increase the oxygen concentration.
23. Administer a prescribed analgesic.

Answer 19

19. 2. PVCs are often a precursor of life-threatening arrhythmias, including ventricular
       tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs
       occur at a rate greater than five or six per minute in the post-MI client, the physician should be
       notified immediately. More than six PVCs per minute is considered serious and usually calls for
       decreasing ventricular irritability by administering medications such as lidocaine hydrochloride.
       Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen
       concentration should not be the nurse’s first course of action; rather, the nurse should notify the
       physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
       CN: Physiological adaptation; CL: Synthesize

Question 20

20. Which of the following is an expected outcome for a client on the second day of
    hospitalization after a myocardial infarction (MI)? The client:
21. Continues to have severe chest pain.
22. Can identify risk factors for MI.
23. Participates in a cardiac rehabilitation walking program.
24. Can perform personal self-care activities without pain.

Answer 20

20. 4. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal
       care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of
       hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a
       walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation
       program.
       CN: Physiological adaptation; CL: Evaluate

Question 21

21. Which of the following is an expected outcome when a client is receiving an IV
    administration of furosemide?
22. Increased blood pressure.
23. Increased urine output.
24. Decreased pain.
25. Decreased premature ventricular contractions.

Answer 21

21. 2. Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not
       increase blood pressure, decrease pain, or decrease arrhythmias.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 22

22. The nurse is preparing to measure central venous pressure (CVP). Mark the spot on the torso
    indicating the location for leveling the transducer.

Answer 22

22. Correct location: The zero point on the CVP transducer needs to be at the level of the right atrium.
    The right atrium is located at the midaxillary line at the fourth intercostal space. The phlebostatic axis
    is determined by drawing an imaginary vertical line from the fourth intercostal space at the sternal
    border to the right side of the chest (A). A secondary imaginary line is drawn horizontally at the level
    of the midpoint between the anterior and posterior surfaces of the chest (B). The phlebostatic axis is
    located at the intersection of points A and B.
    CN: Physiologic adaptation; CL: Apply

Question 23

23. A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring
    with the catheter, the nurse will wedge the catheter to gain information about which of the following?
24. Cardiac output.
25. Right atrial blood flow.
26. Left end-diastolic pressure.
27. Cardiac index.

Answer 23

23. 3. When wedged, the catheter is “pointing” indirectly at the left end-diastolic pressure. The
       pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and
       allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter
       reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left
       ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1
       minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated
       by dividing the client’s cardiac output by the client’s body surface area, and is considered a more
       accurate reflection of the individual client’s cardiac output. Right atrial blood pressure is not
       measured with the pulmonary artery catheter.
       CN: Physiologic adaptation; CL: Apply

Question 24

24. After a myocardial infarction, the hospitalized client is taught to move the legs while resting
    in bed. The expected outcome of this exercise is to:
25. Prepare the client for ambulation.
26. Promote urinary and intestinal elimination.
27. Prevent thrombophlebitis and blood clot formation.
28. Decrease the likelihood of pressure ulcer formation.

Answer 24

24. 3. Encouraging the client to move the legs while in bed is a preventive strategy taught to all
       clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in
       venous return and prevents venous stasis in the lower extremities. These exercises are not intended to
       prepare the client for ambulation. These exercises are not associated with promoting urinary and
       intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer
       formation.
       CN: Physiological adaptation; CL: Apply

Question 25

25. Which of the following is the most appropriate diet for a client during the acute phase of
myocardial infarction?
1. Liquids as desired.
2. Small, easily digested meals.
3. Three regular meals per day.
4. Nothing by mouth.

Answer 25

25. 2. Recommended dietary principles in the acute phase of MI include avoiding large meals
       because small, easily digested foods are better tolerated. Fluids are given according to the client’s
       needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart
       failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids
       only or restricted to nothing by mouth unless their condition is very unstable.
       CN: Physiological adaptation; CL: Apply

Question 26

26. The nurse is caring for a client who recently experienced a myocardial infarction and has
    been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of
    the following points? Select all that apply.
27. The client should report unexpected bleeding or bleeding that lasts a long time.
28. The client should take Plavix with food.
29. The client may bruise more easily and may experience bleeding gums.
30. Plavix works by preventing platelets from sticking together and forming a clot.
31. The client should drink a glass of water after taking Plavix.

Answer 26

26. 1, 3, 4. Plavix is generally well absorbed and may be taken with or without food; it should be
    taken at the same time every day and, while food may help prevent potential GI upset, food has noeffect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must
    understand the importance of reporting any unexpected, prolonged, or excessive bleeding including
    blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the
    client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot
    formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke,
    peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water
    after taking Plavix.
    CN: Pharmacological and parenteral therapies; CL: Create

Question 27

27. Which client is at greatest risk for coronary artery disease?
28. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
29. A 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L).
30. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin.
31. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).

Answer 27

27. 4. The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk.
       Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than
       40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women
       55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and
       decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client
       at greatest risk.
       CN: Health promotion and maintenance; CL: Analyze

Question 28

28. A middle-aged adult with a family history of CAD has the following: total cholesterol 198(11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148
    (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care
    provider prescribes a statin medication and aspirin. The client asks the nurse why these medications
    are needed. Which is the best response by the nurse?
29. “The labs indicate severe hyperlipidemia and the medications will lower your LDL, along
    with a low-fat diet.”
30. “The triglycerides are elevated and will not return to normal without these medications.”
31. “The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be
    lowered by the medications prescribed.”
32. “These medications will reduce the risk of type 2 diabetes.”

Answer 28

28. 3. CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease.
       The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to
       evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels,
       and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas
       statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within
       normal limits.
       CN: Physiological adaptation; CL: Synthesize

Question 29

29. The client has been managing angina episodes with nitroglycerin. Which of the following
indicate the drug is effective?
1. Decreased chest pain.
2. Increased blood pressure.
3. Decreased blood pressure.
4. Decreased heart rate.

Answer 29

29. 1. Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it
       easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand
       reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may
       decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not
       related to the angina the patient is experiencing. Increased blood pressure would mean the heart
       would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect
       of nitroglycerine.
       CN: Pharmacological and parenteral therapy; CL: Evaluate

Question 30

30. If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating
    a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may
    be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors
    by:
31. Explaining how the risk factor behavior leads to poor health.
32. Withholding praise until the new behavior is well established.
33. Rewarding the client whenever the acceptable behavior is performed.
34. Instilling mild fear into the client to extinguish the behavior.

Answer 30

30. 3. A basic principle of behavior modification is that behavior that is learned and continued is
       behavior that has been rewarded. Other reinforcement techniques have not been found to be as
       effective as reward.
       CN: Psychosocial integrity; CL: Synthesize

Question 31

31. Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is
    administered during the first 6 hours after onset of myocardial infarction (MI) to:
32. Control chest pain.
33. Reduce coronary artery vasospasm.
34. Control the arrhythmias associated with MI.
35. Revascularize the blocked coronary artery.

Answer 31

31. 4. The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the
       coronary artery. The drug is most effective when administered within the first 6 hours after onset of
       MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation.
       Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary
       artery and re-establish a blood supply to the area.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 32

32. After the administration of t-PA, the nurse should:
33. Observe the client for chest pain.
34. Monitor for fever.
35. Review the 12-lead electrocardiogram (ECG).
36. Auscultate breath sounds.

Answer 32

32. 1. Although monitoring the 12-lead ECG and monitoring breath sounds are important,observing the client for chest pain is the nursing assessment priority because closure of the previously
       obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent
       closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and
       monitoring of partial thromboplastin time are essential to detect complications. Administration of t-
       PA should not cause fever.
       CN: Reduction of risk potential; CL: Analyze

Question 33

33. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse
    should have resuscitation equipment available because reperfusion of the cardiac tissue can result in
    which of the following?
34. Cardiac arrhythmias.
35. Hypertension.
36. Seizure.
37. Hypothermia.

Answer 33

33. 1. Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac
       arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed
       with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion
       of the cardiac tissue.
       CN: Reduction of risk potential; CL: Synthesiz

Question 34

34. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client
    for which of the following contradictions to administering the drug?
35. Age greater than 60 years.
36. History of cerebral hemorrhage.
37. History of heart failure.
38. Cigarette smoking.

Answer 34

34. 2. A history of cerebral hemorrhage is a contraindication to administration of t-PA because the
       risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and
       cigarette smoking are not contraindications.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 35

35. A client has driven himself to the emergency department. He is 50 years old, has a history of
    hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has
    indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen
    at 2 L/min per nasal cannula. The nurse’s next action should be to:
36. Call for the physician.
37. Start an IV infusion.
38. Obtain a portable chest radiograph.
39. Draw blood for laboratory studies.

Answer 35

35. 2. Advanced cardiac life support recommends that at least one or two IV lines be inserted in
       one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph,
       and drawing blood for the laboratory are important but secondary to starting the IV line.
       CN: Physiological adaptation; CL: Synthesize

Question 36

36. Crackles heard on lung auscultation indicate which of the following?
37. Cyanosis.
38. Bronchospasm.
39. Airway narrowing.
40. Fluid-filled alveoli.

Answer 36

36. 4. Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do
       not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are
       associated with wheezing sounds.
       CN: Physiological adaptation; CL: Analyze

Question 37

37. A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest
    heaviness. The first nursing action should be to:
38. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
39. Administer oxygen via nasal cannula.
40. Offer pain medication for the chest heaviness.
41. Inform the physician of the chest heaviness.

Answer 37

37. 1. Further assessment is needed in this situation. It is premature to initiate other actions until
       further data have been gathered. Inquiring about the onset, duration, location, severity, and
       precipitating factors of the chest heaviness will provide pertinent information to convey to the
       physician.
       CN: Reduction of risk potential; CL: Synthesize

Question 38

38. The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The
    client reports being unable to perform activities that require physical exertion. The nurse should
    further assess the client for which of the following?
39. Left ventricular atrophy.
40. Irregular heartbeats.
41. Peripheral vascular occlusion.
42. Pacemaker placement.

Answer 38

38. 1. In older adults who are less active and do not exercise the heart muscle, atrophy can result.
       Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a
       result, under sudden emotional or physical stress, the left ventricle is less able to respond to the
       increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and
       heart failure are examples of the chronic conditions that may develop in response to inactivity, rather
       than in response to the aging process. Irregular heartbeats are generally not associated with an older
       sedentary adult’s lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect
       response to stress.
       CN: Physiological adaptation; CL: Analyze

Question 39

39. Following diagnosis of angina pectoris, a client reports being unable to walk up two flights
    of stairs without pain. Which of the following measures would most likely help the client prevent this
    problem?
40. Climb the steps early in the day.
41. Rest for at least an hour before climbing the stairs.
42. Take a nitroglycerin tablet before climbing the stairs.
43. Lie down after climbing the stairs.

Answer 39

39. 3. Nitroglycerin may be used prophylactically before stressful physical activities such as stair
       climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact
       on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent anactivity-related pain episode.
       CN: Reduction of risk potential; CL: Synthesize

Question 40

40. The client who experiences angina has been told to follow a low-cholesterol diet. Which of
    the following meals would be best?
41. Hamburger, salad, and milkshake.2. Baked liver, green beans, and coffee.
42. Spaghetti with tomato sauce, salad, and coffee.
43. Fried chicken, green beans, and skim milk.

Answer 40

40. 3. Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a
       low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.
       CN: Basic care and comfort; CL: Apply

Question 41

41. Which of the following symptoms should the nurse teach the client with unstable angina to
    report immediately to the physician?
42. A change in the pattern of the chest pain.
43. Pain during sexual activity.
44. Pain during an argument.
45. Pain during or after a physical activity.

Answer 41

41. 1. The client should report a change in the pattern of chest pain. It may indicate increasing
       severity of coronary artery disease. Pain occurring during stress or sexual activity would not be
       unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or
       after an activity such as lawn mowing also would not be unexpected; the client may be instructed to
       take nitroglycerin to prevent this pain or may be restricted from doing such activities.
       CN: Reduction of risk potential; CL: Apply

Question 42

42. The physician refers the client with unstable angina for a cardiac catheterization. The nurse
    explains to the client that this procedure is being used in this specific situation to:
43. Open and dilate blocked coronary arteries.
44. Assess the extent of arterial blockage.
45. Bypass obstructed vessels.
46. Assess the functional adequacy of the valves and heart muscle

Answer 42

42. 2. Cardiac catheterization is done in clients with angina primarily to assess the extent and the
       severity of the coronary artery blockage. A decision about medical management, angioplasty, or
       coronary artery bypass surgery will be based on the catheterization results. Coronary bypass surgery
       would be used to bypass obstructed vessels. Although cardiac catheterization can be used to assess
       the functional adequacy of the valves and heart muscle, in this case the client has unstable angina and
       therefore would need the procedure to assess the extent of arterial blockage.
       CN: Reduction of risk potential; CL: Apply

Question 43

43. The client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) to treat
    angina. Priority goals for the client immediately after PTCA should include:
44. Minimizing dyspnea.
45. Maintaining adequate blood pressure control.
46. Decreasing myocardial contractility.
47. Preventing fluid volume deficit.

Answer 43

43. 4. Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may
       experience diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium
       levels must be closely monitored because the client may develop hypokalemia due to the diuresis.
       Dyspnea would not be anticipated after this procedure. Maintaining adequate blood pressure control
       should not be a problem after the procedure. Increased myocardial contractility would be a goal, not
       decreased contractility.
       CN: Reduction of risk potential; CL: Synthesize

Question 44

44. Which of the following is not a risk factor for the development of atherosclerosis?
45. Family history of early heart attack.
46. Late onset of puberty.
47. Total blood cholesterol level greater than 220 mg/dL (12.2 mmol/L).
48. Elevated fasting blood glucose concentration.

Answer 44

44. 2. Late onset of puberty is not generally considered to be a risk factor for the development of
       atherosclerosis. Risk factors for atherosclerosis include family history of atherosclerosis, cigarette
       smoking, hypertension, high blood cholesterol level, male gender, diabetes mellitus, obesity, and
       physical inactivity.
       CN: Physiological adaptation; CL: Apply

Question 45

45. As an initial step in treating a client with angina, the physician prescribes nitroglycerin
    tablets, 0.3 mg given sublingually. This drug’s principal effects are produced by:
46. Antispasmodic effects on the pericardium.
47. Causing an increased myocardial oxygen demand.
48. Vasodilation of peripheral vasculature.
49. Improved conductivity in the myocardium

Answer 45

45. 3. Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen
       consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase
       blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand.
       Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 46

46. A client has a throbbing headache when nitroglycerin is taken for angina. The nurse should
    instruct the client that:
47. Acetaminophen (Tylenol) or Ibuprofen (Advil) can be taken for this common side effect.
48. Nitroglycerin should be avoided if the client is experiencing this serious side effect.
49. Taking the nitroglycerin with a few glasses of water will reduce the problem.
50. The client should lie in a supine position to alleviate the headache.

Answer 46

46. 1. Headache is a common side effect of nitroglycerin that can be alleviated with aspirin,
       acetaminophen, or ibuprofen. The sublingual nitroglycerin needs to be absorbed in the mouth, which
       will be disrupted with drinking. Lying flat will increase blood flow to the head and may increase pain
       and exacerbate other symptoms, such as shortness of breath.
       CN: Physiological adaptation; CL: Synthesize

Question 47

47. How should the nurse instruct the client with unstable angina to use sublingual nitroglycerin
    tablets when chest pain occurs? “Sit down and then
48. take one tablet every 2 to 5 minutes until the pain stops.”
49. take one tablet and rest for 15 minutes. Call the physician if pain persists after 15 minutes.”3. take one tablet, then if the pain persists take additional two tablets in 5 minutes. Call the
    physician if pain persists after 15 minutes.”
50. take one tablet. If pain persists after 5 minutes call 911.”

Answer 47

47. 4. The nurse should instruct the client that correct protocol for using sublingual nitroglycerin
       involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the
       bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit
       down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, the
       client should call 911. Although some physicians may recommend taking a second or third tablet
       spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take two
       tablets at once. Nitroglycerin acts within 2 to 3 minutes and the client should not wait 15 minutes to
       take further action. The client should call 911 to obtain emergency help rather than calling the
       physician.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 48

48. A client with angina is taking nifedipine. The nurse should teach the client to:
49. Monitor blood pressure monthly.
50. Perform daily weights.
51. Inspect gums daily.
52. Limit intake of green leafy vegetables.

Answer 48

48. 3. The client taking nifedipine should inspect the gums daily to monitor for gingival
       hyperplasia. This is an uncommon adverse effect but one that requires monitoring and intervention if
       it occurs. The client taking nifedipine might be taught to monitor blood pressure, but more often than
       monthly. These clients would not generally need to perform daily weights or limit intake of green
       leafy vegetables.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 49

49. The nurse is developing a teaching plan for a client who will be starting a prescription for
    Zocor (simvastatin) 40 mg/day. The nurse should instruct the client about which of the following?
    Select all that apply.
50. “Take once a day in the morning.”
51. “If you miss a dose, take it when you remember it, but do not double the dose if you do not
    remember to take it until it is time for your next dose.”
52. “Limit greens such as lettuce in the diet to prevent bleeding.”
53. “Be sure to take the pill with food.”
54. “Report muscle pain or tenderness to your health care provider.”
55. “Continue to follow a diet that is low in saturated fats.”

Answer 49

49. 2, 5, 6. Zocor (simvastatin) is used in combination with diet and exercise to decrease elevated
    total cholesterol. The client should take Zocor in the evening, and the nurse should instruct the client
    that if a dose is missed, to take it as soon as remembered, but not to take at the same time as the next
    scheduled dose. It is not necessary to take the pill with food. The client does not need to limit greens
    (limiting greens is appropriate for clients taking Coumadin), but the nurse should instruct the client to
    avoid grapefruit and grapefruit juice, which can increase the amount of the drug in the bloodstream. A
    serious side effect is myopathy, and the client should report muscle pain or tenderness to the health
    care provider.
    CN: Pharmacology; CL: Create

Question 50

The Client with Heart Failure
50. Captopril, furosemide, and metoprolol are prescribed for a client with systolic heart failure.
The client's blood pressure is 136/82 and the heart rate is 65. Prior to medication administration at 9
AM , the nurse reviews the following lab tests (see chart). Which of the following should the nurse do
first?
Sodium 140 mEq/L
Potassium 6.8 mEq/L
Chloride  101 mEq/L
CO2 Content 26 mEq/L
BUN 18mg/dL
Creatinine 1 mg /dL
Hgb 12g/dL
Hct 37%

1. Administer the medications.
2. Call the physician.
3. Withhold the captopril.
4. Question the metoprolol dose.

Answer 50

The Client with Heart Failure
50. 3. The nurse should withhold the dose of captopril; captopril is an ACE-inhibitor and a side
effect of the medication is hyperkalemia. The BUN and creatinine, which are normal, should be
viewed prior to administration since renal insufficiency is another potential side effect of an ACE-I.
The heart rate is within normal limits. The nurse should question the dose of metoprolol if the client’s
heart rate is bradycardic. The hemoglobin and hematocrit are normal for a female. The nurse should
report the high potassium level and that the captopril was withheld.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 51

51. A client with chronic heart failure has atrial fibrillation and a left ventricular ejection
    fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to:
52. Decrease circulatory overload.
53. Improve the myocardial workload.
54. Prevent thrombus formation.
55. Regulate cardiac rhythm.

Answer 51

51. 3. Coumadin is an anticoagulant, which is used in the treatment of atrial fibrillation and
       decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release
       of emboli into the circulation. The client may also take other medication as needed to manage the
       heart failure. Coumadin does not reduce circulatory load or improve myocardial workload.
       Coumadin does not affect cardiac rhythm.
       CN: Reduction of risk potential; CL: Evaluate

Question 52

52. A client has a history of heart failure and has been furosemide (Lasix), digoxin (Lanoxin), and
    potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes
    that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse
    should assess the client for signs of which of the following?
53. Hyperkalemia.
54. Digoxin toxicity.
55. Fluid deficit.
56. Pulmonary edema.

Answer 52

52. 2. Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual
       disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is acommon cause of digoxin toxicity associated with arrhythmias because low serum potassium can
       enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client’s
       history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is
       manifested by dyspnea and coughing.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 53

53. The nurse should assess the client with left-sided heart failure for which of the following?
    Select all that apply.
54. Dyspnea.
55. Jugular vein distention (JVD).
56. Crackles.4. Right upper quadrant pain.
57. Oliguria.
58. Decreased oxygen saturation levels.

Answer 53

53. 1, 3, 5, 6. Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and
    symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided
    heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated
    with congestion of the peripheral tissues and viscera in right-sided heart failure.
    CN: Physiological adaptation; CL: Apply

Question 54

54. Which of the following sets of conditions is an indication that a client with a history of left-
    sided heart failure is developing pulmonary edema? Select all that apply.
55. Distended jugular veins.
56. Dependent edema.
57. Anorexia.
58. Coarse crackles.
59. Tachycardia.

Answer 54

54. 4, 5. Signs of pulmonary edema are identical to those of acute heart failure. Signs and
    symptoms are generally apparent in the respiratory system and include coarse crackles, severe
    dyspnea, and tachypnea. Severe tachycardia occurs due to sympathetic stimulation in the presence of
    hypoxemia. Blood pressure may be decreased or elevated, depending on the severity of the edema.
    Jugular vein distention, dependent edema, and anorexia are symptoms of right-sided heart failure.
    CN: Physiological adaptation; CL: Analyze

Question 55

55. An older adult with a history of heart failure is admitted to the emergency department with
    pulmonary edema. On admission which of the following should the nurse assess first?
56. Blood pressure.
57. Skin breakdown.
58. Serum potassium level.
59. Urine output.

Answer 55

55. 1. It is a priority to assess blood pressure first because people with pulmonary edema
       typically experience severe hypertension that requires early intervention. The client probably does
       not have skin breakdown, but when the client is stable and when the nurse obtains a complete health
       history, the nurse should inspect the client’s skin for any signs of breakdown; however, when the client
       is stable, the nurse should inspect the skin. Potassium levels are not the first priority. The nurse
       should monitor urine output after the client is stable.
       CN: Reduction of risk potential; CL: Analyze

Question 56

56. The nurse is assessing a client with chronic heart failure who is demonstrating
    neurohormonal compensatory mechanisms. Which of the following are expected findings on
    assessment? Select all that apply.
57. Decreased cardiac output.
58. Increased heart rate.
59. Vasoconstriction in skin, GI tract, and kidneys.
60. Decreased pulmonary perfusion.
61. Fluid overload.

Answer 56

56. 1, 2, 3, 5. Heart failure can be a result of several cardiovascular conditions, which will affect
    the heart’s ability to pump effectively. The body attempts to compensate through several
    neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid
    baroreceptors, which activates the sympathetic nervous system to release norepinephrine and
    epinephrine. This early response increases the heart rate and contractility. It also has some negative
    effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due
    to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process resulting in the
    release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure,
    therefore cardiac output. In the damaged heart, this causes fluid overload. There is no
    parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or
    concomitant pulmonary disease.
    CN: Physiologic adaptation; CL: Analyze

Question 57

57. Lasix (furosemide) 40 mg intravenous push (IVP) is prescribed. Lasix 10 mg/mL is available. The
    nurse should administer
    _________________________ mL.

Answer 57

57. 4 mL. Desired amount (D) divided by what is available (H), times quantity (Q) = amount to
    administer. D = 40 mg divided by H = 10 mg/mL; equals 40 divided by 10 = 4 mL.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 58

58. In which of the following positions should the nurse place a client with heart failure who has
    orthopnea?
59. Semisitting (low Fowler’s position) with legs elevated on pillows.
60. Lying on the right side (Sims’ position) with a pillow between the legs.
61. Sitting upright (high Fowler’s position) with legs resting on the mattress.
62. Lying on the back with the head lowered (Trendelenburg’s position) and legs elevated.

Answer 58

58. 3. Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous
       return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum
       space for lung expansion. Low Fowler’s position would be used if the client could not tolerate highFowler’s position for some reason. Lying on the right side would not be a good position for the client
       in heart failure. The client in heart failure would not tolerate Trendelenburg’s position.
       CN: Reduction of risk potential; CL: Synthesize

Question 59

59. The major goal of nursing care for a client with heart failure and pulmonary edema is to:
60. Increase cardiac output.
61. Improve respiratory status.
62. Decrease peripheral edema.
63. Enhance comfort.

Answer 59

59. 1. Increasing cardiac output is the main goal of therapy for the client with heart failure or
       pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention.
       Respiratory status and comfort will be improved when cardiac output increases to an acceptable
       level. Peripheral edema is not typically associated with pulmonary edema.
       CN: Reduction of risk potential; CL: Apply

Question 60

60. A client with heart failure is receiving digoxin intravenously. The nurse should determine the
    effectiveness of the drug by assessing which of the following?
61. Dilated coronary arteries.2. Increased myocardial contractility.
62. Decreased cardiac arrhythmias.
63. Decreased electrical conductivity in the heart.

Answer 60

60. 2. Digoxin is a cardiac glycoside with positive inotropic activity. This inotropic activity
       causes increased strength of myocardial contractions and thereby increases output of blood from the
       left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat
       arrhythmias and does decrease the electrical conductivity of the myocardium, these are not primary
       reasons for its use in clients with heart failure and pulmonary edema.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 61

61. Furosemide is administered intravenously to a client with heart failure. How soon after
    administration should the nurse begin to see evidence of the drug’s desired effect?
62. 5 to 10 minutes.
63. 30 to 60 minutes.
64. 2 to 4 hours.
65. 6 to 8 hours.

Answer 61

61. 1. After intravenous injection of furosemide, diuresis normally begins in about 5 minutes and
       reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is
       given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given
       intravenously.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 62

62. The nurse teaches a client with heart failure to take oral furosemide in the morning. The
    primary reason for this is to help:
63. Prevent electrolyte imbalances.
64. Retard rapid drug absorption.
65. Excrete excessive fluids accumulated during the night.
66. Prevent sleep disturbances during the night.

Answer 62

62. 4. When diuretics are given early in the day, the client will void frequently during the daytime
       hours and will not need to void frequently during the night. Therefore, the client’s sleep will not be
       disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or
       retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the
       night.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 63

63. The nurse should teach the client that signs of digoxin toxicity include which of the
    following?
64. Rash over the chest and back.
65. Increased appetite.
66. Visual disturbances such as seeing yellow spots.
67. Elevated blood pressure.

Answer 63

63. 3. Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain,
       anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of
       toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and
       elevated blood pressure are not associated with digoxin toxicity.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 64

64. The nurse should assess the client for digoxin toxicity if serum levels indicate that the client
has a:
1. Low sodium level.
2. High glucose level.
3. High calcium level.
4. Low potassium level.

Answer 64

64. 4. A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity.
       Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the
       client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not
       affect digoxin or contribute to digoxin toxicity.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 65

65. Which of the following foods should the nurse teach a client with heart failure to limit when
following a 2-g sodium diet?
1. Apples.
2. Tomato juice.
3. Whole wheat bread.
4. Beef tenderloin.

Answer 65

65. 2. Canned foods and juices such as tomato juice are typically high in sodium and should be
       avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or
       limited are available. The client should be taught to read labels carefully. Apples and whole wheat
       breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato
       juice.CN: Reduction of risk potential; CL: Apply

Question 66

66. A client receiving a loop diuretic should be encouraged to eat which of the following foods?
Select all that apply.
1. Angel food cake.
2. Banana.
3. Dried fruit.
4. Orange juice.
5. Peppers.

Answer 66

66. 2, 3, 4. Hypokalemia is a side effect of loop diuretics. Bananas, dried fruit, and oranges are
    examples of food high in potassium. Angel food cake, yellow cake, and peppers are low in
    potassium.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 67

67. When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal
    space. The nurse should further assess the client for:1. Left atrial enlargement.
68. Left ventricular enlargement.
69. Right atrial enlargement.
70. Right ventricular enlargement.

Answer 67

67. 2. A normal apical impulse is found over the apex of the heart and is typically located and
       auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or
       auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left
       ventricular enlargement.
       CN: Physiological adaptation; CL: Analyze

Question 68

68. The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left
    ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into
    bed. Based on this finding, what should the nurse do first?
69. Assess respiratory status.
70. Draw blood for laboratory studies.
71. Insert a Foley catheter.
72. Weigh the client.

Answer 68

68. 1. The ankle edema suggests fluid volume overload. The nurse should assess respiratory rate,
       lung sounds, and SpO 2 to identify any signs of respiratory symptoms of heart failure requiring
       immediate attention. The nurse can then draw blood for laboratory studies, insert the Foley catheter,
       and weigh the client.
       CN: Physiological adaptation; CL: Synthesize

Question 69

69. The nurse’s discharge teaching plan for the client with heart failure should emphasize the
    importance of doing which of the following?
70. Maintaining a high-fiber diet.
71. Walking 2 miles (3.2 km) every day.
72. Obtaining daily weights at the same time each day.
73. Remaining sedentary for most of the day.

Answer 69

69. 3. Heart failure is a complex and chronic condition. Education should focus on health
       promotion and preventive care in the home environment. Signs and symptoms can be monitored by the
       client. Instructing the client to obtain daily weights at the same time each day is very important. The
       client should be told to call the physician if there has been a weight gain of 2 lb (0.91 kg) or more.
       This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis,
       rather than waiting until the symptoms become life threatening. Following a high-fiber diet is
       beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an
       exercise program for the client, such as walking 2 miles (3.2 km) every day, would not be appropriate
       at discharge. The client’s exercise program would need to be planned in consultation with the
       physician and based on the history and the physical condition of the client. The client may require
       exercise tolerance testing before an exercise plan is laid out. Although the nurse does not prescribe an
       exercise program for the client, a sedentary lifestyle should not be recommended.
       CN: Reduction of risk potential; CL: Create

Question 70

70. When teaching a client with heart failure about preventing complications and future
    hospitalizations, which problems stated by the client as reasons to call the physician would indicate
    to the nurse that the client has understood the teaching? Select all that apply.
71. Becoming increasingly short of breath at rest.
72. Weight gain of 2 lb (0.9 kg) or more in 1 day.
73. High intake of sodium for breakfast.
74. Having to sleep sitting up in a reclining chair.
75. Weight loss of 2 lb (0.9 kg) in 1 day.

Answer 70

70. 1, 2, 4. If the client will call the physician when there is increasing shortness of breath, weight
    gain over 2 lb (0.9 kg) in 1 day, and need to sleep sitting up, this indicates an understanding of the
    teaching because these signs and symptoms suggest worsening of the client’s heart failure. Although
    the client will most likely be placed on a sodium-restricted diet, the client would not need to notify
    the physician if he or she had consumed a high-sodium breakfast. Instead the client would need to be
    alert for possible signs and symptoms of worsening heart failure and work to reduce sodium intake
    for the rest of that day and in the future.
    CN: Reduction of risk potential; CL: Evaluat

Question 71

The Client with Valvular Heart Disease
71. A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty
for mitral stenosis. Which of the following requires immediate nursing action?
1. A low, grade 1 intensity mitral regurgitation murmur.
2. SpO 2 is 94% on 2 L of oxygen via nasal cannula.
3. The client has become more somnolent.
4. Urine output has decreased from 60 mL/h to 40 mL over the last hour.

Answer 71

The Client with Valvular Heart Disease
71. 3. A complication of balloon valvuloplasty is emboli resulting in a stroke. The client’s
increased drowsiness should be evaluated. Some degree of mitral regurgitation is common after the
procedure. The oxygen status and urine output should be monitored closely, but do not warrantconcern.
CN: Reduction of risk potential; CL: Synthesiz

Question 72

72. An elderly client with diabetes who has been maintained on metformin (Glucophage) has
    been scheduled for a cardiac catheterization. The nurse should verify that the physician has written a
    prescription to:
73. Limit the amount of protein in the diet prior to the cardiac cath.
74. Withhold the Glucophage prior to the cardiac catheterization.
75. Administer the Glucophage with only a sip of water prior to the cardiac catheterization.
76. Give the Glucophage before breakfast.

Answer 72

72. 2. The nurse should verify that the physician has requested to withhold the Glucophage prior
       to any procedure requiring dye such as a cardiac catheterization due to the increased risk of lactic
       acidosis. Additionally, the drug will usually be withheld for up to 48 hours following a procedure
       involving dye while it clears the client’s system. The physician may prescribe sliding scale insulin
       during this time if needed. Regardless of how or when the medication is administered, the medication
       should be withheld. The amount of protein in the client’s diet prior to the cardiac catheterization has
       no correlation with the medication or the test.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 73

73. A client with aortic stenosis has increasing dyspnea and dizziness. Identify the area where the
    nurse would place the stethoscope to assess a murmur from aortic stenosis.

Answer 73

73. 73. The stethoscope is placed at the second intercostal space right of sternum (1) to assess the
        aortic area, (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5)
        is the Mitral valve area.
        CN: Physiological adaptation; CL: Apply

Question 74

74. A client is scheduled for a cardiac catheterization. The nurse should do which of the
    following preprocedure tasks? Select all that apply.
75. Administer all prescribed oral medications.
76. Check for iodine sensitivity.
77. Verify that written consent has been obtained.4. Withhold food and oral fluids before the procedure.
78. Insert a urinary drainage catheter.

Answer 74

74. 2, 3, 4. For clients scheduled for a cardiac catheterization it is important to assess for iodine
    sensitivity, verify written consent, and instruct the client to take nothing by mouth for 6 to 18 hours
    before the procedure. Oral medications are withheld unless specifically prescribed. A urinary
    drainage catheter is rarely required for this procedure.
    CN: Reduction of risk potential; CL: Apply

Question 75

75. Which is the most important initial postprocedure nursing assessment for a client who has
    had a cardiac catheterization?
76. Monitor the laboratory values.
77. Observe neurologic function every 15 minutes.
78. Observe the puncture site for swelling and bleeding.
79. Monitor skin warmth and turgor.

Answer 75

75. 3. Assessment of circulatory status, including observation of the puncture site, is of primary
       importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are
       important to monitor but are not the most important initial nursing assessment. Neurologic assessmentevery 15 minutes is not required.
       CN: Reduction of risk potential; CL: Analyze

Question 76

76. A client experiences initial indications of excitation after having an IV infusion of lidocaine
    hydrochloride started. The nurse should further assess the client when the client reports having:
77. Palpitations.
78. Tinnitus.
79. Urinary frequency.
80. Lethargy.

Answer 76

76. 2. Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred
       vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures,
       and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary
       frequency, and lethargy are not considered typical adverse reactions to lidocaine.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 77

77. A pulmonary artery catheter is inserted in a client with severe mitral stenosis and
    regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a
    Nitroprusside (Nipride) drip per physician prescriptions. The nurse notices a sudden drop in the
    pulmonary artery diastolic pressure and pulmonary artery wedge pressure. The nurse should first
    assess:
78. 12-lead EKG.
79. Blood pressure.
80. Lung sounds.
81. Urine output.

Answer 77

77. 2. The nurse should immediately assess the blood pressure since Nipride and Lasix can cause
       severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride
       dose should be reduced or discontinued. Urine output should then be monitored to make sure there is
       adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A
       reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.
       CN: Physiological adaptation; CL: Synthesize

Question 78

78. A client has mitral stenosis and will have a valve replacement. The nurse is instructing the
    client about health maintenance prior to surgery. Inability to follow which of the following regimens
    would pose the greatest health hazard to this client at this time?
79. Medication therapy.
80. Diet modification.
81. Activity restrictions.
82. Dental care.

Answer 78

78. 1. Preoperatively, anticoagulants may be prescribed for the client with advanced valvular
       heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients
       with bioprosthesis are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage
       schedule and observing specific precautions are necessary to prevent hemorrhage or
       thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent
       recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis
       after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet
       modification, activity restrictions, and dental care are important; however, they do not have as much
       significance postoperatively as medication therapy does

CN: Reduction of risk potential; CL: Evaluate

Question 79

79. In preparing the client and the family for a postoperative stay in the intensive care unit (ICU)
    after open heart surgery, the nurse should explain that:
80. The client will remain in the ICU for 5 days.
81. The client will sleep most of the time while in the ICU.
82. Noise and activity within the ICU are minimal.
83. The client will receive medication to relieve pain.

Answer 79

79. 4. Management of postoperative pain is a priority for the client after surgery, including valve
       replacement surgery. The client and family should be informed that pain will be assessed by the nurse
       and medications will be given to relieve the pain. The client will stay in the ICU as long as
       monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and
       disrupted sleep and rest patterns are some environmental factors that affect recovery from valve
       replacement surgery.
       CN: Reduction of risk potential; CL: Synthesize

Question 80

80. A client who has undergone a mitral valve replacement has persistent bleeding from the
    sternal incision during the early postoperative period. The nurse should do which of the following?
    Select all that apply.
81. Administer warfarin.
82. Check the postoperative CBC, INR, PTT, and platelet levels.
83. Confirm availability of blood products.4. Monitor the mediastinal chest tube drainage.
84. Start a dopamine drip for a systolic BP less than 100.

Answer 80

80. 2, 3, 4. The hemoglobin and hematocrit should be assessed to evaluate blood loss. An
    elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may
    require blood products depending on lab values and severity of bleeding; therefore, availability of
    blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from
    the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding.
    Anticoagulation should be held at this time. Information is needed on the type of valve replacement.
    For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require
    anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia.
    Fluid volume assessment should always be done first. Volume replacement should be initiated in a
    hypovolemic client prior to starting an inotrope such as dopamine.
    CN: Physiological adaptation; CL: Synthesize

Question 81

81. The most effective measure the nurse can use to prevent wound infection when changing a
    client’s dressing after coronary artery bypass surgery is to:
82. Observe careful handwashing procedures.
83. Clean the incisional area with an antiseptic.
84. Use prepackaged sterile dressings to cover the incision.
85. Place soiled dressings in a waterproof bag before disposing of them.

Answer 81

81. 1. Many factors help prevent wound infections, including washing hands carefully, using
       sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of
       soiled dressings properly. However, most authorities say that the single most effective measure in
       preventing wound infections is to wash the hands carefully before and after changing dressings.
       Careful hand washing is also important in reducing other infections often acquired in hospitals, such
       as urinary tract and respiratory tract infections.
       CN: Reduction of risk potential; CL: Synthesize

Question 82

82. For a client who excretes excessive amounts of calcium during the postoperative period after
    open heart surgery, which of the following measures should the nurse institute to help prevent
    complications associated with excessive calcium excretion?
83. Ensure a liberal fluid intake.
84. Provide an alkaline-ash diet.
85. Prevent constipation.
86. Enrich the client’s diet with dairy products.

Answer 82

82. 1. In an immobilized client, calcium leaves the bone and concentrates in the extracellular
       fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form
       calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless
       contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the
       solubility of calcium. Preventing constipation is not associated with excessive calcium excretion.
       Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.
       CN: Physiological adaptation; CL: Synthesize

Question 83

83. The nurse should teach the client who is receiving warfarin sodium that:
84. Partial thromboplastin time values determine the dosage of warfarin sodium.
85. Protamine sulfate is used to reverse the effects of warfarin sodium.
86. International Normalized Ratio (INR) is used to assess effectiveness.
87. Warfarin sodium will facilitate clotting of the blood.

Answer 83

83. 3. INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the
       prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health
       Organization was used for the plasma test. It is now the recommended method to monitor
       effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should
       range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium
       and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess
       the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is us84. 1, 4, 5. Daily dental care including brushing the teeth twice a day and flossing once a day and
       frequent checkups by a dentist who is informed about the client’s condition are required to maintain
       good oral health. The client can use a regular tooth brush; it is not necessary to avoid use of an
       electric toothbrush. Taking antibiotics prior to certain dental procedures is recommended only if the
       client has a prosthetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash.
       CN: Reduction of risk potential; CL: Createed to reverse warfarin
       sodium’s anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin
       sodium will help to prevent blood clots.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 84

84. Good dental care is an important measure in reducing the risk of endocarditis. A teaching
    plan to promote good dental care in a client with mitral stenosis should include instructing the client
    to do which of the following? Select all that apply.
85. Brush the teeth at least twice a day.
86. Avoid use of an electric toothbrush.
87. Take an antibiotic prior to oral surgery.
88. Floss the teeth at least once a day.
89. Have regular dental checkups.
90. Rinse the mouth with an antibiotic mouthwash once a day.

Answer 84

84. 1, 4, 5. Daily dental care including brushing the teeth twice a day and flossing once a day and
    frequent checkups by a dentist who is informed about the client’s condition are required to maintain
    good oral health. The client can use a regular tooth brush; it is not necessary to avoid use of an
    electric toothbrush. Taking antibiotics prior to certain dental procedures is recommended only if the
    client has a prosthetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash.
    CN: Reduction of risk potential; CL: Create

Question 85

85. Before a client’s discharge after mitral valve replacement surgery, the nurse should evaluate
    the client’s understanding of postsurgery activity restrictions. Which of the following should the client
    not engage in until after the 1-month postdischarge appointment with the surgeon?
86. Showering.
87. Lifting anything heavier than 10 lb (4.5 kg).
88. A program of gradually progressive walking.
89. Light housework.

Answer 85

85. 2. Most cardiac surgical clients have median sternotomy incisions, which take about 3 months
       to heal. Measures that promote healing include avoiding heavy lifting, performing muscle
       reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as
       the incision is well approximated with no open areas or drainage. Activities should be gradually
       resumed on discharge.
       CN: Safety and infection control; CL: Evaluate

Question 86

86. Three days after mitral valve replacement surgery, the client tells the nurse there is a
    “clicking” noise coming from the chest incision and the incision seems to becoming larger. The
    nurse’s response should reflect the understanding that the client may be experiencing which of the
    following?
87. Anxiety related to altered body image.
88. Anxiety related to altered health status.3. Altered tissue perfusion.
89. Lack of knowledge regarding the postoperative course.

Answer 86

86. 1. Verbalized concerns from this client may stem from anxiety over the changes in the body
       after open heart surgery. Although the client may experience anxiety related to altered health status or
       may have a lack of knowledge regarding the postoperative course, the client is pointing out the
       changes in the body image. The client is not concerned about altered tissue perfusion.
       CN: Psychosocial integrity; CL: Analyze

Question 87

The Client with Hypertension
87. Metoprolol (Toprol XL) is added to the pharmacologic therapy of a diabetic female
diagnosed with stage 2 hypertension initially treated with Furosemide (Lasix) and Ramipril (Altace).
An expected therapeutic effect is:
1. Decrease in heart rate.
2. Lessening of fatigue.
3. Improvement in blood sugar levels.
4. Increase in urine output.

Answer 87

The Client with Hypertension
87. 1. The effect of a beta blocker is a decrease in heart rate, contractility, and afterload, which
leads to a decrease in blood pressure. The client at first may have an increase in fatigue when starting
the beta blocker. The mechanism of action does not improve blood sugar or urine output.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 88

88. Which set of postural vital signs (BP and heart rate) indicate inadequate blood volume?
Supine
124/76, 88.
Sitting 124/74, 92.
Standing 122/74, 92.
Supine
120/70, 70.
Sitting 102/64, 86.
Standing 100/60, 92.
Supine
138/86, 74.
Sitting 136/84, 80.
Standing 134/82, 82.
Supine
100/70, 72.
Sitting 100/68, 74.
Standing 98/68, 80.

Answer 88

88. 2. There was a significant change in both blood pressure and heart rate with position change.
       This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for
       an increase in heart rate of 5 to 20 bpm, a possible slight decrease of less than 5 mm Hg in the
       systolic blood pressure, and a possible slight increase of less than 5 mm Hg in the diastolic blood
       pressure.
       CN: Management of care; CL: Analyz

Question 89

89. A client is taking clonidine (Catapres) for treatment of hypertension. The nurse should teach
    the client about which of the following common adverse effects of this drug? Select all that apply.
90. Dry mouth.
91. Hyperkalemia.
92. Impotence.
93. Pancreatitis.
94. Sleep disturbance.

Answer 89

89. 1, 3, 5. Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces sympathetic
    outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible
    adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 90

90. A client with hypertensive emergency is being treated with sodium nitroprusside (Nipride). In a
    dilution of 50 mg/250 mL, how many micrograms of Nipride are in each milliliter?
    __________________ mcg.

Answer 90

90. 200 mcg

Question 91

91. The nurse is discussing medications with a client with hypertension who has a prescription
    for furosemide (Lasix) daily. The client needs further education when the client states which of the
    following?
92. “I know I should not drive after taking my Lasix.”
93. “I should be careful not to stand up too quickly when taking Lasix.”
94. “I should take the Lasix in the morning instead of before bed.”4. “I need to be sure to also take the potassium supplement that the doctor prescribed along with
    my Lasix.”

Answer 91

91. 1 Furosemide (Lasix) is a diuretic often prescribed for clients with hypertension or heart
    failure; the drug should not affect a client’s ability to drive safely. Lasix may cause orthostatic
    hypotension and clients should be instructed to be careful when changing from supine to sitting to
    standing position. Diuretics should be taken in the morning if possible to prevent sleep disturbance
    due to the need to get up to void. Lasix is a loop diuretic that is not potassium sparing; clients should
    take potassium supplements as prescribed and have their serum potassium levels checked at
    prescribed intervals.
    CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 92

92. In teaching the client with hypertension to avoid orthostatic hypotension, the nurse should
    emphasize which of the following instructions? Select all that apply.
93. Plan regular times for taking medications.
94. Arise slowly from bed.
95. Avoid standing still for long periods.
96. Avoid excessive alcohol intake.
97. Avoid hot baths.

Answer 92

92. 2, 3. Changing positions slowly and avoiding long periods of standing may limit the
    occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood
    pressure management, but this aspect is not related to the development of orthostatic hypotension.
    Excessive alcohol intake and hot baths are associated with vasodilation.
    CN: Reduction of risk potential; CL: Creat

Question 93

93. The nurse is teaching a client with hypertension about taking atenolol (Tenormin). The nurse
    should instruct the client to:
94. Avoid sudden discontinuation of the drug.
95. Monitor the blood pressure annually.
96. Follow a 2-g sodium diet.
97. Discontinue the medication if severe headaches develop.

Answer 93

93. 1. Atenolol is a beta-adrenergic antagonist indicated for management of hypertension. Sudden
       discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should
       not be discontinued without a physician’s prescription. Blood pressure needs to be monitored more
       frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are
       not usually placed on a 2-g sodium diet for hypertension.
       CN: Pharmacological and parenteral therapies; CL: Synthesiz

Question 94

94. The nurse teaches a client who has recently been diagnosed with hypertension about
    following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would
    best meet the client’s needs?
95. Mixed green salad with blue cheese dressing, crackers, and cold cuts.
96. Ham sandwich on rye bread and an orange.
97. Baked chicken, an apple, and a slice of white bread.
98. Hot dogs, baked beans, and celery and carrot sticks.

Answer 94

94. 3. Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high inboth fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary
       restrictions of all types are complex and difficult to implement with clients who are basically
       asymptomatic.
       CN: Basic care and comfort; CL: Apply

Question 95

95. A client who has diabetes is taking metoprolol (Lopressor) for hypertension. Which of the
    following information should the nurse include in the teaching plan? Select all that apply
96. These tablets should be taken with food at same time each day.
97. Do not crush or chew the tablets.
98. Notify the health care provider if pulse is 82 per minute.
99. Have a blood glucose level drawn every 6 to 12 months during therapy.
100. Use an appropriate decongestant if needed.
101. Report any fainting spells to the health care provider.

Answer 95

95. 1, 2, 4, 6. Metoprolol (Lopressor) is a beta-adrenergic blocker indicated for hypertension,
    angina, and myocardial infarction. The tablets should be taken with food at same time each day; they
    should not be chewed or crushed. The health care provider should be notified if pulse falls below 50
    for several days. Blood glucose should be checked regularly during therapy since increased episodes
    of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia,
    and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must
    be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need
    to be reduced or discontinued.
    CN: Pharmacological and parenteral therapies; CL: Create

Question 96

96. An older adult with a history of hypertension is admitted with diagnosis of dehydration. The
    client is becoming increasingly confused and weak. The client reports taking one tablet of
    hydrochlorothiazide (HydroDIURIL) daily, and the prescription is written for 1/2 tablet. The nurse
    should obtain additional information about:
97. Decreased drug half-life of the HydroDIURIL.
98. Decreased hepatic blood flow.
99. Increased GI activity.
100. Increased urinary elimination.

Answer 96

96. 2. Aging causes decreased hepatic blood flow. Decreased drug metabolism, which occurs
       with aging, along with more drug in circulation means the drug will remain in the body longer and
       produce greater drug effects. The client has also taken more drug than prescribed increasing the
       opportunity for more drug action to occur. When there is decreased metabolism of drugs, an increase
       in the half-life will occur most especially in the older adult. In older adults transit time (GI motility)
       is slower, allowing more drug to be absorbed. Increased urinary elimination would mean that drug
       elimination could be higher not lower and accumulating in the body.
       CN: Physiological adaptation; CL: Analyze

Question 97

97. A client diagnosed with primary (essential) hypertension is taking chlorothiazide (Diuril).
    The nurse determines teaching about this medication is effective when the client makes the following
    statement. “I will (Select all that apply.)
98. take my weight daily at the same time each day.”2. not drink alcoholic beverages while on this medication.”
99. reduce salt intake in my diet.”
100. reduce my dosage if I have severe dizziness.”
101. use sunscreen if I have prolonged exposure to sunlight.”
102. take the drug late in the evening.”

Answer 97

97. 1, 2, 3, 5. Chlorothiazide (Diuril) causes increased urination and decreased swelling (if there
    is edema) and weight loss. It is important to check and record weight two to three times per week at
    same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or
    take other medications without the approval of the health care provider. Reducing sodium intake in
    the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses
    are less likely to cause adverse effects and hence excessive table salt as well as salty foods should be
    avoided. Chlorothiazide (Diuril) is a diuretic that is prescribed for lower blood pressure and may
    cause dizziness and faintness when the patient stands up suddenly. This can be prevented or
    decreased by changing positions slowly. If dizziness is severe, the health care provider must be
    notified. Diuretics may cause sensitivity to sunlight, hence the need to avoid prolonged exposure to
    sunlight, use sunscreens, and wear protective clothing. Chlorothiazide (Diuril) causes increased
    urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer
    bathroom trips mean less interference with sleep and less risk of falls.
    CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 98

98. Which intervention would be most likely to assist the client with hypertension in maintaining
    an exercise program?
99. Giving the client a written exercise program.
100. Explaining the exercise program to the client’s spouse.
101. Reassuring the client that he or she can do the exercise program.
102. Tailoring a program to the client’s needs and abilities.

Answer 98

98. 4. Tailoring or individualizing a program to the client’s lifestyle has been shown to be an
       effective strategy for changing health behaviors. Providing a written program, explaining the program
       to the client’s spouse, and reassuring the client that he or she can do the program may be helpful but
       are not as likely to promote adherence as individualizing the program.
       CN: Psychosocial integrity; CL: Synthesize

Question 99

99. The client realizes the importance of quitting smoking, and the nurse develops a plan to help
    the client achieve this goal. Which of the following nursing interventions should be the initial step in
    this plan?
100. Review the negative effects of smoking on the body.
101. Discuss the effects of passive smoking on environmental pollution.
102. Establish the client’s daily smoking pattern.
103. Explain how smoking worsens high blood pressure.

Answer 99

99. 3. A plan to reduce or stop smoking begins with establishing the client’s personal daily
       smoking pattern and activities associated with smoking. It is important that the client understands theassociated health and environmental risks, but this knowledge has not been shown to help clients
       change their smoking behavior.
       CN: Psychosocial integrity; CL: Synthesize

Question 100

100. When teaching a client about propranolol hydrochloride, the nurse should base the
     information on the knowledge that propranolol:
101. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial
     contractility, and conduction.
102. Increases norepinephrine secretion and thus decreases blood pressure and heart rate.
103. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and
     lowers blood pressure.
104. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the
     conversion of angiotensin I to angiotensin II.

Answer 100

100. 1. Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing
        heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not
        increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to
        angiotensin II.
        CN: Pharmacological and parenteral therapies; CL: Apply

Question 101

101. The most important long-term goal for a client with hypertension is to:
102. Learn how to avoid stress.
103. Explore a job change or early retirement.
104. Make a commitment to long-term therapy.
105. Lose weight.

Answer 101

101. 3. Compliance is the most critical element of hypertension therapy. In most cases,
        hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully
        without drug therapy. Stress management is an important component of hypertension therapy, but the
        priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but
        rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will
        contribute to lower blood pressure, but the client must first accept the need for a lifelong management
        plan to control the hypertension.
        CN: Psychosocial integrity; CL: Synthesize

Question 102

102. The client has had hypertension for 20 years. The nurse should assess the client for:
103. Renal insufficiency and failure.
104. Valvular heart disease.
105. Endocarditis.
106. Peptic ulcer disease.

Answer 102

102. 1. Renal disease, including renal insufficiency and failure, is a complication of hypertension.
        Effective treatment of hypertension assists in preventing this complication. Valvular heart disease,
        endocarditis, and peptic ulcer disease are not complications of hypertension.
        CN: Reduction of risk potential; CL: Synthesize

Question 103

103. The nurse is developing a care plan with an older adult with hypertension and is instructing
     the client that hypertension can be a “silent killer.” The nurse should instruct the client to report signs
     of which of the following diseases that are often a result of undetected high blood pressure?
104. Cerebrovascular accidents (CVAs).
105. Liver disease.3. Myocardial infarction.
106. Pulmonary disease.

Answer 103

103. 1. Hypertension is referred to as the silent killer for adults, because until the adult has
        significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-
        term hypertension. Liver or pulmonary disease is not generally associated with hypertension.
        Myocardial infarction is generally related to coronary artery disease.
        CN: Reduction of risk potential; CL: Create

Question 104

104. A hospitalized client who is being treated for hypertension with furosemide (Lasix),
     atenolol (Tenormin), and ramipril (Altace) develops a second-degree heart block Mobitz type 1.
     Which of the following actions should the nurse take?
105. Administer a 250-mL fluid bolus.
106. Withhold the atenolol.
107. Prepare for cardioversion.
108. Set up for an arterial line.

Answer 104

104. 2. The client may be asymptomatic and the underlying cause should be assessed. Drugs that
        block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers,
        digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing.
        There is no indication for a fluid bolus, cardioversion, or arterial line.
        CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 105

The Client with Dysrhythmias
105. A client is admitted to the hospital for evaluation of recurrent episodes of ventricular
tachycardia as observed on Holter monitoring. The client is scheduled for electrophysiology studies
(EPS) the following morning. Which statement should the nurse include in a teaching plan for this
client?
1. “You will continue to take your medications until the morning of the test.”
2. “You might be sedated during the procedure and will not remember what has happened.”
3. “This test is a noninvasive method of determining the effectiveness of your medication
regimen.”
4. “During the procedure, the doctor will insert a special wire to increase the heart rate and
produce the irregular beats that caused your signs and symptoms.”

Answer 105

The Client with Dysrhythmias
105. 4. The purpose of EPS is to study the heart’s electrical system. During this invasive
procedure, a special wire is introduced into the heart to produce dysrhythmia. To prepare for this
procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held
for at least 24 hours before the test in order to study the dysrhythmia without the influence of
medications. Because the client’s verbal responses to the rhythm changes are extremely important,
sedation is avoided if possible.
CN: Physiological integrity; CL: Create

Question 106

106. During physical assessment, the nurse should further assess the client for signs of atrial
     fibrillation when palpation of the radial pulse reveals:
107. Two regular beats followed by one irregular beat.
108. An irregular rhythm with pulse rate greater than 100.
109. Pulse rate below 60 bpm.
110. A weak, thready pulse.

Answer 106

106. 2. Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totallyirregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note
        the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a
        client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular
        contraction.
        CN: Reduction of risk potential; CL: Analyze

Question 107

107. When teaching the client about complications of atrial fibrillation, the nurse should instruct
     the client to avoid which of the following?
108. Stasis of blood in the atria.
109. Increased cardiac output.
110. Decreased pulse rate.
111. Elevated blood pressure.

Answer 107

107. 1. Atrial fibrillation occurs when the sinoatrial node no longer functions as the heart’s
        pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is
        disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to
        emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial
        fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased
        pulse rate; rather, it is associated with an increased pulse rate.
        CN: Reduction of risk potential; CL: Synthesize

Question 108

108. When teaching a client about self-care following placement of a new permanent pacemaker
     to the left upper chest, the nurse should include which information? Select all that apply.
109. Take and record daily pulse rate.
110. Avoid air travel because of airport security alarms.
111. Immobilize the affected arm for 4 to 6 weeks.
112. Avoid using a microwave oven.
113. Avoid lifting anything heavier than 3 lb (1.36 kg).

Answer 108

108. 1, 5. The nurse must teach the client how to take and record the pulse daily. The client should
     be instructed to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It
     takes up to 2 months for the incision site to heal and full range of motion to return. The client should
     avoid heavy lifting until approved by the physician. The pacemaker metal casing does not set off
     airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required.
     Microwave ovens are safe to use and do not alter pacemaker function.
     CN: Reduction of risk potential; CL: Create

Question 109

109. A client has been admitted to the coronary care unit. The nurse observes third-degree heart
     block at a rate of 35 bpm on the client’s cardiac monitor. The client has a blood pressure of 90/60.
     The nurse should take which of the following actions first?
110. Prepare for transcutaneous pacing.
111. Prepare to defibrillate the client at 200 J.
112. Administer an IV lidocaine infusion.
113. Schedule the operating room for insertion of a permanent pacemaker.

Answer 109

109. 1. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an
        emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of
        third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent
        pacemaker can be inserted.
        CN: Physiological adaptation; CL: Synthesize

Question 110

110. A client is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD).
     The spouse expresses anxiety about what would happen if the device discharges during physical
     contact. The nurse should tell the spouse:
111. Physical contact should be avoided whenever possible.2. They will not feel the countershock.
112. The shock would be felt, but it would not cause any harm.
113. A warning device sounds before countershock, so there is time to move away.

Answer 110

110. 4. An implanted defibrillator (ICD) always provides at least three beeps before delivering a
        countershock, and the nurse should tell the spouse to move away when they hear those beeps. The
        spouse can have physical contact with the client but if the ICD were to discharge while the spouse
        had contact with the client the spouse would feel the shock and could also be harmed. The spouse
        will feel the countershock if touching the client and it would harm the spouse.
        CN: Management of care; CL: Synthesize

Question 111

111. An older adult is admitted to the telemetry unit for placement of a permanent pacemaker
     because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a
     permanent pacemaker is to:
112. Maintain skin integrity.
113. Maintain cardiac conduction stability.
114. Decrease cardiac output.
115. Increase activity level.

Answer 111

111. 2. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately
        after artificial pacemaker implantation. The client should have continuous electrocardiographic
        monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an
        immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it.
        The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client
        should also restrict movement of the affected extremity for 24 hours.
        CN: Reduction of risk potential; CL: Synthesize

Question 112

112. The client who had a permanent pacemaker implanted 2 days earlier is being discharged
     from the hospital. The client understands the discharge plan when the client:
113. Selects a low-cholesterol diet to control coronary artery disease.
114. States a need for bed rest for 1 week after discharge.
115. Verbalizes safety precautions needed to prevent pacemaker malfunction.
116. Explains signs and symptoms of myocardial infarction (MI).

Answer 112

112. 3. Education is a major component of the discharge plan for a client with an artificial
        pacemaker. The client with a permanent pacemaker needs to be able to state specific information
        about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and
        bending and to count the pulse once per week, that are necessary to maintain proper pacemakerfunction. The client will not necessarily be placed on a low cholesterol diet. The client should
        resume activities as he is able, and does not need to remain on bed rest. The client should know signs
        and symptoms of MI, but is not at risk because of the pacemaker.
        CN: Basic care and comfort; CL: Evaluate

Question 113

113. An 85-year-old client is admitted to the emergency department (ED) at 8 PM with syncope,
     shortness of breath, and reported palpitations (See nurse’s notes below). At 8:15 PM , the nurse places
     the client on the ECG monitor and identifies the following rhythm (see below). The nurse should do
     which of the following? Select all that apply.

Nurse’s Progress Notes

Admitted to ED 8 PM
PR 150
BP 90/62
O2 Sat 92% on room air
RR 22
Progress Notes
Client has shortness of breath and states, "My heart is kumping out of my chest and hurts some. I am having trouble catching my breath. I don't want to faint again."

R. Black, RN

ECG RHYTHM STRIP

1. Apply oxygen.
2. Prepare to defibrillate the client.
3. Monitor vital signs.
4. Have the client sign consent for cardioversion as prescribed.
5. Teach the client about warfarin (Coumadin) treatment and the need for frequent blood testing.
6. Draw blood for a CBC count and thyroid function study.

Answer 113

113. 1, 3, 4. The client has atrial fibrillation and will have an irregularly irregular pulse and will
     commonly be tachycardic, with rapid ventricular responses (heart rates) typically in the 110 to 140
     range, but rarely over 150 to 170. The goal of treatment is the restoration of sinus rhythm. With a heart
     rate greater than 150 and symptoms such as shortness of breath, dizziness and syncope, and chest
     pain, synchronized cardioversion will most likely be the treatment of choice. With more controlled
     heart rates and more minor signs and symptoms, chemical conversion with drugs such as Cardizem
     and Digitalis (Digoxin) prior to other interventions such as synchronized cardioversion with
     appropriate anticoagulation may be attempted. Because of the decreased cardiac output, monitoring is
     essential. Obtaining consent for cardioversion requires a prescription from a health care provider, but
     with the current heart rate, having cardioversion is a very strong possibility for this client.
     Defibrillation is used for ventricular fibrillation, not atrial fibrillation. Teaching the client about
     Warfarin will be a possibility, but not an immediate intervention. Clients in continued atrial
     fibrillation usually require some form of anticoagulation. Drawing labs for CBCs to detect anemia or
     infection, and thyroid function studies (to determine thyrotoxicosis, a rare, but not-to-be-missed
     cause, especially in older adults), serum electrolytes and BUN/creatinine (looking for electrolyte
     disturbances or renal failure) are commonly drawn for determining the cause of the atrial fibrillation;
     they are not an immediate action.
     CN: Physiological adaptation; CL: Synthesize

Question 114

The Client Requiring Rapid
Cardiopulmonary Resuscitation
Response
or
114. Upon assessment of third-degree heart block on the monitor, the nurse should first:
1. Call a code.
2. Begin cardiopulmonary resuscitation.
3. Have transcutaneous pacing ready at the bedside.
4. Prepare for defibrillation.

Answer 114

The Client Requiring Rapid Response or Cardiopulmonary
Resuscitation
114. 3. Transcutaneous pads should be placed on the client with third-degree heart block. For a
client who is symptomatic, transcutaneous pacing is the treatment of choice. The hemodynamic
stability and pulse should be assessed prior to calling a code or initiating CPR. Defibrillation is
performed for ventricular fibrillation or ventricular tachycardia with no pulse.
CN: Management of care; CL: Synthesize

Question 115

115. The nurse observes the cardiac rhythm (see below) for a client who is being admitted with a
     myocardial infarction. What should the nurse do first?
116. Prepare for immediate cardioversion.
117. Begin cardiopulmonary resuscitation (CPR).
118. Check for a pulse.
119. Prepare for immediate defibrillation.

Answer 115

115. 3. The nurse should first check the client for the presence of a pulse. The presence of a pulse
        determines the treatment for ventricular tachycardia. It is also important to assess the client’s heart
        rate and level of consciousness. Cardioversion may be used to treat hemodynamically unstable
        tachycardias. Assessment of instability is required before cardioversion. It is not appropriate to begin
        CPR unless the pulse is absent. Defibrillation is used to treat ventricular fibrillation or pulseless
        ventricular tachycardia.
        CN: Physiological adaptation; CL: Synthesize

Question 116

116. The nurse is preparing the client for cardioversion. The nurse should do which of the
     following? Select all that apply.
117. Explain the procedure to the client.
118. Place a self-adhesive patch between the skin and the paddles.
119. Place the paddles over the client’s clothing.
120. Call “clear” before discharging the electrical current.
121. Record the delivered energy and the resulting rhythm.

Answer 116

116. 1, 2, 4, 5. The nurse should first explain the procedure to the client, and then place the patch
     electrodes per agency procedure. The nurse must make sure to call “clear” before discharging the
     electrical current to prevent injury to others who may be helping with the procedure. After the
     procedure, the nurse must record the amount of electrical current delivered and the resulting rhythm.
     The paddles are placed on the patch adhered to the client’s skin, not over the client’s clothing.CN: Reduction of risk potential; CL: Synthesize

Question 117

117. A client who has been given cardiopulmonary resuscitation (CPR) is transported by
     ambulance to the hospital’s emergency department, where the admitting nurse quickly assesses the
     client’s condition. The most effective way to determine the effectiveness of CPR is noting whether
     the:
118. Pulse rate is normal.
119. Pupils are reacting to light.
120. Mucous membranes are pink.
121. Systolic blood pressure is at least 80 mm Hg.

Answer 117

117. 2. Pupillary reaction is the best indication of whether oxygenated blood has been reaching
        the client’s brain. Pupils that remain widely dilated and do not react to light probably indicate that
        serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be
        pink, and systolic blood pressure may be 80 mm Hg or higher, and serious brain damage may still
        have occurred.
        CN: Reduction of risk potential; CL: Evaluate

Question 118

118. A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia.
     Which of the following indicates the drug is having the desired effect?
119. The ventricular rate is increasing.
120. The absent pulse is now palpable.
121. The number of premature ventricular contractions is decreasing.4. The fine ventricular fibrillation changes to coarse ventricular fibrillation.

Answer 118

118. 3. Amiodarone is used for the treatment of premature ventricular contractions, ventricular
        tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial
        therapy for a pulseless dysrhythmia.
        CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 119

119. During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the
     sternum should not be compressed when performing cardiac compressions. Which of the following
     organs would be most likely at risk for laceration by forceful compressions over the xiphoid
     process?
120. Lung.
121. Liver.
122. Stomach.
123. Diaphragm.

Answer 119

119. 2. Because of its location near the xiphoid process, the liver is the organ most easily
        damaged from pressure exerted over the xiphoid process during CPR. The pressure on the victim’s
        chest wall should be sufficient to compress the heart but not so great as to damage internal organs.
        Injury may result, however, even when CPR is performed properly.
        CN: Reduction of risk potential; CL: Apply

Question 120

120. When performing external chest compressions on an adult during cardiopulmonary
     resuscitation (CPR), the rescuer should depress the sternum:
121. 0.5 inch (1 cm)
122. 1 inch (2.5 cm)
123. 1.5 inches (5 cm)
124. 2 inches (7.5 cm)

Answer 120

120. 4. An adult’s sternum must be depressed 2 inches (5 cm) with each compression to ensure
        adequate heart compression.
        CN: Reduction of risk potential; CL: Apply

Question 121

121. If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary
resuscitation, the rescuer should first:
1. Try using a bag-mask device.
2. Decrease the rate of compressions.
3. Intubate the client.
4. Reposition the airway.

Answer 121

121. 4. If the chest wall is not rising with rescue breaths, the head should be repositioned first to
        ensure that the airway is adequately opened. A bag-mask device allows for delivery of 100% oxygen,
        but is difficult to manage if there is just one rescuer; ideally two persons are used to operate the bag-
        mask device, one to maintain the seal and the other to provide the ventilations. Compressions should
        be maintained at 100 per minute.
        CN: Physiological adaptation; CL: Synthesize

Question 122

122. During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by:
123. Normal relaxation of the chest.
124. Gentle pressure of the rescuer’s hand on the upper chest.
125. The pressure of cardiac compressions.
126. Turning the head to the side.

Answer 122

122. 1. The exhalation phase of ventilation is a passive activity that occurs during CPR as part of
        the normal relaxation of the victim’s chest. No action by the rescuer is necessary.
        CN: Reduction of risk potential; CL: Apply

Question 123

123. The rapid response team has been called to manage an unwitnessed cardiac arrest in a
     client’s hospital room. The estimated maximum time a person can be without cardiopulmonary
     function and still not experience permanent brain damage is:
124. 1 to 2 minutes.
125. 4 to 6 minutes.
126. 8 to 10 minutes.
127. 12 to 15 minutes.

Answer 123

123. 2. After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain
        damage is almost certain. To prevent permanent brain damage, it is important to begin CPR promptly
        after a cardiopulmonary arrest.
        CN: Reduction of risk potential; CL: Apply

Question 124

124. A nurse is helping a suspected choking victim. The nurse should perform the Heimlich
     maneuver when the victim:
125. Starts to become cyanotic.
126. Cannot speak due to airway obstruction.
127. Can make only minimal vocal noises.
128. Is coughing vigorously.

Answer 124

124. 2. The Heimlich maneuver should be administered only to a victim who cannot make any
        sounds due to airway obstruction. If the victim can whisper words or cough, some air exchange is
        occurring and the emergency medical system should be called instead of attempting the Heimlich
        maneuver. Cyanosis may accompany or follow choking; however, the Heimlich maneuver should only
        be initiated when the victim cannot speak.
        CN: Reduction of risk potential; CL: Apply

Question 125

125. When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers
     inward and upward thrusts specifically:
126. Above the umbilicus.2. At the level of the xiphoid process.
127. Over the victim’s midabdominal area.
128. Below the xiphoid process and above the umbilicus.

Answer 125

125. 4. The thrusts should be delivered below the xiphoid process, but above the umbilicus, tominimize the risk of internal injuries.
        CN: Reduction of risk potential; CL: Apply

Question 126

126. The monitor technician informs the nurse that the client has started having premature
     ventricular contractions every other beat. Which is the priority nursing action?
127. Activate the rapid response team.
128. Assess the client’s orientation and vital signs.
129. Call the physician.
130. Administer a bolus of lidocaine.

Answer 126

126. 2. The priority action is to assess the client and determine whether the rhythm is life
        threatening. More information, including vital signs, should be obtained and the physician should be
        quickly notified. A bolus of lidocaine may be prescribed to treat this arrhythmia. This is not a code-
        type situation unless the client has been determined to be in a life-threatening situation.
        CN: Physiological adaptation; CL: Synthesize

Question 127

127. The nurse is preparing to defibrillate a client on a cardiac monitor who is in ventricular
     fibrillation (see photo). The nurse should do which of the following?
128. Move the paddle in the nurse’s left hand to the midline.
129. Move the paddle in the nurse’s right hand to above the client’s nipple.
130. Grasp the handles of the paddles to allow visibility of the black markings on the paddle.
131. After pressing the charge button and “calling all clear,” push the shock button.

Answer 127

127. 4. The paddles are in the correct position. The nurse can push the shock button to defibrillate
        the client.
        CN: Physiological adaptation; CL: Apply

Question 128

Managing Care Quality and Safety
128. The nurse is caring for a client whose condition has been deteriorating. The client becomes
unresponsive, the blood pressure is 80/40, and SpO 2 is 90% on 50% face mask. The nurse should:
1. Begin chest compressions.
2. Call the rapid response team.
3. Remove the family from the room.
4. Ventilate the client with a bag-mask device.

Answer 128

Managing Care Quality and Safety
128. 2. The rapid response team should be called immediately to evaluate and treat the client.
There is no indication at this time for manual ventilations or chest compressions. If the family is not
interfering in client care, it can be reassuring to the family to see that all possible care is being
provided.
CN: Management of care; CL: Synthesize

Question 129

129. Which activity would be appropriate to delegate to unlicensed personnel for a client
     diagnosed with a myocardial infarction who is stable?
130. Evaluate the lung sounds.
131. Help the client identify risk factors for CAD.
132. Provide teaching on a 2-g sodium diet.
133. Record the intake and output.

Answer 129

129. 4. Unlicensed personnel are able to measure and record intake and output. The nurse is
        responsible for client teaching, physical assessments, and evaluating the information collected on the
        client.
        CN: Management of care; CL: Synthesize

Question 130

130. The nursing assistant reports to the nurse that a client is “feeling short of breath.” The
     client’s blood pressure was 124/78 2 hours ago with a heart rate of 82; the nursing assistant reports
     that blood pressure is now 84/44 with a heart rate of 54 and the client stated, “I just don’t feel good.”
     Which of the following interventions should the nurse initiate? Select all that apply.
131. Confirm the client’s vital signs and complete a quick assessment.
132. Inform the charge nurse of the change in condition and initiate the hospital’s rapid/emergency
     response team.
133. Make a quick check on other assigned clients before spending the amount of time required to
     take care of this client.
134. Position client in semi-Fowler’s position.
135. Stay with the client and reassure the client.
136. Call the physician and report the situation using SBAR format.

Answer 130

130. 1, 2, 4, 5, 6. The nurse must have assessment data and verify vital signs if necessary in order
     to determine the action that is required. If there is a significant change in the client’s condition, the
     charge nurse should be notified in order to help the nurse with both this client and the nurse’s other
     assigned clients if necessary; most acute care facilities have a rapid response team that can also help
     assess and intervene with basic standing orders if necessary. Positioning the client in semi-Fowler’s
     is a nursing action that may assist in breathing and relieve shortness of breath. It is important for the
     nurse to reassure the client by staying calm and remaining with the client. The physician must be
     notified of the change in client’s condition; the nurse must have all information available and present
     it to the physician in a concise and accurate manner using SBAR format including a recommendation
     for treatment if indicated. The nurse should stay with this client and delegate checking on other
     assigned clients to the charge nurse or nursing assistant.
     CN: Management of care; CL: Synthesize

Question 131

The nurse is assessing a client with heart failure who is receiving home health care monitoring using
electronic devices including scales, blood pressure monitoring, and structured questions to which the
client responds daily on a touch-screen monitor. The nurse reviews data obtained within the last 3
days.

APRIL 3, 2012
WEIGHT 160 lbs (72 kgs)
BP 120/80

APRIL 4, 2012
WEIGHT 162 lbs (73 kgs)
BP 130/88

APRIL 5, 2012
WEIGHT 165 lbs (74 kgs)
BP 140/90

The nurse calls the client to follow up. The nurse should ask the client which of the following first:

1. “How are you feeling today?”
2. “Are you having shortness of breath?”
3. “Did you calibrate the scales before using them?”4. “How much fluid did you drink during the last 24 hours?”

Answer 131

131. 2. The client has gained 5 lb (2.3 kg) in 3 days with a steady increase in blood pressure. The
        client is exhibiting signs of heart failure and if the client is short of breath, this will be another sign.
        Asking how the client is feeling is too general and a more focused question will quickly determine the
        client’s current health status. The scales should be calibrated periodically, but a 5-lb (2.3-kg) weight
        gain, along with increased blood pressure, is not likely due to problems with the scale. The weight
        gain is likely due to fluid retention, not drinking too much fluid.
        CN: Management of care; CL: Analyze

Question 132

132. The nurse is tracking data on a group of clients with heart failure who have been discharged
     from the hospital and are being followed at a clinic. Which of the following data indicate that nursing
     interventions of monitoring and teaching have been effective?
133. Ninety percent of clients have not gained weight.
134. Seventy-five percent of the clients viewed the educational DVD.
135. Eighty percent of the clients reported that they are taking their medications.
136. Five percent of the clients required hospitalization in the last 90 days.

Answer 132

132. 4. The goals of managing clients outside of the hospital are for the clients to maintain health
        and prevent readmission, thus interventions, such as monitoring and teaching, appear to have
        contributed to the low readmission rate in this group of clients. Although it is important that clients do
        not gain weight, view educational material, and continue to take their medication, the primary
        indicator of effectiveness of the program is the lack of re-hospitalization.
        CN: Management of care; CL: Evaluate

Question 133

133. The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down
     unit about a client who had coronary artery bypass surgery. Which of the following is the most
     effective way to assure essential information about the client is reported?
134. Give the report face-to-face with both nurses in a quiet room.
135. Audiotape the report for future reference and documentation.
136. Use a printed checklist with information individualized for the client.
137. Document essential transfer information in the client’s electronic health record

Answer 133

133. 3. Using an individualized, printed checklist ensures that all key information is reported; the
        checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves
        room for error in memory; using an audiotape or an electronic health record requires nurses to spend
        unnecessary time retrieving information.
        CN: Safety and infection control; CL: Evaluate

Question 134

134. The nurse is planning care for elderly clients who are affected by orthostatic hypotension.
     The nurse should do which of the following? Select all that apply.
135. Assist the clients to stand to help prevent falls.
136. Teach clients how to gradually change their position.
137. Request a prescription for antihypertensive medications for clients at high risk.
138. Conduct “fall risk” assessments.
139. Consider the use of sequential compression devices (SCDs) for high-risk clients.
140. Place clients on bed rest.

Answer 134

134. 1, 2, 4, 5. Orthostatic hypotension is a drop in blood pressure that occurs when changing
     position, usually to a more upright position. Orthostatic hypotension often occurs in elderly clients,
     and it is a common cause of falls. Nurses must assess clients for orthostatic hypotension, and assist
     all clients with orthostatic hypotension in standing to help prevent falls. Lower limb compression
     devices aid in prevention of decreased orthostatic systolic blood pressure and reduce symptoms in
     elderly clients with progressive orthostatic hypotension. Nurses must teach clients how to gradually
     change their position, and they must conduct “fall risk” assessments. Sequential compression devices
     may be helpful to high-risk clients and should be considered when developing the care plan.
     Antihypertensive medications are not necessary for clients with orthostatic hypertension and may
     precipitate dangerous drops in blood pressure. The clients should be encouraged to be ambulatory.
     CN: Reduction of risk potential; CL: Synthesize