Unit L-Shock

Question 1

A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene?

a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary filling of 4 seconds as normal
d. Palpating both carotid arteries at the same time

Answer 1

ANS: D
The nurse would not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure would be taken and compared in both arms. Prolonged capillary filling is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits would be auscultated

Question 2

A nurse is working with a client who takes clopidogrel. The client’s recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

a. Ask if the client eats grapefruit.
b. Assess the client for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.

Answer 2

ANS:A
There is a drug–food interaction between clopidogrel and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

Question 3

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?

a. “Do you have trouble affording your medications?”
b. “Most people with hypertension do not have symptoms.”
c. “You are lucky; most people get severe morning headaches.”
d. “You need to take your medicine or you will get kidney failure.”

Answer 3

ANS: B
Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse would explain this to the client. Asking about paying for medications utilizes closed-ended questioning and is not therapeutic. Threatening the client with possible complications will not increase compliance.

Question 4

A client asks what “essential hypertension” is. What response by the registered nurse is best?

a. “It means it is caused by another disease.”
b. “It means it is ‘essential’ that it be treated.”
c. “It is hypertension with no specific cause.”
d. “It refers to severe and life-threatening hypertension.”

Answer 4

ANS: C
Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

Question 5

The nurse is caring for four hypertensive clients. Which drug–laboratory value combination would the nurse report immediately to the health care provider?

a. Furosemide/potassium: 2.1 mEq/L
b. Hydrochlorothiazide/potassium: 4.2 mEq/L
c. Spironolactone/potassium: 5.1 mEq/L
d. Torsemide/sodium: 142 mEq/L

Answer 5

ANS: A
Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

Question 6

. A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information?

a. “Could you walk further than that a few months ago?”
b. “Do you walk mostly uphill, downhill, or on flat surfaces?”
c. “Have you ever considered swimming instead of walking?” d. “How much pain medication do you take each day?

Answer 6

ANS: A
As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates that the client’s disease is worsening. The other questions are useful, but not as important.

Question 7

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?

a. “I nearly always wear comfy sweatpants and house shoes.”
b. “I’m glad I get energy assistance so my house isn’t so cold.”
c. “My daughter makes sure I have plenty of lotion for my feet.”
d. “My hands shake when I try to do things requiring coordination.”

Answer 7

ANS: D
Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse would refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

Question 8

A client is taking warfarin and asks the nurse if taking St. John’s wort is acceptable. What response by the nurse is best?

a. “No, it may interfere with the warfarin.”
b. “There isn’t any information about that.”
c. “Why would you want to take that?”
d. “Yes, it is a good supplement for you.”

Answer 8

ANS: A
Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse would advise the client against taking it. The other answers are not accurate

Question 9

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?

a. “No, women should only have one beer a day as a general rule.”
b. “No, you should not drink any alcohol with hypertension.”
c. “Yes, since you are larger, you can have more alcohol.”
d. “Yes, two beers per day is an acceptable amount of alcohol.”

Answer 9

ANS: A
Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A “drink” is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman’s size does not matter

Question 10

A nurse is caring for four clients. Which one would the nurse see first?

a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.
b. Client who had a first dose of captopril and needs to use the bathroom.
c. Hypertensive client with a blood pressure of 188/92 mm Hg.
d. Client who needs pain medication prior to a dressing change of a surgical wound.

Answer 10

ANS: B
Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse would see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse would check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 to 100 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

Question 11

A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met?

a. Client is able to decrease blood pressure medications.
b. Insertion site has healed without redness or tenderness.
c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL.
d. Verbalizes understanding of postprocedure lifestyle changes.

Answer 11

ANS: A
Hypertension can be caused by renovascular disease. Opening up a constricted renal artery can lead to decreased blood pressure, manifested by the need for less blood pressure medication. The other findings are normal and desired, but not specifically related to hypertension caused by renal disease.

Question 12

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important?

a. Administer pain medication as ordered.
b. Assess distal pulses and skin color.
c. Document the findings in the client’s chart.
d. Notify the surgeon immediately.

Answer 12

ANS: B
Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines that the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

Question 13

. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

a. Appropriate hand hygiene before giving care
b. Assessing the client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count

Answer 13

ANS: A
Hand hygiene is the best way to prevent infection in hospitalized clients. Dressing changes would be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

Question 14

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important?

a. Assess the client’s neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
d. Turn down the infusion rate.

Answer 14

ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurologic examination, but would first call the Rapid Response Team based on the client’s manifestations. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

Question 15

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse’s mentor to intervene?

a. Assesses the client for back pain.
b. Auscultates over abdominal bruit.
c. Measures the abdominal girth.
d. Palpates the abdomen in four quadrants.

Answer 15

ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse mentoring the new nurse would intervene when the new nurse attempts to do this. The other actions are appropriate.

Question 16

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met?

a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors

Answer 16

ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not as important.

Question 17

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)?

a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client’s leg.
d. Provide an ice pack.

Answer 17

ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client’s legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

Question 18

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

a. Teach high school students heart-healthy living.
b. Participate in blood pressure screenings at the mall.
c. Provide pamphlets on heart disease at the grocery store.
d. Set up an “Ask the nurse” booth at the pet store.

Answer 18

ANS: B
An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

Question 19

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because “it’s dangerous.” What action by the nurse is best?

a. Assess the reason behind the client’s fear.
b. Remind the client about laboratory monitoring.
c. Tell the client that drugs are safer today than before.
d. Warn the client about consequences of noncompliance.

Answer 19

ANS: A
The first step is to assess the reason behind the client’s fear, which may be related to the experience of someone the client knows who took warfarin or misinformation. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like “drugs are safer today” do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

Question 20

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate?

a. Assess the client’s lung sounds and oxygenation.
b. Instruct the client on another antihypertensive.
c. Obtain a set of vital signs and document them.
d. Remind the client that cough is a side effect of lisinopril.

Answer 20

ANS: A
This client could be having an exacerbation of heart failure or experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse would assess the client’s lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse would assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

Question 21

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

a. Consult with the wound care nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the client for eventual amputation.

Answer 21

ANS: A
A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

Question 22

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?

a. “I can use a heating pad on my legs if it’s set on low.”
b. “I should not cross my legs when sitting or lying down.”
c. “I will go out and buy some warm, heavy socks to wear.”
d. “It’s going to be really hard but I will stop smoking.”

Answer 22

ANS: A
Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

Question 23

What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)

a. Administering mild analgesics for pain
b. Applying elastic compression stockings
c. Elevating the legs when sitting or lying
d. Reminding the client to do leg exercises
e. Teaching the client about surgical options
f. Encouraging participation in high impact aerobic activity

Answer 23

ANS: B,C,D
The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure. High impact aerobics is not encouraged and is not a comfort measure.

Question 24

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

a. Administering preoperative medication
b. Ensuring that the consent is signed
c. Marking pulses with a pen
d. Raising the side rails on the bed
e. Recording baseline vital signs

Answer 24

ANS: D,E
The AP can raise the side rails of the bed for client safety and take and record the vital signs. Administering medications, ensuring that a consent is on the chart, and marking the pulses for later comparison would be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

Question 25

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)

a. Apply compression stockings.
b. Assist with ambulation.
c. Encourage coughing and deep breathing.
d. Offer fluids frequently.
e. Teach leg exercises.

Answer 25

ANS: A,B,D
The AP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The AP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

Question 26

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client’s plan of care? (Select all that apply.)

a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.

Answer 26

ANS: A,B,D
Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2.5 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

Question 27

A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.)

a. Dietary restrictions
b. Driving restrictions
c. Follow-up laboratory monitoring
d. Possible drug–drug interactions
e. Reason to take medication
f. Wearing a Medic Alert bracelet

Answer 27

ANS: A,C,D,E
Best practices state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug–drug interactions, using a Medic Alert bracelet or necklace, and reason for compliance. Driving is typically not restricted

Question 28

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)

a. “A good abrasive pumice stone will keep my feet soft.”
b. “I’ll always wear shoes if I can buy cheap flip-flops.”
c. “I will keep my feet dry, especially between the toes.”
d. “Lotion is important to keep my feet smooth and soft.”
e. “Washing my feet in room-temperature water is best.”
f. “I will inspect my feet daily.”

Answer 28

ANS: C,D,E
Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; cutting the nails straight across; and inspecting the feet daily are all important measures. Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well and won’t offer much protection against injury

Question 29

A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client’s leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)

a. Ask the client to describe his or her current emotions.
b. Assess the client for support systems and family.
c. Offer to stay with the client if he or she desires.
d. Relate how smoking contributed to this situation.
e. Tell the client that many people have amputations.
f. Arrange for an amputee to come visit the client.

Answer 29

ANS: A,B,C
When a client is upset, the nurse would offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the client’s feelings. It is too early to send an amputee to visit the client as the decision to amputate has not yet been made.

Question 30

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.)

a. Atherosclerosis
b. Down syndrome
c. Frequent heartburn
d. History of hypertension
e. History of smoking
f. Hyperlipidemia

Answer 30

ANS: A,D,E,F
Atherosclerosis, hypertension, hyperlipidemia, hyperlipidemia, and smoking are the most commonly related factors. Down syndrome and heartburn have no relation to aneurysm formation

Question 31

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client’s blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)

a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes.

Answer 31

ANS: B,D,E
This client may have a ruptured/rupturing aneurysm. The nurse would notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client’s blood pressure even further. The nurse cannot have the client sign a consent until the surgeon has explained the procedure

Question 32

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.)

a. Abdominal tenderness
b. Difficulty swallowing
c. Changes in bowel habits
d. Shortness of breath
e. Hoarseness

Answer 32

ANS: B,E
Signs of a thoracic aortic aneurysm include shortness of breath, hoarseness, and difficulty swallowing. Pain is often rated as a 10 on a 10-point scale. Bowel habits are not related.

Question 33

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.)

a. Elevated low-density lipopGroRteAinD(ELSDL-ACB).COM
b. Decreased levels of high-density lipoprotein cholesterol (HDL-C)
c. Asian ethnicity
d. History of smoking
e. Blood pressure: 142/92 mm Hg on one occasion

Answer 33

ANS: A,B,D
Elevated levels of lipids (fats) such as low-density lipoprotein cholesterol (LDL-C) and decreased levels of high-density lipoprotein cholesterol can cause chemical damage to blood vessel walls. Smoking can cause endothelial damage in addition to increasing a client’s carbon monoxide levels. African American and Hispanic ethnicities carry an increased risk for atherosclerosis. Hypertension does increase atherosclerosis risk, but an elevated reading on one occasion is not classified as hypertension.

Question 34

A nurse is caring for a client who suffered massive blood loss after trauma. How does the nurse correlate the blood loss with the client’s mean arterial pressure (MAP)?

a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.

Answer 34

ANS: B

Lower blood volume will decrease MAP. The other answers are not accurate.

Question 35

A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last assessed 4 hours ago. What action by the nurse is best?

a. Ask if the client needs pain medication.
b. Assess using the MEWS score.
c. Document the findings in the client’s chart.
d. Increase the rate of the client’s IV infusio

Answer 35

ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of perfusion. The MEWS score (Modified Early Warning Score) was developed to identify clients at risk for deterioration. The client may need pain medication, but this is not the priority at this time. Documentation would be done thoroughly but would be done after the assessment. The nurse would not increase the rate of the IV infusion without an order

Question 36

The nurse gets the hand-off report on four clients. Which client would the nurse assess first?

a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours

Answer 36

ANS:AThis client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of worsening perfusion status and possible shock. The nurse would assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate that the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is above the normal range, which is 30 mL/hr.

Question 37

A nurse is caring for a client after surgery who is restless and apprehensive. The assistive personnel (AP) reports the vital signs and the nurse sees that they are only slightly different from previous readings. What action does the nurse delegate next to the AP?

a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the side.
d. Stay with the client and reassure him or her.

Answer 37

ANS: B
Urine output changes are a sensitive early indicator of shock. The nurse would delegate emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine output measurements. The AP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness, but does not take priority over physical assessments. Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.

Question 38

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?

a. “High glucose is common in shock and needs to be treated.”
b. “Some of the medications we are giving are to raise blood sugar.”
c. “The IV solution has lots of glucose, which raises blood sugar.”
d. “The stress of this illness has made your spouse a diabetic.”

Answer 38

ANS: A
High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not “made” the client diabetic

Question 39

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3 (3.8  109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6°
C). What action by the nurse takes priority?
a. Document the findings in the client’s chart.
b. Give the client warmed blankets for comfort.
c. Notify the primary health care provider immediately.
d. Prepare to administer insulin per sliding scale

Answer 39

ANS: C
This client has several indicators of sepsis with systemic inflammatory response. The nurse would notify the primary health care provider immediately. Documentation needs to be thorough but does not take priority. The client may appreciate warm blankets, but comfort measures do not take priority. The client may need insulin if blood glucose is being regulated tightly.

Question 40

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?

a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.

Answer 40

ANS: B
Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesn’t give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

Question 41

A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?

a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain a pulse oximetry reading
d. Start two large-bore IV catheters.

Answer 41

ANS: B

Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct pressure).

Question 42

A client is receiving norepinephrine for shock. What assessment finding best indicates a therapeutic effect from this drug?

a. Alert and oriented, answering questions
b. Client denies chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours

Answer 42

ANS: A
Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is good but does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

Question 43

A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome (MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the nurse causes the charge nurse to intervene?

a. Assessing the IV site before giving the drug
b. Obtaining a programmable (“smart”) IV pump
c. Removing the IV bag from the brown plastic cover d. Taking and recording a baseline set of vital signs

Answer 43

ANS: C
Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct

Question 44

A nurse on the general medical-surgical unit is caring for a client in shock and assesses the following:
Respiratory rate: 10 breaths/min
Pulse: 136 beats/min
Blood pressure: 92/78 mm Hg
Level of consciousness: responds to voice Temperature: 101.5° F (38.5° C)
Urine output for the last 2 hours: 40 mL/hr. What action by the nurse is best?
a. Transfer the client to the Intensive Care Unit.
b. Continue monitoring every 30 minutes.
c. Notify the unit charge nurse immediately.
d. Call the Rapid Response Team

Answer 44

ANS: D
This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1). Scores above 5 are associated with a high risk of death and ICU admission. The most important action for the nurse is to notify the Rapid Response Team so that timely interventions can be initiated. The client most likely will be transferred to the ICU, but an order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to obtain care for the client. The charge nurse is a valuable resource, but the best action is to notify the Rapid Response Team.

Question 45

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the primary health care provider?

a. Creatinine: 0.9 mg/dL (68.6 mcmol/L)
b. Lactate: 5.4 mg/dL (6 mmol/L)
c. Sodium: 150 mEq/L (150 mmol/L)
d. White blood cell count: 11,000/mm3 (11  109/L)

Answer 45

ANS: B
A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150 mmol/L) is slightly high but does not need to be communicated. A white blood cell count of 11,000/mm3 (11  109/L) is slightly high but is not as critical as the lactate level.

Question 46

A nurse receives hand-off report from the emergency department on a new admission suspected of having septic shock. The client’s qSOFA score is 3. What action by the nurse is best?

a. Plan to calculate a full SOFA score on arrival.
b. Contact respiratory therapy about ventilator setup.
c. Arrange protective precautions to be implemented.
d. Call the hospital chaplain to support the family.

Answer 46

ANS: A
The qSOFA score is an abbreviated Sequential Organ Failure Assessment (or “quick”). A score of 3 is high and requires the nurse to assess the client further for organ impairment. The client may or may not need a ventilator, but that in not specified in the score. The client does not need protective precautions. The client’s family may well need support, but the nurse would assess their needs and wishes prior to calling the chaplain.

Question 47

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client’s sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

a. “All my friends and neighbors are planning a party for me.”
b. “I hope I can get my water turned back on when I get home.”
c. “I am going to have my daughter scoop the cat litter box.”
d. “My grandkids are so excited to have me coming home!”

Answer 47

ANS: B
All these statements indicate a potential for leading to infection once the client gets back home. A large party might include individuals who are themselves ill and contagious. Having litter boxes in the home can expose the client to microbes that can lead to infection. Small children often have upper respiratory infections and poor hand hygiene that spread germs. However, the most worrisome statement is the lack of running water for handwashing and general hygiene and cleaning purposes.

Question 48

A client with MODS has been started on dobutamine. What assessment finding requires the nurse to communicate with the primary health care provider immediately?

a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr

Answer 48

ANS: C
Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dobutamine. While taking dobutamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the client’s previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

Question 49

The nurse studying shock understands that the common signs and symptoms of this condition are directly related to which problems? (Select all that apply.)

a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased systemic perfusion

Answer 49

ANS: A,C
The common signs and symptoms of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not the cause of common signs and symptoms of shock.

Question 50

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.)

a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
f. Limiting the client’s visitors until more stable

Answer 50

ANS: A,C,D,E
Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change. Limiting the client’s visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on entering and leaving the room and that visitors are not ill themselves.

Question 51

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.)

a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
e. Overhydration
f. Use of diuretics

Answer 51

ANS: A,B,C,D,F
Immobility, decreased thirst response, diminished immune response, malnutrition, and use of diuretics can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

Question 52

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)

a. Bringing the client warm blankets
b. Giving the client hot tea to drink
c. Massaging the client’s painful legs
d. Reorienting the client as needed
e. Sitting with the client for reassurance

Answer 52

ANS: A,B,D,E
The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow, small amounts of fluids would be allowed. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

Question 53

The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.)

a. Administer antibiotics.
b. Draw serum lactate levels.
c. Infuse vasopressors.
d. Measure central venous pressure.
e. Obtain blood cultures.
f. Administer rapid bolus of IV crystalloids.

Answer 53

ANS: A,B,C,E,F
Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the cultures have been obtained), bGegRiAn DraEpiSdLadAmBi.niCstOraMtion of 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. and administer vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure 65 mm Hg. Initiating hemodynamic monitoring would be done after these “bundle” measures have been accomplished.

Question 54

A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?

a. Assess the client’s pupillary responses.
b. Request a neurologic consultation.
c. Call the primary health care provider immediately.
d. Take and document a full set of vital signs.

Answer 54

ANS: C
A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse would notify the primary health care provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

Question 55

A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client’s spouse asks why the client needs this medication. What response by the nurse is best?
a. “The t-PA didn’t dissolve the entire coronary clot.”
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b. “The heparin keeps that artery from getting blocked again.”
c. “Heparin keeps the blood as thin as possible for a longer time.”
d. “The heparin prevents a stroke from occurring as the t-PA wears off.

Answer 55

ANS: B
After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a “blood thinner,” although laypeople may refer to it as such.

Question 56

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best?

a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.

Answer 56

ANS:B
This client’s physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

Question 57

A nurse is caring for a client who had a myocardial infarction. The nurse is confused because the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best?

a. “Continue to educate the client on possible healthy changes.”
b. “Emphasize complications that can occur with noncompliance.”
c. “Tell the client that denial is normal and will soon go away.”
d. “You need to make sure the client understands this illness.”

Answer 57

ANS: A
Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The nurse would not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

Question 58

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?

a. Level the transducer at the phlebostatic axis.
b. Lay the client in the supine position.
c. Prepare to administer diuretics.
d. Prepare to administer a fluid bolus.

Answer 58

ANS: D
Normal right atrial pressures are from 0 to 8 mm Hg. This pressure is at the extreme lower end, which indicates hypovolemia, so the nurse would prepare to administer a fluid bolus. The transducer would remain leveled at the phlebostatic axis. Positioning may or may not influence readings but a reading this low is definitive for volume depletion. Diuretics would be contraindicated.

Question 59

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?

a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends.
b. Ensure that the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler position

Answer 59

ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing trends are important nursing actions related to hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring

Question 60

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client’s heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate?

a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.

Answer 60

ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse would assess the client for any bleeding associated with the arterial line. The nurse would document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

Question 61

A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to “just get this over with” when asked to sign the consent form. What action by the nurse is best?

a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client’s stress levels.
d. Tell the client that anxiety is common and that you can help.

Answer 61

ANS: D
Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is common and offer to help. The other actions will not reduce the client’s anxiety.

Question 62

A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best?

a. “Do you have any concerns about sexuality?”
b. “I’m glad to hear you are sleeping well now.”
c. “Sleep near your spouse in case of emergency.”
d. “Why would you move into the guest room?

Answer 62

ANS: A
Concerns about resuming sexual activity are common after cardiac events. The nurse would gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

Question 63

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority?

a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider.

Answer 63

ANS: C
Airway always is the priority. The other actions are important in this situation as well, but the nurse would stay with the client and ensure that the airway remains patent (especially if vomiting occurs) while another person calls the primary health care provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the primary health care provider’s prescription and the client’s current medications

Question 64

An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?

a. Assess for any hemodynamic effects of the rhythm.
b. Prepare to administer antidysrhythmic medication.
c. Notify the primary health care provider or call the Rapid Response Team.
d. Turn the alarms off on the cardiac monitor.

Answer 64

ANS:A
Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. Or this client’s dysrhythmias could be a consequence of the myocardial infarction. They may or may not have significant hemodynamic effects. The nurse would first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor would never be shut off. The other two actions may or may not be needed.

Question 65

The nurse is preparing to change a client’s sternal dressing. What action by the nurse is most important?

a. Assess vital signs.
b. Don a mask and gown.
c. Gather needed supplies.
d. Perform hand hygiene.

Answer 65

ANS: D
To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority and uses sterile technique when changing the dressing. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse would gather needed supplies, but this is not the priority.

Question 66

A client has progressed to Killip class III heart failure after a myocardial infarction. What does the nurse anticipate the client’s care to include?

a. Diuretics
b. Nitrates
c. Clopidogrel
d. Dobutamine

Answer 66

ANS: D
The client in class III heart failure would benefit from a positive inotrope such as dobutamine. Clients in class I typically respond well to diuretics and nitrates so this client would already be on these medications. Clopidogrel is a platelet inhibitor that will be prescribed for anyone having acute coronary syndrome for at least 12 months.

Question 67

A nurse is in charge of the coronary intensive care unit. Which client would the nurse see first?
a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64
mm Hg
c. Client who is 1-day post percutaneous coronary intervention, going home this
morning
d. Client who is 2-day post coronary artery bypass graft, who became dizzy this morning while walkin

Answer 67

ANS: B
Hypotension after coronary artery bypass graft surgery can be dangerous because it can lead to collapse of the graft. The charge nurse would see this client first. The client who became dizzy earlier would be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

Question 68

A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best?

a. “Fish oil is contraindicated with most drugs for CAD.”
b. “The best source is fish, but pills have benefits too.”
c. “There is no evidence to support fish oil use with CAD.”
d. “You can reverse CAD totally with diet and supplements.

Answer 68

ANS: B
Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The preferred source of omega-3 acids is from fish rich in long-chain n-3 polyunsaturated fatty acids two times a week or a daily fish oil nutritional supplement (1 to 2 g/day). The other options are not accurate.

Question 69

A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best for optimal client outcomes?

a. Obtain an electrocardiogram (ECG) within 20 minutes.
b. Give the client a nonenteric coated aspirin.
c. Notify the Rapid Response Team immediately.
d. Prepare to administer thrombolytics within 30 minutes.

Answer 69

ANS: B
Best practice recommendations for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG (within 10 minutes) is vital for best outcomes. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed depending on the type of myocardial infarction the client has.

Question 70

A nurse is caring for four client s. Which client would the nurse assess first?

a. Client with an acute myocardial infarction, pulse 102 beats/min
b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety
c. Client who is post coronary artery bypass, with chest tube drained 100 mL/hr
d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L)

Answer 70

ANS: B
The post-angioplasty client with tongue swelling and anxiety is exhibiting signs and symptoms of an allergic reaction (perhaps to the contrast medium) that could progress to anaphylaxis. The nurse would assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

Question 71

A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action would the nurse perform first for comfort?

a. Allow family members to remain at the bedside.
b. Ask the family if the client would like a fan in the room.
c. Keep the television tuned to the client’s favorite channel.
d. Speak loudly to the client in case of hearing problems.

Answer 71

ANS: A
Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement or may agitate the client further. The TV would not be kept on all the time to allow for rest. Speaking loudly may agitate the client more.

Question 72

The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage stops suddenly. What action by the nurse is most important?

a. Increase the setting on the suction.
b. Notify the primary health care provider immediately.
c. Reposition the chest tube.
d. Take the tubing apart to assess for clots

Answer 72

ANS: B
If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the primary health care provider immediately. The nurse would not independently increase the suction, reposition the chest tube, or take the tubing apart.

Question 73

A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred?

a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours

Answer 73

ANS: C
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would be reported immediately. A blood pressure drop of 20 mm Hg may not be worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

Question 74

A client presents to the emergency department with an acute myocardial infarction (MI) at 15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed?

a. 15:30 (3:30 p.m.)
b. 16:00 (4:00 p.m.)
c. 16:30 (4:30 p.m.)
d. 17:00 (5:00 p.m.)

Answer 74

ANS: C
Percutaneous coronary intervention would be performed within 90 minutes of diagnosis of myocardial infarction. Therefore, the client would have a percutaneous coronary intervention performed no later than 16:30 (4:30 p.m.).

Question 75

The primary health care provider requests the nurse start an infusion of milrinone on a client. How does the nurse explain the action of this drug to the client and spouse?

a. “It constricts vessels, improving blood flow.”
b. “It dilates vessels, which lessens the work of the heart.”
c. “It increases the force of the heart’s contractions.”
d. “It slows the heart rate down for better filling

Answer 75

ANS: C
Milrinone, is a positive inotrope, is a medication that increases the strength of the heart’s contractions. It is not a vasoconstrictor, a vasodilator, nor does it slow the heart rate.

Question 76

A nurse prepares a client for coronary artery bypass graft surgery. The client states, “I am afraid I might die.” What is the nurse’s best response?

a. “This is a routine surgery and the risk of death is very low.”
b. “Would you like to speak with a chaplain prior to surgery?”
c. “Tell me more about your concerns about the surgery.”
d. “What support systems do you have to assist you?

Answer 76

ANS: C
The nurse would discuss the client’s feelings and concerns related to the surgery. The nurse would not provide false hope or simply call the chaplain. The nurse would address support systems after addressing the client’s current issue.

Question 77

A nurse learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.)

a. Age
b. Hypertension
c. Obesity d. Smoking e. Stress
f. Gender

Answer 77

ANS: B,C,D,E
Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age and gender are not nonmodifiable risk factors.

Question 78

A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the commode.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure that the client wears TED hose or sequential compression devices.
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d. Have the client rate pain on a 0-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol.

Answer 78

ANS: A,C,E
The nurse can delegate assisting the client to get up in the chair or commode (if the nurse has evaluated the client as being stable), applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer would be used every hour the day after surgery. Assessing pain using a 0-10 scale is a nursing assessment, although if the client reports pain, the AP would inform the nurse so a more detailed assessment is done

Question 79

A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.)

a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
f. Can be precipitated by exertion or stress

Answer 79

ANS: A,B,D,E
The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion or stress.

Question 80

A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.)

a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing

Answer 80

ANS: B,D,E
Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

Question 81

Prior to discharge, a client who had an acute myocardial infarction and coronary artery bypass graft asks the nurse about sexual activity. What information does the nurse provide? (Select
all that apply.)
a. “You will need to wait at least 6 weeks before intercourse.’
b. “Your usual sexual activity is not likely to damage your heart.”
c. “Start having sex when you are most rested, like in the morning.”
d. “When you can climb four flights of stairs, you can tolerate sex.”
e. “Don’t eat for three hours before engaging in sexual activity.”
f. “Use a comfortable position that doesn’t stress your incision.”

Answer 81

ANS: B,C,F
Clients have many concerns about resuming sexual activity after an acute coronary event. Generally, once the client can walk one block or climb two flights of stairs, he or she can tolerate sex. The client should start after a period of rest and at least 11/2 hours after a heavy meal or exercise. Clients should be taught to choose a position that is comfortable for both parties and does not place undue stress on their incisions or on their hearts.

Question 82

A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (Select all that apply.)

a. Right atrial pressure 12 mm Hg: right ventricular failure
b. Right atrial pressure 4 mm Hg: hypovolemia
c. Pulmonary artery pressure 20/10 mm Hg: normal finding
d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation
e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction

Answer 82

ANS: A,C,D,E
Normal right atrial pressure is 0 to 8 mm Hg; high readings can indicate right ventricular failure; low readings often signify hypovolemia. Normal pulmonary artery pressure ranges from 15 to 30 mm Hg systolic to 3 to 12 mm Hg diastolic. Pulmonary artery occlusion pressure ranges from 5 to 12 mm Hg; high values may indicate left ventricular failure, hypervolemia, mitral regurgitation, or intracardiac shunting. A decreased PAOP is seen with hypovolemia or afterload reduction.