SlideShare a Scribd company logo
1 of 14
Download to read offline
:Question -179
A female client who has had a myocardial infarction asks
the nurse why she should not bear down or strain to
ensure having a bowel movement. The nurse incorporates in
 :a response that this would trigger: Options
Vagus nerve stimulation, causing a decrease in heart . 1
 rate and cardiac contractility
Vagus nerve stimulation, causing an increase in heart . 2
 rate and cardiac contractility
Sympathetic nerve stimulation, causing an increase in . 3
 heart rate and cardiac contractility
Sympathetic nerve stimulation, causing a decrease in . 4
 heart rate and cardiac contractility
 :Answer
 . 1
 :Rationale
Bearing down as if straining to have a bowel movement can
stimulate a vagal reflex. Stimulation of the vagus nerve
causes a decrease in heart rate and cardiac
contractility. The sympathetic nervous system stimulation
has the opposite effect. These two branches of the
autonomic nervous system oppose each other to maintain
 .homeostasis
 :Question -180
A client is experiencing a decrease in cardiac output.
The nurse understands that the client could benefit from
greater endogenous production of which of the following
 ?substances, which also increases blood pressure
 :Options
 Epinephrine . 1
 Norepinephrine . 2
 Dopamine . 3
 Serotonin . 4
 :Answer
 . 3
 :Rationale
Dopaminergic receptors are found in the renal blood
vessels and in the nerves. When these are stimulated,
they dilate renal arteries and help modulate release of
this neurotransmitter. Renal artery dilation helps to
improve urine output by increasing blood flow through the
kidneys. Epinephrine and norepinephrine affect the α and
β receptors in the body. Serotonin is a local hormone
that is released from platelets after an injury. It
 .constricts arterioles but dilates capillaries
 :Question -181
A new nursing graduate is caring for a client who is
attached to a cardiac monitor. While assisting the client
with bathing, the nurse notes the sudden development of
ventricular tachycardia (VT), but the client remains
alert and oriented and has a pulse. Select the
interventions that the nurse would take. (Select all that
 (.apply
 :Options
 .Defibrillate the client . 1
 .Assess airway, breathing, and circulation . 2
 .(Initiate cardiopulmonary resuscitation (CPR . 3
 .Administer oxygen . 4
 .(Obtain an electrocardiogram (ECG . 5
 .Contact the physician . 6
 :Answer
 . 2.4.5.6
 :Rationale
With ventricular tachycardia in a stable client, the
nurse assesses airway, breathing, and circulation;
administers oxygen ; and confirms the rhythm via a 12-
lead ECG . The physician is contacted and antiarrhythmics
may be prescribed. With pulseless ventricular
tachycardia, the physician or a specially trained nurse
must immediately defibrillate the client or initiate CPR
 .followed by defibrillation as soon as possible
 :Question -182
Which of the following laboratory test results may be
associated with peaked or tall, tented T waves on a
 ?(client ’s electrocardiogram (ECG
 :Options
 Chloride level of 98 mEq/L . 1
 Sodium level of 135 mEq/L . 2
 Potassium level of 6.8 mEq/L . 3
 Magnesium level of 1.6 mEq/L . 4
 :Answer
 . 3
 :Rationale
Hyperkalemia can cause tall peaked or tented T waves on
the ECG . Levels of potassium of 5.1 mEq/L or greater
indicate hyperkalemia . Options 1 , 2 , and 4 are normal
 . levels
 :Question -183
A nurse is assessing a client with a history of cardiac
problems. Where should the nurse place the stethoscope in
 ?order to hear the first heart sound (S 1 ) the loudest
 :Options
Over the second intercostal space at the left sternal . 1
 border
Over the fourth intercostal space at the right . 2
 sternal border
Over the second intercostal space at the right . 3
 sternal border
Over the fifth intercostal space in the left . 4
 midclavicular line
 :Answer
 . 4
:Rationale
The first heart sound (S 1 ) is heard loudest at the
lower left sternal border or the apex of the heart . The
apex is located at the fifth intercostal space at the
left midclavicular line . Therefore , options 1 , 2 , and
 .3 are incorrect
 :Question -184
A nurse providing care for a client on cardiac telemetry
notes this cardiac rhythm on the monitor. The nurse
 :interprets the rhythm as
 :Options
 (Normal sinus rhythm (NSR . 1
 Bradycardia . 2
 Atrial fibrillation . 3
 Tachycardia . 4
 :Answer
 . 3
 :Rationale
In atrial fibrillation, the P waves may be absent. There
is no PR interval, and the QRS duration usually is normal
and constant. In NSR, a P wave precedes each QRS complex,
the rhythm is essentially regular, the PR interval is
0.12 to 0.20 second in duration , and the QRS interval is
0.06 to 0.10 second in duration. Bradycardia is a slowed
 .heart rate, and tachycardia is a fast heart rate

 :Question -185
A nurse is assigned the care of a client who experienced
a myocardial infarction and is being monitored by cardiac
telemetry. The nurse notes the sudden onset of this
 :cardiac rhythm on the monitor. The nurse immediately
 :Options
 Takes the client ’s blood pressure . 1
 (Initiates cardiopulmonary resuscitation (CPR . 2
Places a nitroglycerin tablet under the client ’s . 3
 tongue
Continues to monitor the client for 1 minute and then . 4
 contacts the physician
 :Answer
 . 2
 :Rationale
This cardiac rhythm identifies a coarse ventricular
fibrillation (VF). The goals of treatment are to
terminate VF promptly and to convert it to an organized
rhythm. The physician or an advanced cardiac life support
(ACLS)-qualified nurse or other health care provider must
immediately defibrillate the client. If a defibrillator
is not readily available , CPR is initiated until the
defibrillator arrives . Options 1 , 3 , and 4 are
 .incorrect actions and delay life-saving treatment
 :Question -186
A nurse is assigned the care of a client with a diagnosis
of congestive heart failure who is receiving intravenous
doses of furosemide (Lasix). The client is attached to
cardiac telemetry, and the nurse is monitoring the client
’s cardiac status. The nurse notes that the client ’s
cardiac rhythm has changed to this pattern. The nurse
determines that the most likely cause of this cardiac
 :rhythm in this client is: Options
 The effectiveness of the furosemide . 1
 The presence of hypokalemia . 2
 Pacemaker dysfunction . 3
 (An impending myocardial infarction (MI . 4
 :Answer
 . 2
 :Rationale
This cardiac rhythm is normal sinus rhythm with unifocal
premature ventricular complexes (PVCs). PVCs may be
insignificant or may occur with myocardial ischemia or
MI; congestive heart failure; hypokalemia;
hypomagnesemia; medications; stress; nicotine, caffeine,
or alcohol intake; infection; trauma; or surgery. This
client is receiving furosemide, which is a diuretic that
causes the excretion of potassium . The most likely cause
of the PVCs in this client is hypokalemia . Option 1 is
an incorrect interpretation. The question presents no
data indicating that this client has a pacemaker or has
 .signs and symptoms of MI
 :Question -187
A client is attached to a cardiac monitor, and the nurse
notes the presence of this cardiac rhythm on the monitor.
The nurse quickly assesses the client, knowing that this
 :rhythm is indicative of
 :Options
 Atrial fibrillation . 1
 Premature ventricular complexes . 2
 (Ventricular tachycardia (VT . 3
 (Ventricular fibrillation (VF . 4
 :Answer
 . 3
 :Rationale
In VT, it usually is not possible to determine the atrial
rhythm. The ventricular rhythm usually is regular or
nearly regular. The P waves usually are not visible and
are obscured in the QRS complexes. VT occurs with
repetitive firing of an irritable ventricular ectopic
focus , usually at a rate of 140 to 180 beats/min or
 .more


 :Question -188
A nurse is assessing a client ’s legs for the presence of
edema. The nurse notes that the client has mild pitting
with slight indentation and no perceptible swelling of
 :the leg. The nurse documents this finding as defining
 :Options
 edema + 1 . 1
 edema + 2 . 2
 edema + 3 . 3
 edema + 4 . 4
 :Answer
 . 1
 :Rationale
Edema is accumulation of fluid in the intercellular
spaces and is not normally present. To check for edema,
the nurse would imprint his or her thumbs firmly against
the ankle malleolus or the tibia. Normally, the skin
surface stays smooth. If the pressure leaves a dent in
the skin, “pitting ”edema is present . Its presence is
graded on the following 4- point scale : 1 + , mild
pitting , slight indentation , no perceptible swelling of
the leg ; 2 + , moderate pitting , indentation subsides
rapidly ; 3 + , deep pitting , indentation remains for a
short time , leg looks swollen ; 4 + , very deep
pitting , indentation lasts a long time, leg is very
 .swollen
 :Question -189
A client is diagnosed with iron deficiency anemia, and
ferrous sulfate (Feosol) is prescribed. The nurse tells
 :the client that it is best to take the medication with
 :Options
 Milk . 1
 Boiled . 2
 Tomato juice . 3
 Pineapple juice . 4
 :Answer
 . 3
 :Rationale
Ferrous sulfate is an iron preparation and the client is
instructed to take the medication with orange juice or
another vitamin C–containing product, to increase the
absorption of the iron. Milk and eggs inhibit the
absorption of the iron. Tomato juice is highest in
 .vitamin C from the options presented
 :Question-190
A client is diagnosed with iron deficiency anemia, and
ferrous sulfate (Feosol) is prescribed. The nurse tells
 :the client that it is best to take the medication with
 :Options
 Milk . 1
 Boiled . 2
 Tomato juice . 3
 Pineapple juice . 4
:Answer
 . 3
 :Rationale
Ferrous sulfate is an iron preparation and the client is
instructed to take the medication with orange juice or
another vitamin C–containing product, to increase the
absorption of the iron. Milk and eggs inhibit the
absorption of the iron. Tomato juice is highest in
 .vitamin C from the options presented
 :Question-191
A nurse is teaching a client with cardiomyopathy about
home care safety measures. The nurse addresses which of
the following as the most important measure to ensure
 ?client safety
 :Options
 Assessing pain . 1
 Avoiding over-the-counter medications . 2
 Administering vasodilators . 3
 Moving slowly from a sitting to a standing position . 4
 :Answer
 . 4
 :Rationale
Orthostatic changes can occur in the client with
cardiomyopathy as a result of venous return obstruction.
Sudden changes in blood pressure may lead to falls.
Vasodilators normally are not prescribed for the client
with cardiomyopathy . Options 1 and 2 , although
important , are not directly related to the issue of
 .safety
 :Question -192
A client with an acute respiratory infection is admitted
to the hospital with a diagnosis of sinus tachycardia. In
developing a plan of care for the client, the nurse
 :includes which of the following? Options
 Providing the client with short, frequent walks . 1
 Measuring the client ’s pulse each shift . 2
 Eliminating sources of caffeine from meal trays . 3
 Limiting oral and intravenous fluids . 4
 :Answer
 . 3
 :Rationale
Sinus tachycardia often is caused by fever, physical and
emotional stress, heart failure, hypovolemia, certain
medications, nicotine, caffeine, and exercise. Exercise
and fluid restriction will not alleviate tachycardia .
Option 2 will not decrease the heart rate .
Additionally , the pulse should be taken more frequently
 .than each shift
 :Question -193
A client is scheduled for elective cardioversion to treat
chronic high-rate atrial fibrillation. The nurse
determines that the client is not yet ready for the
 :procedure after noting which of the following? Options
The client ’s digoxin (Lanoxin) has been withheld for . 1
 . the last 48 hours
The client has received a dose of midazolam (Versed) . 2
 .intravenously
The client is wearing a nasal cannula delivering . 3
 . oxygen at 2 L/min
The defibrillator has the synchronizer turned on and . 4
 .(is set at 50 joules (J
 :Answer
 . 3
 :Rationale
Digoxin may be withheld for up to 48 hours before
cardioversion because it increases ventricular
irritability and may cause ventricular arrhythmias after
the countershock. The client typically receives a dose of
an intravenous sedative or antianxiety agent. The
defibrillator is switched to synchronizer mode to time
the delivery of the electrical impulse to coincide with
the QRS and avoid the T wave, which could cause
ventricular fibrillation . Energy level typically is set
at 50 to 100 J . During the procedure , any oxygen is
removed temporarily, because oxygen supports combustion,
 .and a fire could result from electrical arcing
 :Question -194
A nurse is assisting in the care of a client scheduled
for cardioversion. The nurse plans to set the
defibrillator to which of the following starting energy
 ?range levels, depending on the specific physician order
 :Options
 to 100 joules 50 . 1
 to 200 joules 150 . 2
 to 300 joules 250 . 3
 to 400 joules 350 . 4
 :Answer
 . 1
 :Rationale
For cardioversion procedures, the defibrillator is
charged to the energy level ordered by the physician.
Countershock usually is started at 50 to 100 joules .
 . Options 2 , 3 , and 4 are incorrect
 :Question-195
A client has developed atrial fibrillation with a
ventricular rate of 150 beats/min . The nurse assesses
 :the client for
 :Options
 Hypotension and dizziness . 1
 Nausea and vomiting . 2
 Hypertension and headache . 3
 Flat neck veins . 4
:Answer
 . 1
 :Rationale
The client with uncontrolled atrial fibrillation with a
ventricular rate over 100 beats/min is at risk for low
cardiac output due to loss of atrial kick. The nurse
assesses the client for palpitations, chest pain or
discomfort, hypotension, pulse deficit, fatigue,
weakness, dizziness, syncope, shortness of breath, and
 .distended neck veins
 :Question -196
A nurse has provided self-care activity instructions to a
client after insertion of an automatic internal
cardioverter-defibrillator (AICD). The nurse determines
that further instruction is needed if the client makes
 ?which of the following statements
 :Options
I should try to avoid doing strenuous things that” . 1
would make my heart rate go up to or above the rate
“ .cutoff on the AICD
I should keep away from electromagnetic sources such” . 2
as transformers, large electrical generators, metal
“ .detectors, and leaning over running motors
I can perform activities such as swimming, driving,” . 3
or operating heavy equipment as I need to. ”4 . “I need
to avoid doing anything that could involve rough contact
 :with the AICD insertion site. ” Answer
 . 3
 :Rationale
Postdischarge instructions typically include avoiding
tight clothing or belts over AICD insertion sites, rough
contact with the AICD insertion site, electromagnetic
fields such as with electrical transformers,
radio/TV/radar transmitters, metal detectors, and running
motors of cars or boats. Clients also must alert
physicians or dentists to the presence of the device,
because certain procedures such as diathermy,
electrocautery, and magnetic resonance imaging may need
to be avoided to prevent device malfunction. Clients
should follow the specific advice of a physician
regarding activities that are potentially hazardous to
self or others, such as swimming, driving, or operating
 .heavy equipment
 :Question -197
A client with a history of hypertension has been
prescribed triamterene (Dyrenium). The nurse determines
that the client understands the impact of this medication
on the diet if the client states to avoid which of the
 ?following fruits
 :Options
 Apples . 1
Pears . 2
 Bananas . 3
 Cranberries . 4
 :Answer
 . 3
 :Rationale
Triamterene is a potassium-sparing diuretic, so the
client should avoid foods high in potassium. Fruits that
are naturally higher in potassium include avocadoes,
bananas, fresh oranges, mangoes, nectarines, papayas, and
.prunes
 :Question -198
The health care provider prescribes bedrest for a client
in whom a deep vein thrombosis develops after surgery.
From the following list, select all appropriate nursing
 .interventions to include in this client ’s plan of care
 :Options
 .Place in Fowler ’s position for eating . 1
 .Encourage increased oral intake of water daily . 2
 .Encourage coughing with deep breathing . 3
 .Place thigh-length elastic stockings on the client . 4
.Encourage the intake of dark, green leafy vegetables . 5

 .Place sequential compression boots on the client . 6
 :Answer
 . 2.3.4
 :Rationale
The client with deep vein thrombosis requires bedrest to
prevent embolization of the thrombus due to skeletal
muscle action, anticoagulation to prevent thrombus
extension and allow for thrombus autodigestion, fluids
for hemodilution and to decrease blood viscosity, and
compression stockings to reduce peripheral edema and
promote venous return. While the client is on bedrest,
the nurse prevents complications of immobility by
encouraging coughing and deep breathing. Venous return is
important to maintain because it is a contributing factor
in DVT, so the nurse maintains venous return from the
lower extremities by avoiding hip flexion, which occurs
with Fowler ’s position. The nurse avoids providing foods
rich in vitamin K such as dark green leafy vegetables
because this vitamin can interfere with anticoagulation,
thereby increasing the risk of additional thrombi and
emboli. The nurse also would not include use of
sequential compression boots for an existing thrombus.
They are used to prevent DVT only, because they mimic
skeletal muscle action and can disrupt an existing
 .thrombus, leading to pulmonary embolism
 :Question -199
Spironolactone (Aldactone), a diuretic, is prescribed for
a client with congestive heart failure. In providing
dietary instructions to the client, the nurse identifies
the need to avoid foods that are high in which
 ?electrolyte
 :Options
 Calcium . 1
 Potassium . 2
 Magnesium . 3
 Phosphorus . 4
 :Answer
 . 2
 :Rationale
Spironolactone is a potassium-sparing diuretic, and the
client should avoid foods high in potassium. If the
client does not avoid foods high in potassium,
hyperkalemia could develop. The client does not need to
avoid foods that contain calcium, magnesium, or
.phosphorus while taking this medication
 :Question -200
A client is seen in the urgent care center for complaints
of chest pain that began 3 days earlier. Since that time
the client has not been feeling well and fatigues easily.
The nurse would suspect myocardial infarction at the time
of chest pain if a test for which of the following
isoenzymes for lactate dehydrogenase (LDH) came back
 ?positive
 :Options
 LDH 1 . 1
 LDH 3 . 2
 LDH 4 . 3
 LDH 5 . 4
 :Answer
 . 1
 :Rationale
The particular isoenzymes that are affected after acute
myocardial infarction are LDH 1 and LDH 2 . The LDH level
begins to elevate about 24 hours after myocardial
infarction and peaks in 48 to 72 hours . Thereafter, it
 . returns to normal , usually within 7 to 14 days
 :Question -201
In planning a low-sodium diet for the client who has
recently been diagnosed with congestive heart failure,
the nurse should ask the client if she would like to have
 ?which food item
 :Options
 Chicken breast . 1
 Cottage cheese . 2
 Grilled cheese . 3
 Beef bouillon . 4
 :Answer
 . 1
 :Rationale
Chicken breast has 70 mg of sodium , compared with 457
for cottage cheese , 700 mg for grilled cheese , and 800
 . mg for beef bouillon
 :Question -202
A clinic nurse is performing a cardiovascular assessment
on a client and auscultates the chest over the apex of
the heart. (Click on sound icon.) The nurse identifies
 :this sound as which of the following? Options
 First heart sound , S 1 . 1
 Ventricular gallop . 2
 Third heart sound , S 3 . 3
 Fourth heart sound , S4 . 4
 :Answer
 . 1
 :Rationale
The sound that the nurse hears is the first heart sound ,
S 1 . The first heart sound (S 1 ) is created by the
closure of the mitral and triscupid valves
(atrioventricular [AV] valves). It marks the onset of
systole (ventricular contraction). When auscultated , the
first heart sound (S 1 ) is softer and longer than the
second heart sound (S2). S 1 is low in pitch and is best
heard at the left lower sternal border or the apex of the
heart . Disease and stiffened AV valves (as in rheumatic
heart disease) may augment S 1 ; rhythms of asynchrony
between the atria and ventricles (as in atrial
fibrillation and with AV block) cause variable intensity
of S 1 . Phonetically , if a typical heartbeat , composed
of the heart sounds S 1 and S2 , is auscultated as “lub-
dup , ”S 1 is the “lub . ”To assess S 1 , the nurse
should assist the client to a supine position (the head
of the bed may be elevated slightly if necessary). The
second heart sound (S2) is related to closure of the
pulmonic and aortic (semilunar) valves and is heard best
with the diaphragm at the aortic area. Phonetically, it
is the “dup ”of the “lub-dup ”of a typical heartbeat (the
first heart sound, S 1 , is the “lub ”). It signifies the
end of systole and the onset of diastole (ventricular
filling). S2 is characteristically shorter and higher
pitched than the first heart sound (S 1 ). Diastolic
filling sounds or gallops (S 3 , the third heart sound ,
and S4 , the fourth heart sound) are produced when
compliance of either or both ventricles is decreased . S
3 is termed ventricular gallop and S4 is referred to as
atrial gallop . The S 3 heart sound (a gallop sound)
occurs in early diastole , during passive , rapid filling
of the ventricles . The S4 sound occurs in the later
stage of diastole , during atrial contraction and active
filling of the ventricles . It is a soft , low- pitched
 . sound and is heard immediately before S 1
 :Question -203
Cardiac monitoring leads are placed on a client who is at
risk for premature ventricular contractions (PVCs). The
nurse assesses the client ’s heart rhythm to detect PVCs
 :by looking for
 :Options
 Premature beats followed by a compensatory pause . 1
 QRS complexes that are short and narrow . 2
 Inverted P waves before the QRS complexes . 3
 A P wave preceding every QRS complex . 4
 :Answer
 . 1
 :Rationale
PVCs are abnormal ectopic beats originating in the
ventricles. They are characterized by an absence of P
waves, presence of wide and bizarre QRS complexes, and a
 .compensatory pause that follows the ectopy
 :Question -204
A nurse is assisting in positioning the client for
pericardiocentesis to treat cardiac tamponade. The best
 :position for this client is
 :Options
Lying on the left side with a pillow under the chest . 1
 wall
 Lying on the right side with a pillow under the head . 2
Supine with the head of bed elevated at a 45- to 60- . 3
 degree angle
 Supine with slight Trendelenburg position . 4
 :Answer
 . 3
 :Rationale
The client undergoing pericardiocentesis is positioned
supine with the head of bed raised to a 45- to 60- degree
angle. This places the heart in close proximity to the
chest wall for easier insertion of the needle into the
 . pericardial sac . Options 1 , 2 , and 4 are incorrect
 :Question -205
A nurse is assessing a client hospitalized with acute
pericarditis. The nurse monitors the client for cardiac
tamponade, knowing that which of the following is
 ?unassociated with this complication of pericarditis
 :Options
 Pulsus paradoxus . 1
 Distant heart sounds . 2
 Distended jugular veins . 3
 Bradycardia . 4
 :Answer
 . 4
 :Rationale
Assessment findings with cardiac tamponade include
tachycardia, distant or muffled heart sounds, jugular
vein distention, and a falling blood pressure (BP),
accompanied by pulsus paradoxus (a drop in inspiratory BP
 .(by greater than 10 mm Hg
 :Question -206
A nurse inquires about smoking history while conducting a
hospital admission assessment for a client with coronary
artery disease (CAD). The most important element of the
 :smoking history for this assessment is the
 :Options
 Number of pack-years . 1
 Brand of cigarettes used . 2
 Desire to quit smoking . 3
 Number of past attempts to quit smoking . 4
 :Answer
 . 1
 :Rationale
The number of cigarettes smoked daily and the duration of
the habit are used to calculate the number of pack-years,
which is the standard method of documenting smoking
history. The brand of cigarettes may give a general
indication of tar and nicotine levels, but the
information is of no immediate clinical use. Desire to
quit and number of past attempts to quit smoking may be
useful when the nurse develops a smoking cessation plan
 .with the client


 :Question -207
A 52-year- old male client is seen in the physician ’s
office for a physical examination after experiencing
unusual fatigue over the last several weeks . The client
’s height is 5 feet 8 inches and his weight is 220 pounds
. Vital signs are as follows : temperature , 98.6° F
orally ; pulse , 86 beats/min ; and respirations , 18
breaths/min . The blood pressure reading is 184/100 mm Hg
. A random blood glucose level is 122 mg/dL. Which of the
following questions should the nurse ask the client
 ?first
 :Options
“ ?Do you exercise regularly” . 1
“ ?Are you considering trying to lose weight” . 2
Is there a history of diabetes mellitus in your” . 3
“ ?family
When was the last time you had your blood pressure” . 4
“ ?checked
 :Answer
 . 4
 :Rationale
The client is hypertensive, which is a known major
modifiable risk factor for coronary artery disease (CAD).
The other major modifiable risk factors not exhibited by
this client include smoking and hypercholesterolemia. The
client is overweight, which is a contributing risk
factor. The client ’s nonmodifiable risk factors are age
and gender. Because the client presents with several risk
factors, the nurse places priority of attention on the
 .client ’s major modifiable risk factors
 :Question -208
A nurse is developing a plan of care for a client with
pulmonary edema. The nurse establishes a goal to have the
client participate in activities that reduce cardiac
workload. The nurse identifies which client action as
 ?contributing to this goal
 :Options
 Elevating the legs when in bed . 1
 Sleeping in the supine position . 2
 Using seasonings to improve the taste of food . 3
 Using a bedside commode . 4
 :Answer
 . 4
 :Rationale
Using a bedside commode decreases the work of getting to
the bathroom or struggling to use the bedpan. Elevating
the client ’s legs increases venous return to the heart,
increasing cardiac workload. The supine position
increases respiratory effort and decreases oxygenation.
This increases cardiac workload. Seasonings may be high
 .in sodium
 :Question- 209
A nurse is performing an admission assessment on a client
with a diagnosis of Raynaud ’s disease. The nurse
 :assesses for associated signs and symptoms by
 :Options
 Observing for softening of the nails or nail beds . 1
 Palpating for diminished or absent peripheral pulses . 2
 Checking for a rash on the digits . 3
 Palpating for a rapid or irregular peripheral pulse . 4
 :Answer
 . 2
 :Rationale
Raynaud ’s disease produces closure of the small arteries
in the distal extremities in response to cold, vibration,
or external stimuli. Palpation for diminished or absent
peripheral pulses checks for interruption of circulation.
The nails grow slowly, become brittle or deformed, and
heal poorly around the nail beds when infected. Skin
changes include hair loss, thinning or tightening of the
skin, and delayed healing of cuts or injuries. Although
palpation of peripheral pulses is correct, a rapid or
irregular pulse would not be noted. Peripheral pulses may
.be normal, absent, or diminished

More Related Content

What's hot (20)

acls-algorithm-diagram-2017
 acls-algorithm-diagram-2017 acls-algorithm-diagram-2017
acls-algorithm-diagram-2017
 
Acls medications
Acls medicationsAcls medications
Acls medications
 
Code blue management
Code blue managementCode blue management
Code blue management
 
Tread mill test lekshmi g nadh 2015
Tread mill test lekshmi g nadh 2015Tread mill test lekshmi g nadh 2015
Tread mill test lekshmi g nadh 2015
 
Medical surgical nursing quiz
Medical surgical nursing quizMedical surgical nursing quiz
Medical surgical nursing quiz
 
Shweta code blue
Shweta code blueShweta code blue
Shweta code blue
 
Ecg
EcgEcg
Ecg
 
Acute biological-crisis ppt lecture
Acute biological-crisis ppt lectureAcute biological-crisis ppt lecture
Acute biological-crisis ppt lecture
 
Advanced Cardiac Life Support
Advanced Cardiac Life SupportAdvanced Cardiac Life Support
Advanced Cardiac Life Support
 
Stress Test Lecture
Stress Test LectureStress Test Lecture
Stress Test Lecture
 
Code management
Code managementCode management
Code management
 
Exercise Treadmill Testing
Exercise Treadmill TestingExercise Treadmill Testing
Exercise Treadmill Testing
 
Tmt
TmtTmt
Tmt
 
Crash Cart Medication
Crash Cart Medication Crash Cart Medication
Crash Cart Medication
 
Stress%20 testing housestaff%20didactic_10092014[1]
Stress%20 testing housestaff%20didactic_10092014[1]Stress%20 testing housestaff%20didactic_10092014[1]
Stress%20 testing housestaff%20didactic_10092014[1]
 
chest pain unit Management-Dr Shahriyari
chest pain unit Management-Dr Shahriyarichest pain unit Management-Dr Shahriyari
chest pain unit Management-Dr Shahriyari
 
Stress test
Stress testStress test
Stress test
 
Ett presentation
Ett presentationEtt presentation
Ett presentation
 
Care For Vent Pt
Care For Vent PtCare For Vent Pt
Care For Vent Pt
 
Tmt Seminary
Tmt SeminaryTmt Seminary
Tmt Seminary
 

Similar to Exam 6

MDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTL
MDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTLMDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTL
MDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTLAbramMartino96
 
Ccns practice questions
Ccns practice questionsCcns practice questions
Ccns practice questionsmichealdeweese
 
Familial Cardiomyopathies ( Fc )
Familial Cardiomyopathies ( Fc )Familial Cardiomyopathies ( Fc )
Familial Cardiomyopathies ( Fc )Liz Sims
 
Pals 2017 part 2
Pals 2017  part 2Pals 2017  part 2
Pals 2017 part 2Sayed Ahmed
 
Cardiac arrest(rev 4 2011)
Cardiac arrest(rev 4 2011)Cardiac arrest(rev 4 2011)
Cardiac arrest(rev 4 2011)Mohan Tiru
 
Dealing with tachycardias
Dealing with tachycardiasDealing with tachycardias
Dealing with tachycardiasDr Varun Patel
 
ACLS (Advanced cardiac life support)
ACLS (Advanced cardiac life support)ACLS (Advanced cardiac life support)
ACLS (Advanced cardiac life support)Abhay Rajpoot
 
Approach to palpitation [autosaved]
Approach to palpitation [autosaved]Approach to palpitation [autosaved]
Approach to palpitation [autosaved]A.Salam Sharif
 
03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt
03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt
03 Samir Rafla-Sudden Cardiac Death and Resuscitation.pptAlexandria University, Egypt
 
Acls mega code pdf
Acls mega code pdfAcls mega code pdf
Acls mega code pdfceipem
 
16672475 23 Mock Codes 2
16672475 23  Mock  Codes 216672475 23  Mock  Codes 2
16672475 23 Mock Codes 2Surgery Center
 
Cardiac Arrest Medical Case Scenarios
Cardiac Arrest Medical Case ScenariosCardiac Arrest Medical Case Scenarios
Cardiac Arrest Medical Case ScenariosKimberly Patterson
 

Similar to Exam 6 (20)

Exam 1
Exam 1Exam 1
Exam 1
 
MDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTL
MDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTLMDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTL
MDC3 -3MAKE SURE TO ANSWER ALL THE FOLLOW CAREFULLY AND CORRECTL
 
Ccns practice questions
Ccns practice questionsCcns practice questions
Ccns practice questions
 
Familial Cardiomyopathies ( Fc )
Familial Cardiomyopathies ( Fc )Familial Cardiomyopathies ( Fc )
Familial Cardiomyopathies ( Fc )
 
Pathogroup2
Pathogroup2Pathogroup2
Pathogroup2
 
Pals 2017 part 2
Pals 2017  part 2Pals 2017  part 2
Pals 2017 part 2
 
Cardiac arrest(rev 4 2011)
Cardiac arrest(rev 4 2011)Cardiac arrest(rev 4 2011)
Cardiac arrest(rev 4 2011)
 
Isosorbide Dinitrate
Isosorbide DinitrateIsosorbide Dinitrate
Isosorbide Dinitrate
 
Adult tachycardia
Adult tachycardiaAdult tachycardia
Adult tachycardia
 
Dealing with tachycardias
Dealing with tachycardiasDealing with tachycardias
Dealing with tachycardias
 
ACLS (Advanced cardiac life support)
ACLS (Advanced cardiac life support)ACLS (Advanced cardiac life support)
ACLS (Advanced cardiac life support)
 
Cpcr
CpcrCpcr
Cpcr
 
Approach to palpitation [autosaved]
Approach to palpitation [autosaved]Approach to palpitation [autosaved]
Approach to palpitation [autosaved]
 
03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt
03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt
03 Samir Rafla-Sudden Cardiac Death and Resuscitation.ppt
 
ECG FOR acls
ECG FOR acls ECG FOR acls
ECG FOR acls
 
Sudden Cardiac Death
Sudden Cardiac DeathSudden Cardiac Death
Sudden Cardiac Death
 
Acls mega code pdf
Acls mega code pdfAcls mega code pdf
Acls mega code pdf
 
Code Blue
 Code Blue Code Blue
Code Blue
 
16672475 23 Mock Codes 2
16672475 23  Mock  Codes 216672475 23  Mock  Codes 2
16672475 23 Mock Codes 2
 
Cardiac Arrest Medical Case Scenarios
Cardiac Arrest Medical Case ScenariosCardiac Arrest Medical Case Scenarios
Cardiac Arrest Medical Case Scenarios
 

More from al asheery

Exercises For Cervical Spondylosis
Exercises For Cervical SpondylosisExercises For Cervical Spondylosis
Exercises For Cervical Spondylosisal asheery
 
Safety notice mobile phone sim alert
Safety notice   mobile phone sim alertSafety notice   mobile phone sim alert
Safety notice mobile phone sim alertal asheery
 
Importantsites
ImportantsitesImportantsites
Importantsitesal asheery
 
اسئلة تمريض 44
اسئلة تمريض 44اسئلة تمريض 44
اسئلة تمريض 44al asheery
 
اسئلة تمريض 3
اسئلة تمريض 3اسئلة تمريض 3
اسئلة تمريض 3al asheery
 
اسئلة تمريض 1
اسئلة تمريض 1اسئلة تمريض 1
اسئلة تمريض 1al asheery
 

More from al asheery (6)

Exercises For Cervical Spondylosis
Exercises For Cervical SpondylosisExercises For Cervical Spondylosis
Exercises For Cervical Spondylosis
 
Safety notice mobile phone sim alert
Safety notice   mobile phone sim alertSafety notice   mobile phone sim alert
Safety notice mobile phone sim alert
 
Importantsites
ImportantsitesImportantsites
Importantsites
 
اسئلة تمريض 44
اسئلة تمريض 44اسئلة تمريض 44
اسئلة تمريض 44
 
اسئلة تمريض 3
اسئلة تمريض 3اسئلة تمريض 3
اسئلة تمريض 3
 
اسئلة تمريض 1
اسئلة تمريض 1اسئلة تمريض 1
اسئلة تمريض 1
 

Exam 6

  • 1. :Question -179 A female client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse incorporates in :a response that this would trigger: Options Vagus nerve stimulation, causing a decrease in heart . 1 rate and cardiac contractility Vagus nerve stimulation, causing an increase in heart . 2 rate and cardiac contractility Sympathetic nerve stimulation, causing an increase in . 3 heart rate and cardiac contractility Sympathetic nerve stimulation, causing a decrease in . 4 heart rate and cardiac contractility :Answer . 1 :Rationale Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. The sympathetic nervous system stimulation has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain .homeostasis :Question -180 A client is experiencing a decrease in cardiac output. The nurse understands that the client could benefit from greater endogenous production of which of the following ?substances, which also increases blood pressure :Options Epinephrine . 1 Norepinephrine . 2 Dopamine . 3 Serotonin . 4 :Answer . 3 :Rationale Dopaminergic receptors are found in the renal blood vessels and in the nerves. When these are stimulated, they dilate renal arteries and help modulate release of this neurotransmitter. Renal artery dilation helps to improve urine output by increasing blood flow through the kidneys. Epinephrine and norepinephrine affect the α and β receptors in the body. Serotonin is a local hormone that is released from platelets after an injury. It .constricts arterioles but dilates capillaries :Question -181 A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse notes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Select the
  • 2. interventions that the nurse would take. (Select all that (.apply :Options .Defibrillate the client . 1 .Assess airway, breathing, and circulation . 2 .(Initiate cardiopulmonary resuscitation (CPR . 3 .Administer oxygen . 4 .(Obtain an electrocardiogram (ECG . 5 .Contact the physician . 6 :Answer . 2.4.5.6 :Rationale With ventricular tachycardia in a stable client, the nurse assesses airway, breathing, and circulation; administers oxygen ; and confirms the rhythm via a 12- lead ECG . The physician is contacted and antiarrhythmics may be prescribed. With pulseless ventricular tachycardia, the physician or a specially trained nurse must immediately defibrillate the client or initiate CPR .followed by defibrillation as soon as possible :Question -182 Which of the following laboratory test results may be associated with peaked or tall, tented T waves on a ?(client ’s electrocardiogram (ECG :Options Chloride level of 98 mEq/L . 1 Sodium level of 135 mEq/L . 2 Potassium level of 6.8 mEq/L . 3 Magnesium level of 1.6 mEq/L . 4 :Answer . 3 :Rationale Hyperkalemia can cause tall peaked or tented T waves on the ECG . Levels of potassium of 5.1 mEq/L or greater indicate hyperkalemia . Options 1 , 2 , and 4 are normal . levels :Question -183 A nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope in ?order to hear the first heart sound (S 1 ) the loudest :Options Over the second intercostal space at the left sternal . 1 border Over the fourth intercostal space at the right . 2 sternal border Over the second intercostal space at the right . 3 sternal border Over the fifth intercostal space in the left . 4 midclavicular line :Answer . 4
  • 3. :Rationale The first heart sound (S 1 ) is heard loudest at the lower left sternal border or the apex of the heart . The apex is located at the fifth intercostal space at the left midclavicular line . Therefore , options 1 , 2 , and .3 are incorrect :Question -184 A nurse providing care for a client on cardiac telemetry notes this cardiac rhythm on the monitor. The nurse :interprets the rhythm as :Options (Normal sinus rhythm (NSR . 1 Bradycardia . 2 Atrial fibrillation . 3 Tachycardia . 4 :Answer . 3 :Rationale In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is normal and constant. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second in duration , and the QRS interval is 0.06 to 0.10 second in duration. Bradycardia is a slowed .heart rate, and tachycardia is a fast heart rate :Question -185 A nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this :cardiac rhythm on the monitor. The nurse immediately :Options Takes the client ’s blood pressure . 1 (Initiates cardiopulmonary resuscitation (CPR . 2 Places a nitroglycerin tablet under the client ’s . 3 tongue Continues to monitor the client for 1 minute and then . 4 contacts the physician :Answer . 2 :Rationale This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The physician or an advanced cardiac life support (ACLS)-qualified nurse or other health care provider must immediately defibrillate the client. If a defibrillator is not readily available , CPR is initiated until the defibrillator arrives . Options 1 , 3 , and 4 are .incorrect actions and delay life-saving treatment :Question -186
  • 4. A nurse is assigned the care of a client with a diagnosis of congestive heart failure who is receiving intravenous doses of furosemide (Lasix). The client is attached to cardiac telemetry, and the nurse is monitoring the client ’s cardiac status. The nurse notes that the client ’s cardiac rhythm has changed to this pattern. The nurse determines that the most likely cause of this cardiac :rhythm in this client is: Options The effectiveness of the furosemide . 1 The presence of hypokalemia . 2 Pacemaker dysfunction . 3 (An impending myocardial infarction (MI . 4 :Answer . 2 :Rationale This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant or may occur with myocardial ischemia or MI; congestive heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, which is a diuretic that causes the excretion of potassium . The most likely cause of the PVCs in this client is hypokalemia . Option 1 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has .signs and symptoms of MI :Question -187 A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on the monitor. The nurse quickly assesses the client, knowing that this :rhythm is indicative of :Options Atrial fibrillation . 1 Premature ventricular complexes . 2 (Ventricular tachycardia (VT . 3 (Ventricular fibrillation (VF . 4 :Answer . 3 :Rationale In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT occurs with repetitive firing of an irritable ventricular ectopic focus , usually at a rate of 140 to 180 beats/min or .more :Question -188 A nurse is assessing a client ’s legs for the presence of
  • 5. edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of :the leg. The nurse documents this finding as defining :Options edema + 1 . 1 edema + 2 . 2 edema + 3 . 3 edema + 4 . 4 :Answer . 1 :Rationale Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, “pitting ”edema is present . Its presence is graded on the following 4- point scale : 1 + , mild pitting , slight indentation , no perceptible swelling of the leg ; 2 + , moderate pitting , indentation subsides rapidly ; 3 + , deep pitting , indentation remains for a short time , leg looks swollen ; 4 + , very deep pitting , indentation lasts a long time, leg is very .swollen :Question -189 A client is diagnosed with iron deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells :the client that it is best to take the medication with :Options Milk . 1 Boiled . 2 Tomato juice . 3 Pineapple juice . 4 :Answer . 3 :Rationale Ferrous sulfate is an iron preparation and the client is instructed to take the medication with orange juice or another vitamin C–containing product, to increase the absorption of the iron. Milk and eggs inhibit the absorption of the iron. Tomato juice is highest in .vitamin C from the options presented :Question-190 A client is diagnosed with iron deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells :the client that it is best to take the medication with :Options Milk . 1 Boiled . 2 Tomato juice . 3 Pineapple juice . 4
  • 6. :Answer . 3 :Rationale Ferrous sulfate is an iron preparation and the client is instructed to take the medication with orange juice or another vitamin C–containing product, to increase the absorption of the iron. Milk and eggs inhibit the absorption of the iron. Tomato juice is highest in .vitamin C from the options presented :Question-191 A nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse addresses which of the following as the most important measure to ensure ?client safety :Options Assessing pain . 1 Avoiding over-the-counter medications . 2 Administering vasodilators . 3 Moving slowly from a sitting to a standing position . 4 :Answer . 4 :Rationale Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy . Options 1 and 2 , although important , are not directly related to the issue of .safety :Question -192 A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. In developing a plan of care for the client, the nurse :includes which of the following? Options Providing the client with short, frequent walks . 1 Measuring the client ’s pulse each shift . 2 Eliminating sources of caffeine from meal trays . 3 Limiting oral and intravenous fluids . 4 :Answer . 3 :Rationale Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Exercise and fluid restriction will not alleviate tachycardia . Option 2 will not decrease the heart rate . Additionally , the pulse should be taken more frequently .than each shift :Question -193 A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. The nurse
  • 7. determines that the client is not yet ready for the :procedure after noting which of the following? Options The client ’s digoxin (Lanoxin) has been withheld for . 1 . the last 48 hours The client has received a dose of midazolam (Versed) . 2 .intravenously The client is wearing a nasal cannula delivering . 3 . oxygen at 2 L/min The defibrillator has the synchronizer turned on and . 4 .(is set at 50 joules (J :Answer . 3 :Rationale Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular arrhythmias after the countershock. The client typically receives a dose of an intravenous sedative or antianxiety agent. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation . Energy level typically is set at 50 to 100 J . During the procedure , any oxygen is removed temporarily, because oxygen supports combustion, .and a fire could result from electrical arcing :Question -194 A nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which of the following starting energy ?range levels, depending on the specific physician order :Options to 100 joules 50 . 1 to 200 joules 150 . 2 to 300 joules 250 . 3 to 400 joules 350 . 4 :Answer . 1 :Rationale For cardioversion procedures, the defibrillator is charged to the energy level ordered by the physician. Countershock usually is started at 50 to 100 joules . . Options 2 , 3 , and 4 are incorrect :Question-195 A client has developed atrial fibrillation with a ventricular rate of 150 beats/min . The nurse assesses :the client for :Options Hypotension and dizziness . 1 Nausea and vomiting . 2 Hypertension and headache . 3 Flat neck veins . 4
  • 8. :Answer . 1 :Rationale The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and .distended neck veins :Question -196 A nurse has provided self-care activity instructions to a client after insertion of an automatic internal cardioverter-defibrillator (AICD). The nurse determines that further instruction is needed if the client makes ?which of the following statements :Options I should try to avoid doing strenuous things that” . 1 would make my heart rate go up to or above the rate “ .cutoff on the AICD I should keep away from electromagnetic sources such” . 2 as transformers, large electrical generators, metal “ .detectors, and leaning over running motors I can perform activities such as swimming, driving,” . 3 or operating heavy equipment as I need to. ”4 . “I need to avoid doing anything that could involve rough contact :with the AICD insertion site. ” Answer . 3 :Rationale Postdischarge instructions typically include avoiding tight clothing or belts over AICD insertion sites, rough contact with the AICD insertion site, electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert physicians or dentists to the presence of the device, because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a physician regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating .heavy equipment :Question -197 A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the impact of this medication on the diet if the client states to avoid which of the ?following fruits :Options Apples . 1
  • 9. Pears . 2 Bananas . 3 Cranberries . 4 :Answer . 3 :Rationale Triamterene is a potassium-sparing diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocadoes, bananas, fresh oranges, mangoes, nectarines, papayas, and .prunes :Question -198 The health care provider prescribes bedrest for a client in whom a deep vein thrombosis develops after surgery. From the following list, select all appropriate nursing .interventions to include in this client ’s plan of care :Options .Place in Fowler ’s position for eating . 1 .Encourage increased oral intake of water daily . 2 .Encourage coughing with deep breathing . 3 .Place thigh-length elastic stockings on the client . 4 .Encourage the intake of dark, green leafy vegetables . 5 .Place sequential compression boots on the client . 6 :Answer . 2.3.4 :Rationale The client with deep vein thrombosis requires bedrest to prevent embolization of the thrombus due to skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and compression stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler ’s position. The nurse avoids providing foods rich in vitamin K such as dark green leafy vegetables because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used to prevent DVT only, because they mimic skeletal muscle action and can disrupt an existing .thrombus, leading to pulmonary embolism :Question -199 Spironolactone (Aldactone), a diuretic, is prescribed for a client with congestive heart failure. In providing
  • 10. dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which ?electrolyte :Options Calcium . 1 Potassium . 2 Magnesium . 3 Phosphorus . 4 :Answer . 2 :Rationale Spironolactone is a potassium-sparing diuretic, and the client should avoid foods high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client does not need to avoid foods that contain calcium, magnesium, or .phosphorus while taking this medication :Question -200 A client is seen in the urgent care center for complaints of chest pain that began 3 days earlier. Since that time the client has not been feeling well and fatigues easily. The nurse would suspect myocardial infarction at the time of chest pain if a test for which of the following isoenzymes for lactate dehydrogenase (LDH) came back ?positive :Options LDH 1 . 1 LDH 3 . 2 LDH 4 . 3 LDH 5 . 4 :Answer . 1 :Rationale The particular isoenzymes that are affected after acute myocardial infarction are LDH 1 and LDH 2 . The LDH level begins to elevate about 24 hours after myocardial infarction and peaks in 48 to 72 hours . Thereafter, it . returns to normal , usually within 7 to 14 days :Question -201 In planning a low-sodium diet for the client who has recently been diagnosed with congestive heart failure, the nurse should ask the client if she would like to have ?which food item :Options Chicken breast . 1 Cottage cheese . 2 Grilled cheese . 3 Beef bouillon . 4 :Answer . 1 :Rationale
  • 11. Chicken breast has 70 mg of sodium , compared with 457 for cottage cheese , 700 mg for grilled cheese , and 800 . mg for beef bouillon :Question -202 A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. (Click on sound icon.) The nurse identifies :this sound as which of the following? Options First heart sound , S 1 . 1 Ventricular gallop . 2 Third heart sound , S 3 . 3 Fourth heart sound , S4 . 4 :Answer . 1 :Rationale The sound that the nurse hears is the first heart sound , S 1 . The first heart sound (S 1 ) is created by the closure of the mitral and triscupid valves (atrioventricular [AV] valves). It marks the onset of systole (ventricular contraction). When auscultated , the first heart sound (S 1 ) is softer and longer than the second heart sound (S2). S 1 is low in pitch and is best heard at the left lower sternal border or the apex of the heart . Disease and stiffened AV valves (as in rheumatic heart disease) may augment S 1 ; rhythms of asynchrony between the atria and ventricles (as in atrial fibrillation and with AV block) cause variable intensity of S 1 . Phonetically , if a typical heartbeat , composed of the heart sounds S 1 and S2 , is auscultated as “lub- dup , ”S 1 is the “lub . ”To assess S 1 , the nurse should assist the client to a supine position (the head of the bed may be elevated slightly if necessary). The second heart sound (S2) is related to closure of the pulmonic and aortic (semilunar) valves and is heard best with the diaphragm at the aortic area. Phonetically, it is the “dup ”of the “lub-dup ”of a typical heartbeat (the first heart sound, S 1 , is the “lub ”). It signifies the end of systole and the onset of diastole (ventricular filling). S2 is characteristically shorter and higher pitched than the first heart sound (S 1 ). Diastolic filling sounds or gallops (S 3 , the third heart sound , and S4 , the fourth heart sound) are produced when compliance of either or both ventricles is decreased . S 3 is termed ventricular gallop and S4 is referred to as atrial gallop . The S 3 heart sound (a gallop sound) occurs in early diastole , during passive , rapid filling of the ventricles . The S4 sound occurs in the later stage of diastole , during atrial contraction and active filling of the ventricles . It is a soft , low- pitched . sound and is heard immediately before S 1 :Question -203
  • 12. Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). The nurse assesses the client ’s heart rhythm to detect PVCs :by looking for :Options Premature beats followed by a compensatory pause . 1 QRS complexes that are short and narrow . 2 Inverted P waves before the QRS complexes . 3 A P wave preceding every QRS complex . 4 :Answer . 1 :Rationale PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a .compensatory pause that follows the ectopy :Question -204 A nurse is assisting in positioning the client for pericardiocentesis to treat cardiac tamponade. The best :position for this client is :Options Lying on the left side with a pillow under the chest . 1 wall Lying on the right side with a pillow under the head . 2 Supine with the head of bed elevated at a 45- to 60- . 3 degree angle Supine with slight Trendelenburg position . 4 :Answer . 3 :Rationale The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60- degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the . pericardial sac . Options 1 , 2 , and 4 are incorrect :Question -205 A nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which of the following is ?unassociated with this complication of pericarditis :Options Pulsus paradoxus . 1 Distant heart sounds . 2 Distended jugular veins . 3 Bradycardia . 4 :Answer . 4 :Rationale Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure (BP),
  • 13. accompanied by pulsus paradoxus (a drop in inspiratory BP .(by greater than 10 mm Hg :Question -206 A nurse inquires about smoking history while conducting a hospital admission assessment for a client with coronary artery disease (CAD). The most important element of the :smoking history for this assessment is the :Options Number of pack-years . 1 Brand of cigarettes used . 2 Desire to quit smoking . 3 Number of past attempts to quit smoking . 4 :Answer . 1 :Rationale The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan .with the client :Question -207 A 52-year- old male client is seen in the physician ’s office for a physical examination after experiencing unusual fatigue over the last several weeks . The client ’s height is 5 feet 8 inches and his weight is 220 pounds . Vital signs are as follows : temperature , 98.6° F orally ; pulse , 86 beats/min ; and respirations , 18 breaths/min . The blood pressure reading is 184/100 mm Hg . A random blood glucose level is 122 mg/dL. Which of the following questions should the nurse ask the client ?first :Options “ ?Do you exercise regularly” . 1 “ ?Are you considering trying to lose weight” . 2 Is there a history of diabetes mellitus in your” . 3 “ ?family When was the last time you had your blood pressure” . 4 “ ?checked :Answer . 4 :Rationale The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The
  • 14. client is overweight, which is a contributing risk factor. The client ’s nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the .client ’s major modifiable risk factors :Question -208 A nurse is developing a plan of care for a client with pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse identifies which client action as ?contributing to this goal :Options Elevating the legs when in bed . 1 Sleeping in the supine position . 2 Using seasonings to improve the taste of food . 3 Using a bedside commode . 4 :Answer . 4 :Rationale Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client ’s legs increases venous return to the heart, increasing cardiac workload. The supine position increases respiratory effort and decreases oxygenation. This increases cardiac workload. Seasonings may be high .in sodium :Question- 209 A nurse is performing an admission assessment on a client with a diagnosis of Raynaud ’s disease. The nurse :assesses for associated signs and symptoms by :Options Observing for softening of the nails or nail beds . 1 Palpating for diminished or absent peripheral pulses . 2 Checking for a rash on the digits . 3 Palpating for a rapid or irregular peripheral pulse . 4 :Answer . 2 :Rationale Raynaud ’s disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted. Peripheral pulses may .be normal, absent, or diminished