Exam 4

106106 -Question :A client in the telemetry unit is receiving an intravenous infusion of 1000 mL of 5% dextrose in water (D 5W) plus 40 mEq of potassium chloride . Which of the following if noted on the cardiac monitor would indicate

the presence of hyperkalemia ?Options :

1 . Tall, peaked T waves 2 . ST-segment depression

3 . Shortening of the QRS complex 4 . Shortened PR interval

Answer :1 .

Rationale :The signs and symptoms of hyperkalemia relate to the effect of potassium on the myocardial muscle. These include changes noted on the electrocardiogram (ECG), such as tall and peaked T waves, prolonged PR interval, widening of the QRS complex, shortening of the QT interval, and disappearance of the P wave. Other cardiac signs and symptoms include ventricular dysrhythmias that may lead to cardiac arrest. ST-segment depression is noted in

hypokalemia .107 -Question :

A nurse in the telemetry unit is monitoring a client for cardiac changes indicative of hypokalemia. Which of the following if noted on the cardiac monitor would indicate the

presence of hypokalemia? Options :1 . Tall, peaked T wave

2 . ST-segment depression 3 . Widening of the QRS complex

4 . Prolonged PR interval Answer :2 .

Rationale :In the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client also may exhibit a flat T wave . Options 1 , 3 , and 4 are cardiac monitor findings that would be noted in the

client with hyperkalemia .108 -Question :

A client is admitted to the visiting nurse services for assessment and follow-up after being discharged from the hospital for new-onset congestive heart failure (CHF). The nurse teaches the client about the dietary restrictions required with CHF. Which statement by the client indicates that further

teaching is needed ?Options :

1“ . I ’m going to have a ham and cheese sandwich and potato chips for lunch” .

2“ . I ’m going to weigh myself daily to be sure I don ’t gain too much fluid” .

3“ . I can have most fresh fruits and fresh vegetables” .

4“ . I ’m not supposed to eat cold cuts” .Answer :1 .

Rationale :When a client has CHF, the goal is to reduce fluid accumulation. One way that this is accomplished is sodium reduction. Ham, cheese (and most cold cuts), and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client

monitor fluid overload. Most fresh fruits and vegetables are low in sodium .

109 -Question :A nurse is performing health screening on a 54-year- old client . The client has a blood pressure of 118/78 mm Hg , total cholesterol of 190 mg/dL , and fasting blood glucose level of 184 mg/dL . The nurse interprets that the client has which of the following modifiable risk factors for coronary artery

disease (CAD) ?Options :

1 . Hypertension 2 . Glucose intolerance

3 . Age 4 . Hyperlipidemia

Answer :2 .

Rationale :Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors to CAD . Age greater than 40 is a nonmodifiable risk factor. The nurse places priority on risk

factors that can be modified .110 -Question :

A nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for

difficulty after discharge ?Options :

1“ . I don ’t have anyone to help me with doing heavy housework at home” .

2“ . I think I have a good understanding of what all my medications are for” .

3“ . I will be sure to keep my appointment with the cardiologist” .

4“ . I need to start exercising more to improve my health” .

Answer :1 .

Rationale :To ensure the best outcome, clients should be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital following an MI. All of the options except option 1 indicate that the client will be

successful in these areas . 111 -Question :

A home care nurse has taught a client with a nursing diagnosis of decreased cardiac output about helpful lifestyle adaptations to promote health. Which of the following statements by the client best demonstrates an understanding of the information

provided ?Options :

1“ . I will eat enough daily fiber to prevent straining at stool” .

2“ . Drinking 2 to 3 ounces of liquor each night will promote blood flow by enlarging blood vessels . ”3 . “I will drink 3000 to 3500 mL of fluid daily to promote good kidney

function” . 4“ . I will try to exercise vigorously to

strengthen my heart muscle” .

Answer :1 .

Rationale :Standard home care instructions for a client with this nursing diagnosis include among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance . Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac

workload .112 .-Question :

A client has a nursing diagnosis of activity intolerance related to underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting

goals for this nursing diagnosis ?Options :

1 . Chooses a healthy diet that meets caloric needs

2 . Sleeps without awakening throughout the night

3 . Verbalizes the benefits of increasing activity

4 . Ambulates 10 feet farther each day Answer :4 .

Rationale :Each of the options indicates a positive outcome on the part of the client . However, option 1 would most likely indicate progress

if the client had a nursing diagnosis of imbalanced nutrition . Option 2 would be a satisfactory outcome for disturbed sleep pattern . Both options 3 and 4 relate to the nursing diagnosis of activity intolerance . However, the question asks about progress . Option 4 is more action - oriented and

therefore is the better choice .113 -Question :

The physician has written an order for a client to have an echocardiogram. The nurse takes which of the following actions to

prepare the client for the procedure ?Options :

1 . Questions the client about allergies to iodine or shellfish

2 . Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure

3 . Tells the client that the procedure is painless and takes 30 to 60 minutes

4 . Has the client sign an informed consent form for an invasive procedure Answer :3 .

Rationale :Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis . The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of

the client .114 -Question :

The physician has written an order for a client to have an echocardiogram. The nurse takes which of the following actions to

prepare the client for the procedure ?Options :

1 . Questions the client about allergies to iodine or shellfish

2 . Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure

3 . Tells the client that the procedure is painless and takes 30 to 60 minutes

4 . Has the client sign an informed consent form for an invasive procedure Answer :3 .

Rationale :Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis . The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of

the client .115 -Question :

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which of the following sensations during the

procedure ?Options :

1 . Pressure at the insertion site 2 . Urge to cough

3 . Warm, flushed feeling 4 . Chest pain

Answer :4 .

Rationale :The client is taught to immediately report chest pain or any unusual sensations. The client is informed that a warm, flushed feeling may accompany dye injection and is normal. The client also is told that he or she may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client is expected to feel pressure at the insertion

site .116 -Question :

A client recovering from pulmonary edema is preparing for discharge. The nurse plans to teach the client to do which of the following to manage or prevent recurrent symptoms

after discharge ?Options :

1 . Take a double dose of the diuretic if peripheral edema is noted .

2 . Withhold prescribed digoxin (Lanoxin) if slight respiratory distress occurs .

3 . Weigh himself on a daily basis .4 . Sleep with the head of bed flat .

Answer :3 .

Rationale :The client can best determine fluid status at home by weighing himself on a daily basis . Increases of 2 to 3 pounds in a short time period are reported to the physician . The client should sleep with the head of the bed

elevated. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of bed flat is therefore avoided. The client does not modify medication dosages without

consulting the physician .117 -Question :

A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates a clear

understanding of the instructions? Options :1“ . I will have to go to the operating room

for this procedure” .2“ . I probably will feel tired after the test

from lying on a hard x-ray table for a few hours” .

3“ . It will really hurt when the catheter is first put in” .

4“ . I will receive general anesthesia for the procedure” .

Answer :2 .

Rationale :It is common for the client to feel fatigued after the cardiac catheterization procedure. Other pre- procedure teaching points include that the procedure is done in a darkened cardiac catheterization room. A local anesthetic is used, so little to no pain is experienced with catheter insertion. General anesthesia is not used . The x- ray table is hard and may be tilted periodically , and the procedure may take 1 to 2 hours. The client

may feel various sensations with catheter passage and dye injection .

118 -Question :A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. A nurse caring for the client uses which of the following items as the best means to monitor respiratory status on an

ongoing basis ?Options :

1 . Oxygen flowmeter 2 . Oxygen saturation monitor 3 . Telemetry cardiac monitor

4 . Apnea monitor Answer :2 .

Rationale :Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if used continuously. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias. An apnea monitor detects apnea episodes, such as when the

client has stopped breathing briefly .119 -Question :

A nurse has an order to remove the nasogastric (NG) tube from a post–cardiac surgery client on the first postoperative day. The nurse would question the order if which of the following was noted on assessment of

the client ?Options :

1 . Bowel sounds are absent .2 . The abdomen is slightly distended .

3 . NG tube drainage is Hematest negative .4 . The client is drowsy .

Answer :1 .

Rationale :The NG tube should remain in place until the client has bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued. It is normal for NG tube drainage to be Hematest negative. The abdomen is likely to be slightly distended after surgery, and it also is likely that the client may be drowsy after experiencing a stressor such as cardiac

surgery .120 -Question :

A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. The nurse places the client in which position for the

procedure ?Options :

1 . Upright and leaning forward with the arms on an over-the-bed table

2 . Right side-lying, with the legs curled up into a fetal position

3 . Left lateral, with the right arm supported by a pillow

4 . Dorsal recumbent Answer :1 .

Rationale :The client undergoing thoracentesis usually sits in an upright position, with the anterior thorax supported by pillows, or leaning over

an over-the-bed table. The client must be placed in a position that will enlist the aid of gravity in accessing and draining the effusion. Any form of side-lying position will cause fluid to accumulate under that side, which is inaccessible to the physician. The dorsal recumbent position also is an

inaccessible position .121 -Question :

A client receiving parenteral nutrition has a history of congestive heart failure. The physician has ordered furosemide (Lasix) 40 mg by mouth daily to prevent fluid overload . The nurse monitors which laboratory value to identify an adverse effect from this

medication ?Options :

1 . Glucose 2 . Sodium

3 . Potassium 4 . Magnesium

Answer :3 .

Rationale :Furosemide is a non–potassium-sparing diuretic, and insufficient replacement of potassium may lead to hypokalemia. Although the glucose, sodium, and magnesium levels may be monitored, these laboratory values are not specific to

administering furosemide .122-Question :

A client with a history of recent upper respiratory infection comes to the urgent care center complaining of chest pain. The nurse interprets that the pain is most likely

of a respiratory origin if the client states which of the following about the pain ?Options :

1“ . It hurts on the left side of my chest” .2“ . I have never had this pain before” .

3“ . The pain is about a 6 on a scale of 1 to 10” .

4“ . It hurts more when I breathe in” .Answer :4 .

Rationale :Chest pain is assessed using the standard pain assessment parameters, such as, characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms. Pain of pleuropulmonary (respiratory) origin usually becomes worse on inspiration.

123-Question :A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The nurse interprets that the client is experiencing which of the following

types of angina ?Options :

1 . Stable 2 . Unstable

3 . Variant 4 . Intractable

Answer :1 .

Rationale :Stable angina is triggered by a predictable amount of effort or emotion. Unstable angina

is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and incapacitating and is refractory to medical

therapy .

124 -Question :A client with a first-degree heart block has an electrocardiogram (ECG) taken during an episode of chest pain. The nurse interprets that which ECG finding indicates first-degree

heart block ?Options :

1 . Prolonged PR interval 2 . Widened QRS complex

3 . Tall, peaked T waves 4 . Presence of Q waves

Answer :1 .

Rationale :A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. Tall, peaked T waves may indicate hyperkalemia. The development of Q waves indicates myocardial necrosis. An ECG taken during a pain episode is intended to capture ischemic changes, which also includes ST-

segment elevation or depression .

125 _Question :A nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for

further teaching ?Options :

1“ . I will take nitroglycerin whenever chest discomfort begins” .

2“ . I will use muscle relaxation to cope with stressful situations” .

3“ . It is best to exercise once a week for 1 hour” .

4“ . I will avoid using table salt with meals .”

Answer :3 .

Rationale :Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously has caused the pain, and to take the medication at the first sign of chest

discomfort .

126 _Question :A home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by three sublingual nitroglycerin tablets given by the nurse.

Which action by the nurse would be appropriate at this time ?Options :

1 . Notify a family member who is the next of kin .

2 . Inform the home care agency supervisor that the visit may be prolonged .

3 . Call for an ambulance to transport the client to the hospital emergency

department .4 . Drive the client to the physician ’s office.

Answer :3 .

Rationale :Chest pain that is unrelieved by rest and three doses of nitroglycerin administered 5 minutes apart may not be typical anginal pain but may signal myocardial infarction (MI). Because the risk of sudden cardiac death is greatest in the first 24 hours after MI , it is imperative that the client receive emergency cardiac care. A physician ’s office is not equipped to treat MI. Communication with the family or home care agency delays client treatment, which is needed

immediately .

127 _Question :An ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal ’s (variant) angina. The nurse plans to reinforce to the client that this type

of angina :Options :

1 . Is most effectively managed by β-

blocking agents 2 . Generally is treated with calcium

channel–blocking agents 3 . Has the same risk factors as for stable

and unstable angina 4 . Can be controlled with a low-sodium,

high-potassium diet Answer :2 .

Rationale :Prinzmetal ’s angina results from spasm of the coronary vessels and is treated with calcium channel blockers. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. β- Blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not

specifically indicated .

128-Question :A nurse working in a long-term care facility is assessing a client experiencing chest pain. The nurse would interpret that the pain is most likely due to myocardial infarction (MI) on the basis of which of the following

assessment findings ?Options :

1 . The client is not experiencing nausea or vomiting .

2 . The client says the pain began while she was trying to open a stuck dresser drawer .

3 . The pain has not been relieved by rest and three nitroglycerin tablets .

4 . The client is not experiencing dyspnea .Answer :3 .

Rationale :The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes , and frequently is accompanied by associated symptoms (such as nausea , vomiting, dyspnea, diaphoresis, or anxiety). The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as

morphine sulfate, for relief .

129 _Question :A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, the nurse obtains which of the following pieces of equipment for use at the

bedside? Options :1 . Central venous pressure (CVP) insertion

tray 2 . Noninvasive blood pressure monitor

3 . Defibrillator 4 . Pulse oximeter

Answer :2 .

Rationale :Nitroglycerin dilates both arteries and veins, causing peripheral blood pooling, thereby reducing preload, afterload, and myocardial

work. This also accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of continuous direct arterial pressure (intra-arterial) monitoring, the nurse should use an automatic noninvasive blood pressure monitor. Options 1 , 3 , and 4 are not specifically associated with the

administration of intravenous nitroglycerin .

130 _Question :A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. The nurse encourages which of the following activity levels for the client immediately after

transfer ?Options :

1 . Ad lib activities because the client will be discharged soon

2 . Unsupervised hallway ambulation for distances up to 200 feet

3 . Bathroom privileges and self-care activities

4 . Strict bed rest for 24 hours after transfer

Answer :3 .

Rationale :On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. It is unnecessary and possibly harmful to limit the client to bed rest. The client should ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50 , 100 , and 200 feet

.

.131 _Question :A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with t-PA (tissue plasminogen activator). The nurse identifies which of the following assessment findings as the most likely indicator that the client is experiencing complications of this

therapy ?Options :

1 . Tarry stools 2 . Nausea and vomiting

3 . Decreased urine output 4 . Orange-colored urine

Answer :1 .

Rationale :Thrombolytic agents are used to dissolve existing thrombi, and the nurse must monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes “hematesting ”secretions for occult blood . Option 1 is the only option that

indicates the presence of blood . 132 _Question :

A nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement would the nurse make to try to motivate the client to

quit smoking ?Options :

1“ . If you quit now , your risk of

cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years” .

2“ . Because most of the damage has already been done, it will be all right to cut down a little at a time. ”3 . “If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year. ”4 . “None of the cardiovascular effects are reversible, but quitting might prevent lung

cancer. ” Answer :1 .

Rationale :The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation , a client ’s cardiovascular risk is similar to that of a person who never smoked . Options

2 , 3 , and 4 are incorrect . 133 _Question :

A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as daily prescribed medications. The nurse tells the client to report which of the following as an indication that the medications are not having the

intended effect ?Options :

1 . Cough accompanied by other signs of respiratory infection

2 . Sudden increase in appetite 3 . Weight gain of 2 to 3 pounds in a few

days 4 . Increased urine output during the day

Answer :3 .

Rationale :

Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia. An increase in urine output during the day is expected with diuretic therapy (Lasix). A cough due to respiratory infection does not necessarily

indicate that heart failure is worsening .134 _Question :

A client has experienced an episode of pulmonary edema. The nurse determines that the client ’s respiratory status is improving after this episode if which of the following breath sounds are noted? Options:

1 . Crackles throughout the lung fields 2 . Crackles in the bases

3 . Wheezes 4 . Rhonchi

Answer :2 .

Rationale :Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the client ’s condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.) Wheezes and rhonchi are not associated with pulmonary

edema . .135 _Question :

A client with pulmonary edema has an order

to receive morphine sulfate intravenously. The nurse determines that the client is experiencing an intended effect of the medication as indicated by which of the

following assessment findings ?Options :

1 . Relief of apprehension 2 . Decreased urine output

3 . Increased pulse rate 4 . Increased blood pressure

Answer :1 .

Rationale :Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. It also promotes peripheral vasodilation and causes blood to pool in the periphery. It decreases pulmonary capillary pressure, which reduces fluid migration into the alveoli. The client receiving morphine sulfate is monitored for signs and symptoms of respiratory depression and extreme drops in blood pressure, especially when it is administered intravenously . Options 2 , 3 , and 4 are unrelated to the action of morphine

sulfate .136 _Question :

The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse interprets that which observation of the client ’s clinical condition

is most favorable ?Options :

1 . Central venous pressure (CVP) of 15 mm Hg

2 . Frequent premature ventricular

contractions (PVCs) 3 . Urine output of 40 mL/hr

4 . Heart rate of 110 beats/min Answer :3 .

Rationale :Urine output of greater than 30 mL/hr indicates adequate perfusion to the kidneys , so the other organs are most likely equally perfused. Classic cardiovascular signs of cardiogenic shock include low blood pressure and tachycardia. The CVP rises as the effects of the backward blood flow of the left ventricular failure became apparent. Arrhythmias commonly occur as a result of decreased oxygenation to the myocardium

and are not a favorable sign .137 _Question :

A client is scheduled to begin therapy with acetazolamide (Diamox) for the management of glaucoma. Before initiating therapy, the nurse asks the client about a history of

allergy or sensitivity to: Options :1 . Corticosteroids

2 . Nonsteroidal anti-inflammatory agents 3 . Penicillin

4 . Sulfa drugs Answer :4 .

Rationale :Acetazolamide is a carbonic anhydrase inhibitor that contains sulfonamide properties. Before administration of this medication, the client should be assessed for an allergy to sulfonamides because the medication is contraindicated if an allergy

exists. The client also should be monitored during therapy for an allergic reaction and

for photosensitivity ..138 _Question :

A client recovering from an exacerbation of left-sided heart failure has a nursing diagnosis of activity intolerance. Which of the following changes in vital signs during activity would be the best indicator that the

client is tolerating mild exercise ?Options :

1 . Pulse rate increased from 80 beats/min to 104 beats/min .

2 . Respiratory rate increased from 16 breaths/min to 19 breaths/min .

3 . Oxygen saturation decreased from 96% to 91% .

4 . Blood pressure decreased from 140/86 mm Hg to 112/72 mm Hg . Answer: 2 .

Rationale :Vital signs that remain near baseline indicate good cardiac reserve with exercise . Options 1 and 3 are incorrect because they represent changes from normal values to abnormal ones. Blood pressure decrease by more than 10 mm Hg is not a sign that indicates tolerance of activity . Only the respiratory rate remains within the normal range. Additionally, it reflects a minimal increase.