The document provides nursing questions and answers related to cardiovascular health. Question 139 discusses discharge instructions for a client with infective endocarditis, with the correct answer being to notify healthcare providers of the history before any invasive procedures. Question 140 discusses avoiding use of the knee gatch on a post-cardiac surgery client's bed to prevent venous stasis. Question 141 lists appropriate activity limitations for the first 6 weeks after cardiac surgery discharge.

1. :Question _139
A client is being discharged from the hospital after
being treated for infective endocarditis. The nurse
?provides the client with which discharge instructions
:Options
Take acetaminophen (Tylenol) if the chest pain . 1
.worsens
Use a firm bristle toothbrush and floss vigorously to . 2
.prevent cavities
Take antibiotics until the chest pain is fully . 3
.resolved
Notify all health care providers of the history of . 4
.infective endocarditis before any invasive procedures
. Answer: 4
:Rationale
The client should alert any health care provider about
the history of infective endocarditis before any
procedure that involves instrumentation. The provider
should place the client on prophylactic antibiotics.
Antibiotics should be taken for the full course of
therapy. The client should notify the physician if chest
pain worsens or if dyspnea or other symptoms occur. The
client should use a soft toothbrush and floss carefully
to avoid any trauma to the gums, which could provide a
.portal of entry for bacterial infection
:Question _140
A nurse is concerned about the adequacy of peripheral
tissue perfusion in the post–cardiac surgery client.
Which action would the nurse avoid in giving care to this
?client
:Options
Use of the knee gatch on the bed . 1
Covering the legs lightly when sitting in chair . 2
Performing range-of-motion (ROM) exercises to the . 3
ankles
Applying pneumatic boots . 4
:Answer
. 1
:Rationale
The nurse plans postoperative measures to prevent venous
stasis. These include applying elastic stockings or leg
wraps, use of pneumatic compression boots, discouraging
leg-crossing, avoiding use of the knee gatch on the bed,
performing passive and active ROM exercises, and omitting
placement of pillows in the popliteal space. Covering the
legs with a light blanket during sitting promotes warmth
.and vasodilation of the leg vessels
:Question _141
A nurse is instructing the post–cardiac surgery client
about activity limitations for the first 6 weeks after
hospital discharge. The nurse would include which of the

2. :following items in the instructions? Options
Activities that involve straining can be resumed so . 1
.long as they do not cause pain
Driving is permitted so long as the lap and shoulder . 2
.seat belts are worn
Lifting should be restricted to objects that do not . 3
. weigh more than 25 pounds
Use the arms for balance, not weight support, when . 4
.getting out of bed or a chair
:Answer
. 4
:Rationale
Typical discharge activity instructions for the first six
weeks include instructing the client to lift nothing
heavier than 5 pounds , to not drive , and to avoid any
activities that cause straining . The client is taught to
use the arms for balance, but not weight support, to
avoid the effects of straining. These limitations are to
allow for sternal healing , which takes approximately 6
. weeks
:Question _142
A nurse is assessing an electrocardiogram (ECG) rhythm
strip for a client. The P waves and QRS complexes are
regular. The PR interval is 0.14 second , and the QRS
complexes measure 0.08 second . The overall heart rate is
82 beats/min . The nurse interprets the cardiac rhythm to
: be
:Options
Sinus bradycardia . 1
Sick sinus syndrome . 2
Normal sinus rhythm . 3
First-degree heart block . 4
:Answer
. 3
:Rationale
Normal sinus rhythm is defined as a regular rhythm with
an overall rate of 60 to 100 beats/min . The PR and QRS
measurements are normal , measuring 0.12 to 0.20 second
.and 0.04 to 0.10 second , respectively
:Question _143
A client ’s electrocardiogram (ECG) strip shows atrial
and ventricular rates of 70 complexes/min . The PR
interval is 0.16 second , the QRS complex measures 0.06
second , and the PP interval is slightly irregular. The
:nurse interprets this rhythm to be
:Options
Sinus bradycardia . 1
Normal sinus rhythm . 2
Sinus tachycardia . 3
Sinus arrhythmia . 4
:Answer

3. . 4
:Rationale
Sinus arrhythmia has all of the characteristics of normal
sinus rhythm except for the presence of an irregular PP
interval. This irregular rhythm occurs because of phasic
changes in the rate of firing of the sinoatrial node,
which may occur with vagal tone and with respiration.
.Cardiac output is not affected
:Question _144
A nurse is watching the cardiac monitor and notices that
the rhythm suddenly changes. No P waves or QRS complexes
are seen; instead, the monitor screen shows wavy lines.
:The nurse interprets that the client is experiencing
:Options
(Premature ventricular contractions (PVCs . 1
Sinus tachycardia . 2
Ventricular tachycardia . 3
Ventricular fibrillation . 4
:Answer
. 4
:Rationale
Ventricular fibrillation is characterized by the absence
of P waves and QRS complexes. The rhythm is instantly
recognizable by the presence of coarse or fine
fibrillatory waves on the cardiac monitoring screen. Each
of the incorrect options has a recognizable complex that
.appears on the monitoring screen
:Question -144.
A nurse is watching the cardiac monitor and notices that
the rhythm suddenly changes. No P waves or QRS complexes
are seen; instead, the monitor screen shows wavy lines.
:The nurse interprets that the client is experiencing
:Options
(Premature ventricular contractions (PVCs . 1
Sinus tachycardia . 2
Ventricular tachycardia . 3
Ventricular fibrillation . 4
:Answer
. 4
:Rationale
Ventricular fibrillation is characterized by the absence
of P waves and QRS complexes. The rhythm is instantly
recognizable by the presence of coarse or fine
fibrillatory waves on the cardiac monitoring screen. Each
of the incorrect options has a recognizable complex that
.appears on the monitoring screen
:Question -145
A client with myocardial infarction is experiencing new,
multiform premature ventricular contractions (PVCs).
Knowing that the client is allergic to lidocaine
hydrochloride, the nurse plans to have which of the

4. ?following medications available for immediate use
:Options
(Digoxin (Lanoxin . 1
(Metoprolol (Lopressor . 2
(Verapamil (Calan . 3
(Procainamide (Pronestyl . 4
:Answer
. 4
:Rationale
Procainamide is an antiarrhythmic that may be used to
treat ventricular arrhythmias in clients who are allergic
to lidocaine. Digoxin is a cardiac glycoside; metoprolol
is a beta-adrenergic blocking agent; verapamil is a
.calcium channel–blocking agent
:Question -146
A client has received antiarrhythmic therapy for the
treatment of premature ventricular contractions (PVCs).
The nurse would evaluate this therapy as most effective
:if the client ’s PVCs continued to: Options
Be multifocal in appearance . 1
Occur in pairs . 2
Decrease to a frequency of less than 6/min . 3
Fall on the second half of the T wave . 4
. Answer: 3
:Rationale
PVCs are considered dangerous when they are frequent
(more than 6/min) , occur in pairs or couplets , are
multifocal (multiform), or fall on the T wave. In each of
these instances, the client ’s cardiac rhythm is likely
to degenerate into ventricular tachycardia or ventricular
fibrillation, both of which are potentially deadly
.arrhythmias
:Question-147
A client has received antiarrhythmic therapy for the
treatment of premature ventricular contractions (PVCs).
The nurse would evaluate this therapy as most effective
:if the client ’s PVCs continued to: Options
Be multifocal in appearance . 1
Occur in pairs . 2
Decrease to a frequency of less than 6/min . 3
Fall on the second half of the T wave . 4
:Answer
. 3
:Rationale
PVCs are considered dangerous when they are frequent
(more than 6/min) , occur in pairs or couplets , are
multifocal (multiform), or fall on the T wave. In each of
these instances, the client ’s cardiac rhythm is likely
to degenerate into ventricular tachycardia or ventricular
fibrillation, both of which are potentially deadly

5. .arrhythmias
:Question -148
An adult client has been defibrillated three times
unsuccessfully for ventricular fibrillation, and
cardiopulmonary resuscitation (CPR) is resumed. The nurse
confirms that CPR is being administered effectively by
:noting that
:Options
. The ratio of compressions to ventilations is 30:2 . 1
. Respirations are given at a rate of 12 breaths/min . 2
The chest compressions are given at a depth of 1.5 to . 3
. 2 inches
.The carotid pulse is palpable with each compression . 4
:Answer
. 4
:Rationale
Correct procedure for CPR with two rescuers includes a
compression -to-ventilation ratio of 30:2 . With adults ,
compressions are performed at a depth of 1.5 to 2
inches . The 30:2 compression -ventilation ratio yields
an effective rate of 12 breaths/min . With effective
compressions , carotid pulsations should be present . At
its best , CPR produces only 30% of the normal cardiac
. output , so correct technique is vital
:Question -149
A nurse is assessing the client ’s condition after
cardioversion. Which of the following observations would
?be of highest priority to the nurse
:Options
Status of airway . 1
Oxygen flow rate . 2
Level of consciousness . 3
Blood pressure . 4
:Answer
. 1
:Rationale
Nursing responsibilities after cardioversion include
maintenance of a patent airway, oxygen administration,
assessment of vital signs and level of consciousness, and
arrhythmia detection. Airway, however, is always the
.highest priority
:Question -150
A home health nurse makes a home visit to a client who
has an implantable cardioverter-defibrillator (ICD) and
reviews the instructions concerning pacemakers and
arrhythmias with the client. Which client statement
?indicates that further teaching is necessary
:Options
If I feel an internal defibrillator shock, I should” . 1
“ .sit down

6. I can stop taking my antiarrhythmic medicine now,” . 2
“ .because I have a pacemaker
My wife knows how to call the emergency medical” . 3
“ .services if I need it
I won ’t be able to have a magnetic resonance” . 4
“ .imaging test
:Answer
. 2
:Rationale
Clients with an ICD usually continue to receive
antiarrhythmic medications after discharge from the
hospital. The nurse should stress the importance of
continuing to take these medications as prescribed. The
nurse should provide clear instructions about the
purposes of the medications, dosage schedule, and side
effects to report . Options 1 , 3 , and 4 are correct
statements regarding this implantable device
:Question -151
A client with complete heart block has had a permanent
demand ventricular pacemaker inserted. The nurse assesses
for proper pacemaker function by examining the
electrocardiogram (ECG) strip for the presence of
:pacemaker spikes
:Options
Just after each T wave . 1
Before each QRS complex . 2
Just after each P wave . 3
Before each P wave . 4
:Answer
. 2
:Rationale
If a ventricular pacemaker is functioning properly, there
will be a pacer spike followed by a QRS complex. An
atrial pacemaker spike precedes a P wave if an atrial
pacemaker is implanted. A demand pacemaker fires only
when needed and should therefore discharge only when no
electrical activity is occurring in the client ’s own
.heart
:Question -152
A client complains of calf tenderness. On assessment, the
nurse notes the presence of Homans ’sign. The nurse next
:assesses the client for
:Options
Coolness and pallor of the affected limb . 1
Diminished distal peripheral pulses . 2
Increased calf circumference . 3
Bilateral edema . 4
:Answer
. 3
:Rationale
The client with thrombophlebitis, also known as deep vein

7. thrombosis, exhibits redness or warmth of the affected
leg, tenderness at the site, possibly dilated veins (if
superficial), low-grade fever, edema distal to the
obstruction, Homans ’sign, and increased calf
circumference in the affected extremity. Pedal pulses are
unchanged from baseline because this is a venous, not an
arterial, problem. Often, thrombophlebitis develops
silently; that is, the client does not present with any
signs and symptoms unless pulmonary embolism occurs as a
.complication
:Question -153
A nurse is implementing a plan of care for a client with
deep vein thrombosis of the right leg. Which intervention
would be inappropriate for the nurse to include in
:delivering care to this client? Options
Elevation of the right leg . 1
Ambulation in the hall twice per shift . 2
Application of moist heat to the right leg . 3
(Administration of acetaminophen (Tylenol . 4
:Answer
. 2
:Rationale
Standard management of the client with deep vein
thrombosis includes bed rest for possibly 5 to 7 days ,
limb elevation, relief of discomfort with warm moist heat
and analgesics as needed, anticoagulant therapy, and
monitoring for signs of pulmonary embolism. Ambulation is
contraindicated, because it increases the likelihood of
dislodgment of the tail of the thrombus, which could
.travel to the lungs as a pulmonary embolism
:Question -154
A client has been diagnosed with thromboangiitis
obliterans (Buerger ’s disease). The nurse is identifying
measures to help the client cope with lifestyle changes
needed to control the disease process. The nurse plans to
:refer the client to a
:Options
Medical social worker . 1
Dietitian . 2
Smoking cessation program . 3
Pain management clinic . 4
:Answer
. 3
:Rationale
Buerger ’s disease is a vascular occlusive disease that
affects the medium and small arteries and veins. Smoking
is highly detrimental to the client with Buerger ’s
disease, so stopping smoking completely is recommended.
Because smoking is a form of chemical dependency,
referral to a smoking cessation program may be helpful
for many clients. For many clients with Burger ’s

8. disease, symptoms are relieved or alleviated once smoking
stops . Options 1 , 2 , and 4 are not specifically
associated with the lifestyle changes required in this
.disorder
:Question -155
A home health nurse is visiting a client who has had a
prosthetic valve replacement for severe mitral valve
stenosis. Which statement by the client reflects an
understanding of specific postoperative care after this
?surgery
:Options
I threw away my straight razor and bought an” . 1
“ .electric razor
I have to go to the bathroom frequently because of” . 2
“ .my medication
“ .I need to count my pulse every day” . 3
I have to do deep breathing exercises every 2” . 4
“ . hours
:Answer
. 1
:Rationale
Prosthetic valves require long-term anticoagulation to
prevent clots from forming on the “foreign “tissue
implanted in the client ’s body. Anticoagulation therapy
requires clients to avoid any trauma or potential means
of causing bleeding , such as use of straight razors .
Options 2 , 3 , and 4 are not specifically related to
postoperative care after prosthetic valve replacement .
Option 2 relates to a client taking a diuretic . Option 3
relates to a client with a pacemaker. Option 4 is
.necessary in the immediate postoperative period
:Question-156 .
A nurse is planning to teach a client with peripheral
arterial disease about measures to limit disease
progression. Which of the following items would be
inappropriate for the nurse to include on a list of
?suggestions for the client
:Options
.Cut down on the amount of fats consumed in the diet . 1
.Use a heating pad on the legs to aid vasodilation . 2
.Walk each day to increase circulation to the legs . 3
.Be careful not to injure the legs or feet . 4
:Answer
. 2
:Rationale
Long-term management of peripheral arterial disease
consists of measures that increase peripheral circulation
(exercise), promote vasodilation (warmth), relieve pain,
and maintain tissue integrity (foot care and nutrition).
Application of a heating pad directly to the extremity is
contraindicated. The affected extremity may have

9. decreased sensitivity and is at risk for burns. Also, the
affected tissue does not obtain adequate circulation at
rest. Direct application of heat raises oxygen and
.nutritional requirements of the tissue even further
:Question -157
A home health nurse visits a client recovering from
cardiogenic shock secondary to an anterior myocardial
infarction and provides home care instructions to the
client. Which statement by the client indicates an
?understanding of these home care measures
:Options
“ .I wear a medical identification bracelet” . 1
I have planned periods of rest at 10 AM and 3 PM” . 2
“ . daily
“ .I ’ve lost four pounds since discharge” . 3
My daily pulse has remained between 65 and 80 beats” . 4
“ . a minute
:Answer
. 2
:Rationale
The client recovering from cardiogenic shock secondary to
a myocardial infarction will require a progressive
rehabilitation related to physical activity. The heart
requires several months to heal from an uncomplicated
myocardial infarction. The complication of cardiogenic
shock will increase recovery period for healing. Paced
activities with planned rest periods will decrease the
chance of experiencing angina or delayed healing .
Options 1 , 3 , and 4 are not related to the instructions
.needed after this diagnosis
:Question -158
A client who had coronary artery bypass surgery states to
the home health nurse: “I get so frustrated. I can ’t
even do my gardening. ”The nurse assesses the client for
activity level since the surgery. Which client statement
?indicates a need for further teaching
:Options
“ .I plan regular rest periods during the day” . 1
“ .I pace my activities throughout the day” . 2
I avoid outdoor physical activity during the heat of” . 3
“ .the day
I try to walk immediately after lunch, after I ’ve” . 4
“ .finished my morning house cleaning
. Answer: 4
:Rationale
Exercise is an integral part of the rehabilitation
program. It is necessary for optimal physiological
functioning and psychological well-being. Postoperative
physical rehabilitation must be progressive with planned
periods of rest. Exercise tolerance is judged by the

10. client ’s response, such as heart rate and endurance .
Options 1 , 2 , and 3 identify appropriate client
activities . Option 4 lacks planned periods of rest, and
the client has grouped too many activities in a brief
period of time, which will decrease endurance. Also,
exercise after meals can decrease the client ’s tolerance
because of shunting of blood to the gastrointestinal
.tract for digestion
:Question -159
A client in cardiogenic shock has a pulmonary artery
catheter (Swan-Ganz type) placed. The nurse would
interpret that the client is most unstable if which of
the following cardiac output (CO) and pulmonary capillary
?wedge pressure (PCWP) readings were obtained
:Options
CO 5 L/min , PCWP low . 1
CO 2 L/min , PCWP low . 2
CO 4 L/min , PCWP high . 3
CO 3 L/min , PCWP high . 4
:Answer
. 4
:Rationale
The normal cardiac output is 4 to 7 L/min . With
cardiogenic shock , the CO falls below normal because of
failure of the heart as a pump. The PCWP, however, rises
because it is a reflection of the left ventricular end-
.diastolic pressure, which rises with pump failure
:Question -160
A client in cardiogenic shock had an intra- aortic
balloon pump inserted 24 hours earlier via the left
femoral approach. The nurse notes that the client ’s left
foot is cool and mottled, and the left pedal pulse is
weak. Which of the following is an appropriate
?intervention by the nurse
:Options
.Call the physician immediately . 1
.Re- evaluate the neurovascular status in 1 hour . 2
Increase the rate of intravenous nitroglycerin that . 3
.is infusing
Document these findings, which are expected because . 4
.of the catheter size
:Answer
. 1
:Rationale
The nursing interventions for the client with an intra-
aortic balloon pump are the same as for any client who
has had cardiovascular surgery. The peripheral
circulation to the affected limb is monitored for signs
of occlusion, such as coolness, mottling, pain, tingling,
and decreased or absent distal pulse. Adverse changes are
.reported immediately

11. :Question -161
A hospitalized client has been diagnosed with heart
failure as a complication of hypertension. In explaining
the disease process to the client, the nurse identifies
which of the following chambers of the heart as primarily
?responsible for the client ’s symptoms
:Options
Left atrium . 1
Left ventricle . 2
Right atrium . 3
Right ventricle . 4
:Answer
. 2
:Rationale
Hypertension increases the workload of the left
ventricle, because the ventricle has to pump the stroke
volume against increased resistance (afterload) in the
major blood vessels. Over time, this causes the left
ventricle to fail, leading to signs and symptoms of heart
failure. Left-sided heart failure is characterized by
pulmonary signs and symptoms, because the lungs lie
behind the left side of the heart from the perspective of
circulation . Therefore options 1 , 3 , and 4 are
. incorrect
:Question -162 .
A client has experienced a myocardial infarction. The
nurse caring for the client understands that the client
’s chest pain is due to tissue hypoxia in which of the
?following layers of the heart
:Options
Parietal pericardium . 1
Visceral pericardium . 2
Myocardium . 3
Endocardium . 4
:Answer
. 3
:Rationale
The myocardial layer of the heart is damaged when the
client experiences a myocardial infarction. This is the
middle layer that contains the striated muscle fibers
responsible for the contractile force of the heart. The
endocardium is the thin inner layer of cardiac tissue.
The parietal pericardium and visceral pericardium are
outer layers that protect the heart from injury and
.infection
:Question -163
A client is admitted to the hospital with a diagnosis of
mitral stenosis. The nurse caring for the client
understands that the narrowing of this valve impedes
:circulation of blood from the
:Options

12. Left atrium to left ventricle . 1
Left ventricle to aorta . 2
Right atrium to right ventricle . 3
Right ventricle to pulmonary artery . 4
:Answer
. 1
:Rationale
The mitral valve separates the left atrium from the left
ventricle . Options 2 , 3 , and 4 describe the aortic ,
.tricuspid, and pulmonic valves, respectively
:Question -164
A client is admitted to the hospital with a diagnosis of
aortic regurgitation. The nurse caring for the client
understands that the failure of the aortic valve to close
:completely allows blood to flow retrograde from
:Options
The left ventricle to the left atrium . 1
The aorta to the left ventricle . 2
The right ventricle to the right atrium . 3
The pulmonary artery to the right ventricle . 4
:Answer
. 2
:Rationale
The aortic valve separates the aorta from the left
ventricle . Options 1 , 3 , and 4 describe the mitral ,
.tricuspid, and pulmonic valves, respectively
:Question -165
A hospitalized client is experiencing a decrease in blood
pressure. The nurse caring for the client anticipates
that this change will have which of the following primary
:effects on the client ’s heart? Options
Increased resistance to electrical stimulation . 1
Decreased heart rate . 2
Increased contractility . 3
Decreased myocardial blood flow . 4
. Answer: 4
:Rationale
The primary effect of a decreased blood pressure is
reduced blood flow to the myocardium. This in turn
decreases the oxygenation to cardiac tissue. Cardiac
tissue is likely to become more excitable or irritable in
the presence of hypoxia. Correspondingly, the heart rate
is likely to increase in response to this change, not
decrease. The effects of tissue ischemia will lead to
.decreased contractility over time
:Question -166
A hospitalized client ’s serum calcium level is 7.9 mg/dL
. The nurse is immediately concerned , knowing that this
:level could ultimately lead to
:Options
High blood pressure . 1

13. Stroke . 2
Cardiac arrest . 3
Urinary stone formation . 4
:Answer
. 3
:Rationale
The normal calcium level is 8.6 to 10 mg/dL . A low
calcium level could lead to severe ventricular
dysrhythmias, prolonged QT interval, and ultimately
cardiac arrest. Calcium is needed by the heart for
contraction. Calcium ions move across cell membranes into
cardiac cells during depolarization, and move back during
repolarization . Depolarization is responsible for
cardiac contraction . Options 1 and 2 are unrelated to
calcium levels. Elevated calcium levels can lead to
.urinary stone formation
:Question -167
A nurse is reinforcing instructions to a hospitalized
client with heart block about the fundamental concepts
regarding the cardiac rhythm. The nurse explains to the
client that the normal site in the heart responsible for
:initiating electrical impulses is the
:Options
Atrioventricular (AV) node . 1
Bundle of His . 2
Purkinje fibers . 3
Sinoatrial (SA) node . 4
:Answer
. 4
:Rationale
The SA node is responsible for initiating electrical
impulses that are conducted through the heart. The
impulse leaves the SA node, travels down through
internodal and interatrial pathways to the AV node. From
there, impulses travel through the bundle of His to the
right and left bundle branches, and then to the Purkinje
fibers. This group of specialized cardiac cells is
referred to as the cardiac conduction system. The ability
of this specialized tissue to generate its own impulses
.is called automaticity
:Question -168
A nursing instructor asks a nursing student to describe
the structure and function of the coronary arteries.
Which of the following responses by the student indicates
a need to further research anatomy and physiology related
?to the heart
:Options
“ .The coronary arteries branch from the aorta” . 1
The coronary arteries supply the heart muscle with” . 2
“ .blood
The left coronary artery provides blood for the left” . 3

14. “ .atrium and the left ventricle
The left coronary artery supplies the right atrium” . 4
“ .and right ventricle with blood
:Answer
. 4
:Rationale
The left coronary artery divides into the anterior
descending artery and the circumflex artery, providing
blood for the left atrium and left ventricle. The right
coronary artery supplies the right atrium and right
. ventricle . Options 1 , 2 , and 3 are correct
:Question -169
A nurse is assigned to care for a client with a cardiac
disorder and is told that the client has an alteration in
cardiac output. The nurse plans care with the
understanding that the heart normally sends out how many
?liters of blood per minute to the body
:Options
L/min 2 . 1
L/min 5 . 2
L/min 10 . 3
L/min 15 . 4
:Answer
. 2
:Rationale
The cardiac cycle consists of contraction and relaxation
of the heart muscle. The heart normally sends out about 5
. L of blood every minute to the body
:Question -170
A nurse is caring for a client who has lost a significant
amount of blood as a result of complications of a
surgical procedure. The nurse understands that which of
the following client assessments will provide the
?earliest indication of new decreases in fluid volume
:Options
Pulse rate . 1
(Blood pressure (BP . 2
Assessment for edema . 3
Lung auscultation for crackles . 4
:Answer
. 1
:Rationale
The cardiac output is determined by the volume of the
circulating blood, the pumping action of the heart, and
the tone of the vascular bed. Early decreases in fluid
volume are compensated for by an increase in the pulse
rate . Options 3 and 4 indicate an increase in fluid
volume . Although the BP will decrease , it is not the
.earliest indicator
:Question-171
A nurse is preparing to take an apical pulse on an

15. assigned client. The nurse places the diaphragm of the
?stethoscope over which cardiac site
:Options
Right atrium . 1
Right ventricle . 2
Mitral area . 3
Pulmonic valve . 4
:Answer
. 3
:Rationale
The diaphragm of the stethoscope is placed over the skin
at the mitral area to listen to the apical pulse. S 1
(lub) and S2 (dub) should be distinguished . The pulse
. should be counted for a full minute
:Question -172
A male client who has been exercising in a gymnasium
stops to measure his pulse and places his fingers over
both carotid arteries simultaneously. A nurse exercising
nearby cautions him to check the pulse on only one side,
:primarily because
:Options
.It is unnecessary to use both hands . 1
Feeling dual pulsations may lead to an incorrect . 2
.measurement
.The client could occlude the trachea . 3
.The heart rate and blood pressure could drop . 4
. Answer: 4
:Rationale
Applying pressure to both carotid arteries at the same
time is contraindicated. Excess pressure to the
baroreceptors in the carotid vessels could cause the
heart rate and blood pressure to reflexively drop. In
addition, the manual pressure could interfere with the
flow of blood to the brain, causing possible dizziness
.and syncope
:Question -173
A nursing student who is researching a medication at the
nursing station asks the registered nurse (RN) what an α
1 - adrenergic receptor is . The RN responds by telling
:the student that these receptors are found primarily in
:Options
The heart, and when stimulated cause an increase in . 1
heart rate, atrioventricular (AV) node conduction, and
contractility
Arterial and bronchial walls, and when stimulated . 2
cause vasodilation and bronchodilation 3 . The peripheral
arteries and veins, and when stimulated cause
vasoconstriction
Several tissues, and when stimulated cause . 4
contraction of smooth muscle, inhibition of lipolysis,
and promotion of platelet aggregation

16. :Answer
. 3
:Rationale
Found in the peripheral arteries and veins, α 1 -
adrenergic receptors cause a powerful vasoconstriction
when stimulated . Options 1 , 2 , and 4 describe β 1 - ,
. β2- , and α2- adrenergic receptors , respectively
:Question -174
A nurse reading the operative record for a client who had
cardiac surgery notes that the client ’s cardiac output
immediately after surgery was 3.6 L/min . The nurse
:interprets that this measurement is : Options
Above the normal range . 1
In the high-normal range . 2
In the low-normal range . 3
Below the normal range . 4
:Answer
. 4
:Rationale
The normal cardiac output for the adult can range from 4
to 8 L/min and varies greatly with body size . The heart
. normally pumps 5 L of blood every minute
:Question-175
A nurse who is auscultating a 56-year- old client ’s
apical heart rate before administering digoxin (Lanoxin)
notes that the heart rate is 52 beats/min . The nurse
: interprets this heart rate as
:Options
Normal, because of the client ’s age . 1
Normal, because this is the reason the client is . 2
receiving digoxin
Normal, as a result of the effects of digoxin . 3
Abnormal, requiring further assessment . 4
:Answer
. 4
:Rationale
The normal heart rate is 60 to 100 beats/min in an
adult . On auscultating a heart rate that is less than 60
beats/min, the nurse would not administer the digoxin and
would report the finding to the physician. Options 1 ,
2 , and 3 are incorrect because the heart rate of 52
. beats/min is not normal
:Question-176
A male client who is beginning an exercise program asks
the nurse why his heart “feels like it ’s pounding ”when
he is exercising vigorously. In formulating a response,
the nurse understands that this is due to the client ’s
:need for an increased
:Options
Pulse rate . 1
Stroke volume . 2

17. Cardiac output . 3
Cardiac index . 4
:Answer
. 3
:Rationale
The client ’s symptoms are the direct result of the body
’s attempt to meet the metabolic demands of the body
during exercise. An adequate cardiac output is needed to
maintain perfusion to the vital organs of the body. With
exercise, these demands increase, and the heart must beat
faster (increased heart rate) and harder (increased
stroke volume) to achieve this. Cardiac index is an
artificial number used to determine the adequacy of the
cardiac output for a given individual. It is calculated
.by adjusting the cardiac output by body surface area
:Question -177
A nurse is listening to a cardiologist explain the
results of a cardiac catheterization to a client and
family. The physician tells the client that a blockage is
present in the large blood vessel that supplies the
anterior wall of the left ventricle. The nurse interprets
that the physician is referring to which of the following
?arteries
:Options
(Left anterior descending coronary artery (LAD . 1
(Right coronary artery (RCA . 2
Circumflex coronaryartery . 3
(Posterior descending coronary artery (PDA . 4
:Answer
. 1
:Rationale
The LAD bifurcates from the left main coronary artery to
supply the anterior wall of the left ventricle and a few
other structures. The RCA supplies the right side of the
heart, including the atrium and ventricles. The
circumflex coronary artery bifurcates from the left
coronary artery, and supplies the left atrium and the
lateral wall of the left ventricle. The PDA supplies the
.posterior wall of the heart
:Question-178
A nurse is assigned to the care of a client hospitalized
with a diagnosis of hypothermia. The nurse anticipates
that the client will exhibit which of the following vital
?signs
:Options
Increased heart rate and increased blood pressure . 1
Increased heart rate and decreased blood pressure . 2
Decreased heart rate and increased blood pressure . 3
Decreased heart rate and decreased blood pressure . 4
:Answer
. 4

18. :Rationale
Hypothermia decreases the heart rate and blood pressure
because the metabolic needs of the body are reduced in
this condition. With fewer metabolic needs, the workload
of the heart decreases, with drops in both the heart rate
.and the blood pressure