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Medical Surgical Nursing 5th Edition LeMone Burke Bauldoff Test Bank

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Medical Surgical Nursing 5th Edition LeMone Burke Bauldoff Test Bank

ISBN-13: 978-0135075944

ISBN-10: 0135075947

 

 

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Medical Surgical Nursing 5th Edition LeMone Burke Bauldoff Test Bank

ISBN-13: 978-0135075944

ISBN-10: 0135075947

 

 

 

 

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LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank
Chapter 31

Question 1

Type: MCSA

The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate?

  1. expiratory wheezes
  2. friction rub
  3. harsh vesicular
  4. crackles

Correct Answer: 4

Rationale 1: Expiratory wheezes, friction rub, and harsh vesicular sounds are not associated with chronic heart failure.

Rationale 2: Expiratory wheezes, friction rub, and harsh vesicular sounds are not associated with chronic heart failure.

Rationale 3: Expiratory wheezes, friction rub, and harsh vesicular sounds are not associated with chronic heart failure.

Rationale 4: Fluid accumulates in the alveolar spaces with left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration.

Global Rationale: Fluid accumulates in the alveolar spaces with left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration. Expiratory wheezes, friction rub, and harsh vesicular sounds are not associated with chronic heart failure.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 2

Type: MCSA

When caring for a chronic heart failure patient with left-sided failure, the nurse would most likely note the following statement in the physician’s written report following cardiac catheterization?

  1. “Pressures in the left ventricle and atrium are increased.”
  2. “Pressures in the left ventricle and atrium are decreased.”
  3. “Pressures in the right ventricle and atrium match the ventricle pressures.”
  4. “Pressures in the right ventricle reflect functioning of all heart chambers.”

Correct Answer: 1

Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume.

Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume.

Rationale 3: This patient is in left-sided heart failureRemember, pressure is higher in the left side of the heart, not the right side.

Rationale 4: This patient is in left-sided heart failureRemember, pressure is higher in the left side of the heart, not the right side.

Global Rationale: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume. This patient is in left-sided heart failureRemember, pressure is higher in the left side of the heart, not the right side.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 3

Type: MCSA

A nurse caring for a patient with heart failure would expect to find which of the following during assessment of the patient?

  1. S1, S2 and flat neck veins
  2. S3 and distended neck veins
  3. S2 is heard the loudest and followed by S1
  4. S4 and flat neck veins

Correct Answer: 2

Rationale 1: S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding.

Rationale 2: The abnormal S3 sound is reflective of the heart’s attempts to fill an already distended ventricle and the neck veins distend because of the increased venous pressure.

Rationale 3: S1 and S2 sounds may be diminished in the heart failure patient and not vary in intensity.

Rationale 4: S4 (gallop) may be present but neck veins would be distended.

Global Rationale: The abnormal S3 sound is reflective of the heart’s attempts to fill an already distended ventricle and the neck veins distend because of the increased venous pressure. S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding. The S1 and S2 sounds may be diminished in the heart failure patient and not vary in intensity. S4 (gallop) may be present but neck veins would be distended.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 4

Type: MCSA

When obtaining the health history of a patient who is being assessed for possible congestive heart failure, it is significant when the patient says which of the following?

  1. “I break out in a cold sweat when I eat a large meal.”
  2. “I am sleepy after I eat lunch each day.”
  3. “I have to prop myself up on three pillows to sleep at night, otherwise I can’t breathe.”
  4. “I feel better with my legs down when I sit in my favorite chair.”

Correct Answer: 3

Rationale 1: Diaphoresis and sleepiness after meals and comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.

Rationale 2: Diaphoresis and sleepiness after meals and comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.

Rationale 3: Needing to prop oneself up with pillows at night in order to breathe describes orthopnea, which is consistent with congestive heart failure (CHF). Congestive heart failure produces a volume excess, congestion in the lungs, and dyspnea when attempting to lie down.

Rationale 4: Diaphoresis and sleepiness after meals and comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.

Global Rationale: Needing to prop oneself up with pillows at night in order to breathe describes orthopnea, which is consistent with congestive heart failure (CHF). Congestive heart failure produces a volume excess, congestion in the lungs, and dyspnea when attempting to lie down. Diaphoresis and sleepiness after meals and comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 5

Type: MCMA

A patient is admitted with acute heart failure. The nurse realizes that acute heart failure is associated with an abrupt onset of which of the following?

Standard Text: Select all that apply.

  1. cardiomyopathy
  2. heart valve disease
  3. coronary heart disease (CHD)
  4. massive infarction (MI))
  5. myocardial injury

Correct Answer: 4,5

Rationale 1: Cardiomyopathy, valve disease, and coronary heart disease (CHD) are all associated with chronic heart failure.

Rationale 2: Cardiomyopathy, valve disease, and coronary heart disease (CHD) are all associated with chronic heart failure.

Rationale 3: Cardiomyopathy, valve disease, and coronary heart disease (CHD) are all associated with chronic heart failure.

Rationale 4: Patients often present for care with signs of acute heart failure when they have had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI).

Rationale 5: Patients often present for care with signs of acute heart failure when they have had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI).

Global Rationale: Patients often present for care with signs of acute heart failure when they have had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI). Cardiomyopathy, valve disease, and coronary heart disease (CHD) are all associated with chronic heart failure.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 6

Type: MCSA

Blood tests are ordered for a patient who is diagnosed with possible congestive heart failure (CHF). The nurse understands which of the following lab tests indicates heart failure? The most specific test(s) to accurately indicate CHF would be which of the following?

  1. liver function
  2. urinalysis and blood urea nitrogen (BUN)
  3. brain natriuretic peptide (BNF).
  4. serum electrolytes

Correct Answer: 3

Rationale 1: Liver function, urinalysis, blood urea nitrogen (BUN)), and serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate with pressures in the left ventricle and pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase.

Rationale 2: Liver function, urinalysis, blood urea nitrogen (BUN), and serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate with pressures in the left ventricle and pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase.

Rationale 3: Liver function, urinalysis, blood urea nitrogen (BUN) and serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate with pressures in the left ventricle and pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase.

Rationale 4: Liver function, urinalysis, blood urea nitrogen (BUN), and serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate with pressures in the left ventricle and pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase.

Global Rationale: Liver function, urinalysis, blood urea nitrogen (BUN), and serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate with pressures in the left ventricle and pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 7

Type: MCSA

The nurse is caring for a patient who has invasive hemodynamic monitoring. The highest priority of care for this patient is which of the following?

  1. Prevent infection at the catheter site by changing the dressing as prescribed.
  2. Set alarm limits and turn monitor alarms on.
  3. Explain to family members why the monitoring is in use.
  4. Coil IV tubing on the bed.

Correct Answer: 2

Rationale 1: Prevention of infection by changing dressings is important but not the priority of care.

Rationale 2: Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. Alarms should always be investigated since they are suspended only when drawing blood or changing tubing.

Rationale 3: Keeping family members informed about monitoring is important, but again, not the priority of care.

Rationale 4: Coiling the IV tubing on the bed is contraindicated.

Global Rationale: Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. Alarms should always be investigated since they are suspended only when drawing blood or changing tubing. Prevention of infection by changing dressings is important but not the priority of care. Keeping family members informed about monitoring is important, but again, not the priority of care. Coiling the IV tubing on the bed is contraindicated.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 8

Type: MCHS

The patient in the critical care area has an invasive hemodynamic pressure monitoring line. This position should be marked on the chest wall as a consistent reference point for calibrating and leveling. Indicate on the diagram below, where the chest should be marked by placing an “X” at the appropriate reference point.

Correct Answer:

Rationale : Calibration and leveling should be done every shift to ensure that accurate pressures are recorded. The right atrial position at the fourth intercostal space, left midaxillary line, should be marked on the chest wall so that all caregivers use a consistent reference point for calibrating and leveling. Pressure monitoring is done within the right atrium, not the left atrium or outside of the heart.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 9

Type: MCSA

The nurse is caring for a patient in the critical care area whose fluid volume status needs to be assessed closely. The most likely type of monitoring that will be used is which of the following?

  1. arterial pressure monitoring
  2. pulmonary artery pressure monitoring
  3. central venous pressure monitoring
  4. intra-aortic balloon pump monitoring

Correct Answer: 3

Rationale 1: Arterial pressure monitoring would not measure central venous pressure.

Rationale 2: Central venous pressure (CVP) monitoring can be accomplished with a central IV line and an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status. If the patient is acutely ill with a cardiac condition, then CVP can be obtained from a pulmonary artery pressure monitoring system as well.

Rationale 3: Central venous pressure (CVP) monitoring can be accomplished with a central IV line and an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status. If the patient is acutely ill with a cardiac condition, then CVP can be obtained from a pulmonary artery pressure monitoring system as well.

Rationale 4: An intra-aortic balloon pump not be used for pressure monitoring.

Global Rationale: Central venous pressure (CVP) monitoring can be accomplished with a central IV line and an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status. If the patient is acutely ill with a cardiac condition, then CVP can be obtained from a pulmonary artery pressure monitoring system as well. Arterial pressure monitoring would not measure central venous pressure. An intra-aortic balloon pump not be used for pressure monitoring.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 10

Type: MCSA

A pulmonary artery (PA) catheter is used in critical care patients who

  1. cannot tolerate hemodynamic monitoring.
  2. requires a peripheral intravenous catheter for medication administration.
  3. would benefit from having the right ventricle pressures measured each shift.
  4. requires evaluation of left ventricular pressures each shift.

Correct Answer: 4

Rationale 1: PA catheters are a form of hemodynamic monitoring.

Rationale 2: The PA catheter does not measure right ventricular pressures and would not be used to administer medications since it is a central arterial catheter, not a peripheral line.

Rationale 3: The PA catheter does not measure right ventricular pressures and would not be used to administer medications since it is a central arterial catheter, not a peripheral line.

Rationale 4: Pulmonary artery (PA) catheters can be used to evaluate pulmonary artery pressures, left ventricular pressures, measure cardiac output, and manipulate fluid volume status in acutely ill patients.

Global Rationale: Pulmonary artery (PA) catheters can be used to evaluate pulmonary artery pressures, left ventricular pressures, measure cardiac output, and manipulate fluid volume status in acutely ill patients. PA catheters are a form of hemodynamic monitoring. The PA catheter does not measure right ventricular pressures and would not be used to administer medications since it is a central arterial catheter, not a peripheral line.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 11

Type: MCSA

The nurse should instruct a patient who is prescribed digoxin (Lanoxin) on which of the following information?

  1. How to manage nausea that can be associated with taking digoxin.
  2. Foods that should be eaten while taking this drug.
  3. Do not take the medication and to not take it if the pulse is under 60 beats per minute.
  4. Checking the pulse for one minute each day and recording the result on a notepad.

Correct Answer: 3

Rationale 1: This is necessary but is not priority. All four answers include important teaching information but the highest priority is for the patient to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) and to contact the physician.

Rationale 2: This is necessary but is not priority. All four answers include important teaching information but the highest priority is for the patient to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) and to contact the physician.

Rationale 3: The highest priority is for the patient to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) and to contact the physician.

Rationale 4: This is necessary but is not priority. All four answers include important teaching information but the highest priority is for the patient to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) and to contact the physician.

Global Rationale: All four answers include important teaching information but the highest priority is for the patient to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) and to contact the physician.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Discuss the effects and nursing implications for medications commonly prescribed for patients with cardiac disorders.

 

Question 12

Type: MCSA

An elderly patient was recently discharged to home after treatment for chronic heart failure. The patient experiences a pulse rate increase from 80 beats per minute (bpm) to 102 bpm when walking from the kitchen to the utility room to do laundry. Which of the following are appropriate nursing actions for the home health nurse?

  1. Encourage the patient to complete tasks such as laundry early in the morning before fatigue is an issue.
  2. Recommend that the patient ignore the pulse rate and become more active to build stamina.
  3. Encourage the patient to rest for 30 minutes between completing each load of laundry.
  4. Encourage the patient to rest on a chair in the utility room and sit and rest when the patient feels his pulse rate increase.

Correct Answer: 4

Rationale 1: Recommending that the patient complete household tasks in the morning, to ignore the pulse rate and become more active, and to rest 30 minutes between loads of laundry are not practical strategies for an elderly patient with compromised heart function.

Rationale 2: Recommending that the patient complete household tasks in the morning, to ignore the pulse rate and become more active, and to rest 30 minutes between loads of laundry are not practical strategies for an elderly patient with compromised heart function.

Rationale 3: All home activities should be performed at a comfortable pace for the patient.

Rationale 4: The increase in pulse rate indicates that activity is not being tolerated. Rest should help to bring the heart rate down to the pre-exercise level.

Global Rationale: The increase in pulse rate indicates that activity is not being tolerated. Rest should help to bring the heart rate down to the pre-exercise level. Recommending that the patient complete household tasks in the morning, to ignore the pulse rate and become more active, and to rest 30 minutes between loads of laundry are not practical strategies for an elderly patient with compromised heart function. All home activities should be performed at a comfortable pace for the patient.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 13

Type: MCSA

The nurse recognizes which of the following as a sign of decreased cardiac output and tissue perfusion in a patient with heart failure?

  1. decreased mental alertness
  2. increased urine output
  3. abdominal distention
  4. strong peripheral pulses

Correct Answer: 1

Rationale 1: A change in mentation is a common sign of decreased cardiac output and tissue perfusion.

Rationale 2: Urine output would decrease.

Rationale 3: Abdominal distention a sign of right-sided failure which is a problem with venous return, not cardiac output or tissue perfusion.

Rationale 4: Pulses would weaken

Global Rationale: A change in mentation is a common sign of decreased cardiac output and tissue perfusion. Urine output would decrease; pulses would weaken. Abdominal distention is a sign of right-sided failure which is a problem with venous return, not cardiac output or tissue perfusion.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 14

Type: MCSA

The nurse is assessing a patient who is demonstrating dyspnea, orthopnea, cyanosis, clammy skin, a productive cough with pink, frothy sputum, and crackles. The nurse realizes that the patient likely has which of the following conditions?

  1. chronic heart failure
  2. pulmonary edema
  3. endocarditis
  4. angina

Correct Answer: 2

Rationale 1: Not all patients with chronic heart failure have pink, frothy sputum. The presence of this symptom differentiates pulmonary edema from chronic heart failure.

Rationale 2: Dyspnea, orthopnea, cyanosis, clammy skin, productive cough with pink frothy sputum, and crackles are signs and symptoms indicative of pulmonary edema which is considered a medical emergency.

Rationale 3: Endocarditis would manifest with pain and potentially fever.

Rationale 4: Angina is chest pain.

Global Rationale: Dyspnea, orthopnea, cyanosis, clammy skin, productive cough with pink frothy sputum, and crackles are signs and symptoms indicative of pulmonary edema, which is considered a medical emergency. Not all patients with chronic heart failure have pink, frothy sputum. The presence of this symptom differentiates pulmonary edema from chronic heart failure. Endocarditis would manifest with pain and potentially fever. Angina is chest pain.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 15

Type: MCSA

The priority nursing action the nurse would implement for the patient who is admitted with pulmonary edema would be to do which of the following?

  1. Insert a peripheral intravenous catheter.
  2. Seek a prescription to medicate the patient for comfort.
  3. Monitor the blood glucose level.
  4. Place a pulse oximeter and administer oxygen.

Correct Answer: 4

Rationale 1: Inserting an IV would be second, but often, if there is more than one caregiver present, this action can be done simultaneously.

Rationale 2: Medication would not be given until the ABCs have been addressed.

Rationale 3: The blood glucose level is not related to pulmonary edema.

Rationale 4: Since this is a medical emergency, priority nursing actions focus on maintaining the airway and improving oxygenation, then breathing and circulation.

Global Rationale: Since this is a medical emergency, priority nursing actions focus on maintaining the airway and improving oxygenation, then breathing and circulation. Inserting an IV catheter would follow, but often, if there is more than one caregiver present, this action can be done simultaneously. Medication would not be given until the ABCs have been addressed. The blood glucose level is not related to pulmonary edema.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 16

Type: MCSA

Which of the following is important to consider when caring for patients with possible endocarditis?

  1. Endocarditis does not pose a high risk for damage to affected heart valves.
  2. Patients with this disorder can be treated by open heart surgery to clean the heart valves.
  3. The condition is unrelated to fever so medicate patients with the prescribed antipyretic and observe.
  4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.

Correct Answer: 4

Rationale 1: Endocarditis does not pose a high risk for damage to affected heart valves.

Rationale 2: Endocarditis can be treated by open heart surgery to clean the heart valves.

Rationale 3: Endocarditis does not cause fever but administer an antipyretic and observe.

Rationale 4: Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures.

Global Rationale: Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures. Endocarditis carries serious risks for damage to heart valves. Fever may be present in endocarditis. Open heart surgery is not an appropriate treatment for this condition.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 17

Type: MCMA

The nurse would assess which of the following as clinical signs and symptoms of pericarditis?

Standard Text: Select all that apply.

  1. pericardial friction rub
  2. abdominal discomfort and nausea
  3. chest pain
  4. bradycardia
  5. distended neck veins

Correct Answer: 1,3

Rationale 1: Pericardial friction is a hallmark sign of pericarditis in addition to fever.

Rationale 2: Abdominal discomfort and nausea are not associated with pericarditis.

Rationale 3: Chest pain is a hallmark sign of pericarditis in addition to fever.

Rationale 4: Bradycardia is not associated with pericarditis.

Rationale 5: Distended neck veins are not associated with pericarditis.

Global Rationale: Pericardial friction rub and chest pain are hallmark signs of pericarditis in addition to fever. Abdominal discomfort, nausea, bradycardia, and distended neck veins are not associated with pericarditis.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 18

Type: MCSA

The nurse, caring for a patient diagnosed with cardiac tamponade, realizes treatment would be with which of the following?

  1. antidysrhythmic drugs and oxygen
  2. oxygen and rest
  3. pericardiocentesis
  4. antibiotics

Correct Answer: 3

Rationale 1: Antidysrhythmic drugs, oxygen, rest, and antibiotics may be indicated after the pericardiocentesis is performed.

Rationale 2: Antidysrhythmic drugs, oxygen, rest, and antibiotics may be indicated after the pericardiocentesis is performed.

Rationale 3: When cardiac tamponade occurs, it is considered a medical emergency. Pericardiocentesis is performed to removed fluid or blood that has collected around the heart and is preventing the heart from pumping effectively.

Rationale 4: Antidysrhythmic drugs, oxygen, rest, and antibiotics may be indicated after the pericardiocentesis is performed.

Global Rationale: When cardiac tamponade occurs, it is considered a medical emergency. Pericardiocentesis is performed to removed fluid or blood that has collected around the heart and is preventing the heart from pumping effectively. Antidysrhythmic drugs, oxygen, rest, and antibiotics may be indicated after the pericardiocentesis is performed.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 19

Type: MCSA

A nurse caring for a patient with coronary artery disease hears a murmur during auscultation of the heart. The nurse suspects the a patient has which of the following?

  1. valvular heart disease
  2. pericarditis
  3. cardiac tamponade
  4. heart failure

Correct Answer: 1

Rationale 1: Valvular disorders interfere with the smooth flow of blood through the heart. The flow becomes turbulent, causing a murmur, a characteristic manifestation of valvular disease.

Rationale 2: The heart sound characteristic of pericarditis is a pericardial friction rub

Rationale 3: Distant and muffled heart sounds are typical of cardiac tamponade.

Rationale 4: Extra heart sounds S3 and S4 are heard in heart failure

Global Rationale: Valvular disorders interferes with the smooth flow of blood through the heart. The flow becomes turbulent, causing a murmur, a characteristic manifestation of valvular disease. The heart sound characteristic of pericarditis is a pericardial friction rub. Distant and muffled heart sounds are typical of cardiac tamponade. Extra heart sounds S3 and S4 are heard in heart failure.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 20

Type: MCMA

The nurse realizes that a patient is experiencing paroxysmal nocturnal dyspnea (PND) when which of the following is assessed?

Standard Text: Select all that apply.

  1. Symptoms occur at night
  2. pulmonary congestion
  3. improving cardiac reserve
  4. voiding more than one time per night
  5. daytime peripheral edema

Correct Answer: 1,2,5

Rationale 1: PND is a condition in which the patient is awakened at night and frightened by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night causing pulmonary congestion.

Rationale 2: PND is a condition in which the patient is awakened at night and frightened by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night causing pulmonary congestion.

Rationale 3: Chronic heart failure is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses.

Rationale 4: Nocturia is the term that describes voiding more than one time per night.

Rationale 5: PND is a condition in which the patient is awakened at night and frightened by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night causing pulmonary congestion.

Global Rationale: PND is a condition in which the patient is awakened at night and frightened by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night causing pulmonary congestion. Chronic heart failure is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses. Nocturia is the term that describes voiding more than one time per night.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 21

Type: MCSA

Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which of the following statements by the patient would indicate that the teaching has been effective?

  1. “I will be sure to tell my dentist that I had rheumatic fever.”
  2. “I will try to focus on eating less protein and more fatRemember, I will have more energy.”
  3. “I will avoid brushing my teeth so often and quit using mouth rinse since I have gingivitis.”
  4. “I know that if my joints start to hurt again, I need to slow down, but I won’t have to worry since I’m immune to getting rheumatic fever again.”

Correct Answer: 1

Rationale 1: Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the patient recovering from rheumatic fever.

Rationale 2: Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing and combat fatigue.

Rationale 3: Maintaining good oral hygiene and preventive dental care are important to preventing gingival infections, which can lead to recurrence of the disease.

Rationale 4: Rheumatic fever is manifested by joint pain. Immunity is not conferred by having had an episode of rheumatic fever.

Global Rationale: Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the patient recovering from rheumatic fever. Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing and combat fatigue. Maintaining good oral hygiene and preventive dental care are important to preventing gingival infections, which can lead to recurrence of the disease. Rheumatic fever is manifested by joint pain. Immunity is not conferred by having had an episode of rheumatic fever.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 22

Type: MCSA

The nurse realizes that which of the following persons are at risk for high-output heart failure?

  1. a patient with chronic anemia
  2. a person with untreated hypertension
  3. an individual with untreated hypothyroidism
  4. someone who abuses sedatives and analgesics

Correct Answer: 1

Rationale 1: High-output heart failure occurs in patients in hypermetabolic states such as anemia, hyperthyroidism, pregnancy, and infection, which require increased cardiac output to maintain blood flow and oxygen to tissues.

Rationale 2: Hypertension is typically associated with low-output heart failure.

Rationale 3: High-output heart failure occurs in patients in hypermetabolic states such as anemia, hyperthyroidism, pregnancy, and infection, which require increased cardiac output to maintain blood flow and oxygen to tissues.

Rationale 4: Sedatives and analgesics slow metabolic function.

Global Rationale: High-output heart failure occurs in patients in hypermetabolic states such as anemia, hyperthyroidism, pregnancy, and infection, which require increased cardiac output to maintain blood flow and oxygen to tissues. Hypertension is typically associated with low-output heart failure. Sedatives and analgesics slow metabolic function.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 23

Type: MCMA

The nurse, caring for an elderly patient, realizes that aging adults are at higher risk for development of heart failure due to which of the following?

Standard Text: Select all that apply.

  1. impaired diastolic filling
  2. increased cardiac reserve
  3. increased maximal heart rate
  4. decreased ventricular compliance
  5. high responsiveness to sympathetic nervous system stimulation

Correct Answer: 1,4

Rationale 1: Impaired diastolic filling occurs due to decreased ventricular compliance.

Rationale 2: With aging, cardiac function is less responsive to increased stress because cardiac reserve decreases.

Rationale 3: Maximal heart rate is reduced.

Rationale 4: The heart becomes less responsive to sympathetic nervous system stimulation.

Rationale 5:

Global Rationale: Impaired diastolic filling occurs due to decreased ventricular compliance. With aging, cardiac function is less responsive to increased stress because cardiac reserve decreases, maximal heart rate is reduced, and the heart becomes less responsive to sympathetic nervous system stimulation.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 24

Type: MCSA

An elderly patient arrives at the clinic complaining of dyspnea, weight gain, chest pain, and increasing edema of the lower extremities. The patient’s blood pressure is elevated. The nurse discovers the patient has a history of heart failure. Which of the following questions by the nurse may best help with determining why the patient is currently having health problems?

  1. “Are you married?”
  2. “Have you been out of the country lately?”
  3. “Do you have grandchildren that you babysit?”
  4. “Have you attended any recent family or social gatherings?”

Correct Answer: 4

Rationale 1: This does not apply to help determine why the patient may suddenly be experiencing an exacerbation of the heart failure.

Rationale 2: This does not apply to help determine why the patient may suddenly be experiencing an exacerbation of the heart failure.

Rationale 3: This does not apply to help determine why the patient may suddenly be experiencing an exacerbation of the heart failure.

Rationale 4: If the patient has attended a recent family or social gathering in which food was served, it is possible that the sodium content of the food was higher than the patient anticipating

Global Rationale: If the patient has attended a recent family or social gathering in which food was served, it is possible that the sodium content of the food was higher than the patient anticipated. The other options do not apply to help determine why the patient may suddenly be experiencing an exacerbation of the heart failure.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 25

Type: MCSA

Which of the following patients should the nurse assess first?

  1. the patient with occasional chest pain who has recently been diagnosed with gallbladder disease
  2. the elderly patient with heart failure who was admitted with increasing edema of the lower extremities
  3. the newly admitted patient complaining of substernal chest pain. Patient has recently had a father die from heart disease
  4. the patient complaining of chest pain and is hyperventilating after a family member leaves the room following an argument

Correct Answer: 3

Rationale 1: The patient with gallbladder disease may have chest pain that is not cardiac related.

Rationale 2: The elderly patient with increasing edema of the extremities would need evaluation, but after the newly admitted patient.

Rationale 3: The nurse would want to assess the newly admitted patient with substernal chest pain with a family history of cardiac disease and initiate any interventions that are appropriate.

Rationale 4: The patient who is hyperventilating could be having an anxiety attack, but needs to be assessed as soon as possible.

Global Rationale: The nurse would want to assess the newly admitted patient with substernal chest pain with a family history of cardiac disease and initiate any interventions that are appropriate. The patient who is hyperventilating could be having an anxiety attack, but needs to be assessed as soon as possible. The patient with gallbladder disease may have chest pain that is not cardiac related. The elderly patient with increasing edema of the extremities would need evaluation, but after the newly admitted patient.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 26

Type: MCSA

The nurse caring for patients on a cardiac unit should plan to see which of the following assigned patients first?

  1. a patient with hypertrophic cardiomyopathy who is reporting dyspnea
  2. a patient who had a cardiac catheterization and will be ambulating for the first time
  3. a patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
  4. a patient who is recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101° F.

Correct Answer: 3

Rationale 1: Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment. However, the patient with a possible PE is the most emergent.

Rationale 2: The patient ambulating for the first time will be assessed by a nurse. However, the patient with a possible PE is the most emergent.

Rationale 3: The patient with bacterial endocarditis is at risk for thrombus formation. This patient requires immediate attention as chest pain and anxiety are signs of pulmonary embolism (PE), which is life-threatening.

Rationale 4: A temperature of 101° F requires further assessment; will be assessed by a nurse. However, the patient with a possible PE is the most emergent.

Global Rationale: The patient with bacterial endocarditis is at risk for thrombus formation. This patient requires immediate attention as chest pain and anxiety are signs of pulmonary embolism (PE), which is life-threatening. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment; a temperature of 101° F requires further assessment; and the patient ambulating for the first time will be assessed by a nurse. However, the patient with a possible PE is the most emergent.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 27

Type: MCSA

A patient with endocarditis develops sudden leg pain with pallor, tingling, and a loss of peripheral pulses. The initial nursing intervention should be to do which of the following?

  1. Notify the physician about these findings.
  2. Elevate the leg above the level of the heart.
  3. Wrap the extremity in a loose, warm blanket. Apply a foot cradle.
  4. Perform passive range of motion (PROM) exercises to stimulate circulation.

Correct Answer: 3

Rationale 1: The physician should be notified after the nurse wraps the leg in a loose, warm blanket to maintain temperature and protect it from injury.

Rationale 2: The leg should not be elevated above the heart because this can worsen the ischemia.

Rationale 3: The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will ensue and ultimately loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain temperature and protect from injury, then notify the physician.

Rationale 4: Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia.

Global Rationale: The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will ensue and ultimately loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain temperature and protect from injury, apply a foot cradle, then notify the physician. The leg should not be elevated above the heart because this can worsen the ischemia. Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 28

Type: MCSA

A patient, newly diagnosed with heart failure, is prescribed 40 mg of furosemide (Lasix) to be given IV push. Knowing that the patient is also prescribed digoxin (Lanoxin), the nurse should review which laboratory result?

  1. sodium level
  2. digoxin level
  3. creatinine level
  4. potassium level

Correct Answer: 4

Rationale 1: Furosemide can cause hyponatremia but the risk of hypokalemia has more severe consequences in this situation.

Rationale 2: Heightened digoxin effect can occur in the patient with hypokalemia.

Rationale 3: No data indicates renal insufficiency; therefore creatinine level is not relevant.

Rationale 4: Serum potassium level is measured in the patient receiving digoxin and furosemide. Heightened digoxin effect can occur in the patient with hypokalemia. Hypokalemia also predisposes the patient to ventricular dysrhythmias.

Global Rationale: Serum potassium level is measured in the patient receiving digoxin and furosemide. Heightened digoxin effect can occur in the patient with hypokalemia. Hypokalemia also predisposes the patient to ventricular dysrhythmias. No data indicates renal insufficiency, therefore creatinine level is not relevant. Furosemide can cause hyponatremia but the risk of hypokalemia has more severe consequences in this situation.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4. Discuss the effects and nursing implications for medications commonly prescribed for patients with cardiac disorders.

 

Question 29

Type: MCSA

A patient is admitted with acute pericarditis. When auscultating heart sounds, the nurse should ask the patient to do which of the following?

  1. Sit, lean forward, and auscultate at the left lower sternal border.
  2. Lay supine and breathe quietly while auscultating for expiratory wheezes.
  3. Sit upright and auscultate the outer aspects of the upper lobes for vesicular breath sounds.
  4. Sit, lean forward, and auscultate at the second right intercostal space, near the sternal border.

Correct Answer: 1

Rationale 1: Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward. The rub is usually heart on expiration and may be constant or intermittent.

Rationale 2: Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward.

Rationale 3: Auscultating lung sounds for expiratory wheezes and vesicular breath sounds is done, but does not focus on the pericardial friction rub.

Rationale 4: Auscultating lung sounds for expiratory wheezes and vesicular breath sounds is done, but does not focus on the pericardial friction rub.

Global Rationale: Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward. The rub is usually heart on expiration and may be constant or intermittent. Auscultating lung sounds for expiratory wheezes and vesicular breath sounds is done, but does not focus on the pericardial friction rub.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 30

Type: MCSA

A patient is being discharged from the healthcare facility following surgical replacement of a mitral valve with a mechanical valve. The patient asks the nurse how much longer he will need to take warfarin (Coumadin). What is the nurse’s best response?

  1. “You will be on it for the rest of your life because you have a mechanical valve.”
  2. “That will depend upon your surgeon. Ask him when you go to your office visit.”
  3. “You will be on it for the rest of your life because you have a biologic tissue valve.”
  4. “You will be told when to stop, which means your mechanical prosthetic valve is probably healed and there is minimal risk of clots.”

Correct Answer: 1

Rationale 1: Long-term anticoagulation is necessary with a mechanical prosthetic valve, due to the risk of development of clots on the valve.

Rationale 2: Option 2 gives false reassurance to the patient and does not answer the patient’s question.

Rationale 3: Biologic tissue valves have a low risk of thrombus formation and long-term anticoagulation is rarely necessary.

Rationale 4: Long-term anticoagulation is necessary with a mechanical prosthetic valve, due to the risk of development of clots on the valve

Global Rationale: Long-term anticoagulation is necessary with a mechanical prosthetic valve, due to the risk of development of clots on the valve. Biologic tissue valves have a low risk of thrombus formation and long-term anticoagulation is rarely necessary. Option 2 gives false reassurance to the patient and does not answer the patient’s question.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 31

Type: MCSA

The nurse measures a patient’s blood pressure as 144/88 mmHg. Which of the following interventions would be most appropriate for this patient?

  1. Provide stress-reduction techniques.
  2. Inform the physician so antihypertensive medication can be prescribed.
  3. Offer the patient a glass of water.
  4. Remeasure the blood pressure in a few minutes.

Correct Answer: 4

Rationale 1: The patient may not feel stressed.

Rationale 2: There is no evidence that this patient has had previously high blood pressure readings. The patient may not need medication.

Rationale 3: Offering a glass of water would have no effect on the blood pressure.

Rationale 4: There is no evidence that this patient has had previously high blood pressure readings. The nurse should remeasure the blood pressure in a few minutes in the event the reading was because of physical activity or anxiety. Hypertension is defined as systolic blood pressure of 140 mmHg or higher, or diastolic pressure of 90 mmHg or higher, based on the average of three or more readings taken on separate occasions.

Global Rationale: There is no evidence that this patient has had previously high blood pressure readings. The nurse should remeasure the blood pressure in a few minutes in the event the reading was because of physical activity or anxiety. Hypertension is defined as systolic blood pressure of 140 mmHg or higher, or diastolic pressure of 90 mmHg or higher, based on the average of three or more readings taken on separate occasions. The patient may not feel stressed or need antihypertensive medication. Offering a glass of water would have no effect on the blood pressure.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 32

Type: MCSA

A patient with diabetes is beginning treatment for hypertension. The nurse shares with the patient that a desirable blood pressure would be which of the following?

  1. 140/90 mmHg
  2. 135/85 mmHg
  3. 130/80 mmHg
  4. 120/80 mmHg

Correct Answer: 3

Rationale 1: Hypertension management focuses on reducing the blood pressure to less than 140 mmHg systolic and 90 mmHg diastolic.

Rationale 2: The treatment goal is a blood pressure less than 130/80.

Rationale 3: Hypertension management focuses on reducing the blood pressure to less than 140 mmHg systolic and 90 mmHg diastolic. The ultimate goal of hypertension management is to reduce cardiovascular and renal morbidity and mortality. The risk of cardiovascular complications decreases when the average blood pressure is less than 140/90; when the patient also has diabetes or renal disease, the treatment goal is a blood pressure less than 130/80.

Rationale 4: The treatment goal is a blood pressure less than 130/80.

Global Rationale: Hypertension management focuses on reducing the blood pressure to less than 140 mmHg systolic and 90 mmHg diastolic. The ultimate goal of hypertension management is to reduce cardiovascular and renal morbidity and mortality. The risk of cardiovascular complications decreases when the average blood pressure is less than 140/90; when the patient also has diabetes or renal disease, the treatment goal is a blood pressure less than 130/80.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 33

Type: MCMA

The nurse is instructing a patient with hypertension about lifestyle modifications. Which of the following would be appropriate to include in the teaching for this patient?

Standard Text: Select all that apply.

  1. Review the DASH diet.
  2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week.
  3. Plan a weight lifting regimen.
  4. Eliminate dairy products from the diet.
  5. Restrict fluid intake.

Correct Answer: 1,2

Rationale 1: Lifestyle modifications are recommended for all patients whose blood pressure falls within the prehypertension range and everyone with intermittent or sustained hypertension. These modifications include weight loss, dietary changes, restricted alcohol use and cigarette smoking, increased physical activity, and stress reduction. Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium and calcium intakes, and reducing total and saturated fat intake. The DASH diet has proven beneficial effects in lowering blood pressure.

Rationale 2: Previously sedentary patients are encouraged to engage in aerobic exercise for 30 to 45 minutes per day most days of the week.

Rationale 3: Isometric exercise, such as weight training, may not be appropriate, as it can raise the systolic blood pressure.

Rationale 4: Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium and calcium intakes, and reducing total and saturated fat intake.

Rationale 5: Fluid restriction is not indicated.

Global Rationale: Lifestyle modifications are recommended for all patients whose blood pressure falls within the prehypertension range and everyone with intermittent or sustained hypertension. These modifications include weight loss, dietary changes, restricted alcohol use and cigarette smoking, increased physical activity, and stress reduction. Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium and calcium intakes, and reducing total and saturated fat intake. The DASH diet has proven beneficial effects in lowering blood pressure. Regular exercise reduces blood pressure and contributes to weight loss, stress reduction, and feelings of overall well-being. Previously sedentary patients are encouraged to engage in aerobic exercise for 30 to 45 minutes per day most days of the week. Isometric exercise, such as weight training, may not be appropriate, as it can raise the systolic blood pressure.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 34

Type: MCSA

A patient is being started on enalapril (Vasotec). The most common complaint from patients who routinely take this medication is which of the following?

  1. increased thirst
  2. reduced urine output
  3. persistent cough
  4. sore throat

Correct Answer: 3

Rationale 1: Primary adverse affects for both ACE I and ARBs include persistent cough, first dose hypotension, and hyperkalemia, not thirst.

Rationale 2: Primary adverse affects for both ACE I and ARBs include persistent cough, first dose hypotension, and hyperkalemia, not reduced urine output.

Rationale 3: Primary adverse affects for both ACE I and ARBs include persistent cough, first dose hypotension, and hyperkalemia.

Rationale 4: Primary adverse affects for both ACE I and ARBs include persistent cough, first dose hypotension, and hyperkalemia, not sore throat.

Global Rationale: Primary adverse affects for both ACE I and ARBs include persistent cough, first dose hypotension, and hyperkalemia.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 35

Type: MCSA

A patient’s blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks. Which of the following would be most appropriate for the nurse to do at this time?

  1. Ask if the patient is taking the prescribed medication.
  2. Suggest to the physician that another medication be added.
  3. Schedule the patient to have the blood pressure checked again in a week.
  4. Realize the patient is anxious because of the diagnosis.

Correct Answer: 1

Rationale 1: Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for any patient with a chronic disease. Prescribed medications may have undesirable effects; whereas hypertension itself often has no symptoms or noticeable effects. The nurse should inquire about reasons for noncompliance with the recommended treatment plan by assessing for factors that can contribute to noncompliance, such as adverse drug effects.

Rationale 2: If it is determined that the patient is not taking the prescribed medication, this intervention would not be indicated at this time.

Rationale 3: If it is determined that the patient is not taking the prescribed medication, this intervention would not be indicated at this time.

Rationale 4: If it is determined that the patient is not taking the prescribed medication, this intervention would not be indicated at this time.

Global Rationale: Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for any patient with a chronic disease. Prescribed medications may have undesirable effects; whereas hypertension itself often has no symptoms or noticeable effects. The nurse should inquire about reasons for noncompliance with the recommended treatment plan by assessing for factors that can contribute to noncompliance, such as adverse drug effects. If it is determined that the patient is not taking the prescribed medication, the other interventions would not be indicated at this time.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 36

Type: MCSA

During the abdominal assessment of an elderly patient, the nurse palpates a mass in the mid-abdomen. Which of the following should the nurse do next?

  1. Percuss the mass.
  2. Ask the patient to cough.
  3. Notify the physician.
  4. Auscultate the mass.

Correct Answer: 4

Rationale 1: If an aneurysm is suspected, asking the patient to cough and percussing the mass would be inappropriate responses that could increase the pressure on the weakened site.

Rationale 2: If an aneurysm is suspected, asking the patient to cough and percussing the mass would be inappropriate responses that could increase the pressure on the weakened site.

Rationale 3: Further assessment is needed before the physician would be contacted, typically first by phone.

Rationale 4: Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen and a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam.

Global Rationale: Further assessment is needed before the physician would be contacted, typically first by phone. Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen and a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam. If an aneurysm is suspected, asking the patient to cough and percussing the mass would be inappropriate responses that could increase the pressure on the weakened site.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 37

Type: MCMA

The nurse suspects a patient who is recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. Which of the following are indications of this event?

Standard Text: Select all that apply.

  1. urine output 45 mL/hr
  2. complaint of groin pain
  3. abdominal dressing dry and intact
  4. respiratory rate 16 and regular
  5. complaint of back discomfort

Correct Answer: 2,5

Rationale 1: This is considered within normal limits.

Rationale 2: The nurse should monitor for and report any of the following manifestations of graft leakage: ecchymoses of the scrotum, perineum, or penis; a new or expanding hematoma; increased abdominal girth; weak or absent peripheral pulses; tachycardia; hypotension; decreased motor function or sensation in the extremities; decreased hemoglobin and hematocrit; increased abdominal, pelvic, back, or groin pain; decreased urinary output (less than 30 mL/ hour); decreased CVP, pulmonary artery pressure, or pulmonary artery wedge pressure. These manifestations may signal graft leakage and possible hemorrhage. Pain may be due to pressure from an expanding hematoma or bowel ischemia.

Rationale 3: This is considered within normal limits.

Rationale 4: This is considered within normal limits.

Rationale 5: The nurse should monitor for and report any of the following manifestations of graft leakage: ecchymoses of the scrotum, perineum, or penis; a new or expanding hematoma; increased abdominal girth; weak or absent peripheral pulses; tachycardia; hypotension; decreased motor function or sensation in the extremities; decreased hemoglobin and hematocrit; increased abdominal, pelvic, back, or groin pain; decreased urinary output (less than 30 mL/ hour); decreased CVP, pulmonary artery pressure, or pulmonary artery wedge pressure. These manifestations may signal graft leakage and possible hemorrhage. Pain may be due to pressure from an expanding hematoma or bowel ischemia.

Global Rationale: The nurse should monitor for and report any of the following manifestations of graft leakage: ecchymoses of the scrotum, perineum, or penis; a new or expanding hematoma; increased abdominal girth; weak or absent peripheral pulses; tachycardia; hypotension; decreased motor function or sensation in the extremities; decreased hemoglobin and hematocrit; increased abdominal, pelvic, back, or groin pain; decreased urinary output (less than 30 mL/ hour); decreased CVP, pulmonary artery pressure, or pulmonary artery wedge pressure. These manifestations may signal graft leakage and possible hemorrhage. Pain may be due to pressure from an expanding hematoma or bowel ischemia. The other findings listed are considered within normal limits.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 4. Discuss the effects and nursing implications for medications commonly prescribed for patients with cardiac disorders.

 

Question 38

Type: MCSA

The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis. Which of the following did the nurse most likely assess in this patient?

  1. rubor with extremity elevation
  2. normal hair distribution bilaterally over lower extremities
  3. peripheral pulses present bilaterally
  4. complaints of leg pain upon rest

Correct Answer: 4

Rationale 1: Manifestations of peripheral atherosclerosis include rubor with extremities in dependent position.

Rationale 2: Manifestations of peripheral atherosclerosis include thin, shiny, hairless skin.

Rationale 3: Manifestations of peripheral atherosclerosis include diminished or absent peripheral pulses.

Rationale 4: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest; paresthesias; diminished or absent peripheral pulses; pallor with extremity elevation; rubor with extremities in dependent position; thin, shiny, hairless skin; thickened toenails; and areas of skin discoloration or skin breakdown.

Global Rationale: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest; paresthesias; diminished or absent peripheral pulses; pallor with extremity elevation; rubor with extremities in dependent position; thin, shiny, hairless skin; thickened toenails; and areas of skin discoloration or skin breakdown.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Compare and contrast the etiology, pathophysiology, and manifestations of common cardiac disorders, including heart failure, structural disorders, and inflammatory disorders.

 

Question 39

Type: MCSA

A patient is having segmental pressure measurements conducted to help diagnose peripheral vascular disease. Which of the following would indicate the presence of this disorder?

  1. thigh pressure higher than the arm
  2. calf pressure higher than the arm
  3. calf pressure lower than the arm
  4. no difference between the arm or leg

Correct Answer: 3

Rationale 1: In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms.

Rationale 2: In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms.

Rationale 3: Noninvasive studies often are sufficient to diagnose peripheral vascular disease. Segmental pressure measurements use sphygmomanometer cuffs and a Doppler device to compare blood pressures between the upper and lower extremities and within different segments of the affected extremity.

Rationale 4: In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms.

Global Rationale: Noninvasive studies often are sufficient to diagnose peripheral vascular disease. Segmental pressure measurements use sphygmomanometer cuffs and a Doppler device to compare blood pressures between the upper and lower extremities and within different segments of the affected extremity. In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 40

Type: MCSA

A patient is demonstrating signs of ineffective peripheral tissue perfusion. Which of the following interventions would be appropriate for this patient?

  1. Encourage patient to reduce level of exercise.
  2. Discuss smoking cessation techniques.
  3. Keep extremities cool.
  4. Assist with pillow placement under knees.

Correct Answer: 2

Rationale 1: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion discussing the benefits of regular exercise.

Rationale 2: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include assessing peripheral pulses, pain, color, temperature, and capillary refill every four hours and as needed; positioning with extremities dependent; instructing to avoid smoking; discussing the benefits of regular exercise; using a foot cradle and lightweight blanketsRemember,cks, and slippers to keep extremities warm; avoiding electric heating pads or hot water bottles; encouraging frequent position changes; and instructing to avoid crossing legs or using a pillow under the knees.

Rationale 3: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include using a foot cradle and lightweight blanketsRemember,cks, and slippers to keep extremities warm and avoiding electric heating pads or hot water bottles.

Rationale 4: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include instructing to avoid crossing legs or using a pillow under the knees.

Global Rationale: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include assessing peripheral pulses, pain, color, temperature, and capillary refill every four hours and as needed; positioning with extremities dependent; instructing to avoid smoking; discussing the benefits of regular exercise; using a foot cradle and lightweight blanketsRemember,cks, and slippers to keep extremities warm; avoiding electric heating pads or hot water bottles; encouraging frequent position changes; and instructing to avoid crossing legs or using a pillow under the knees.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 41

Type: MCSA

A patient is diagnosed with thromboangiitis obliterans. Appropriate teaching for this patient includes which of the following?

  1. Medications are the only cure.
  2. Surgical procedures can be performed to cure this disorder.
  3. Management depends upon the patient’s willingness to stop smoking.
  4. Management strategies have no effect on disorder.

Correct Answer: 3

Rationale 1: No cure is available.

Rationale 2: No cure is available.

Rationale 3: The prognosis for thromboangiitis obliterans depends significantly on the patient’s ability and willingness to stop smoking. With smoking cessation and good foot care, the prognosis for saving the extremities is good, even though no cure is available.

Rationale 4: With smoking cessation and good foot care, the prognosis for saving the extremities is good, even though no cure is available.

Global Rationale: The prognosis for thromboangiitis obliterans depends significantly on the patient’s ability and willingness to stop smoking. With smoking cessation and good foot care, the prognosis for saving the extremities is good, even though no cure is available.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 42

Type: MCSA

A patient is being discharged on long-term oral anticoagulant therapy for arterial thrombus formation in the lower extremity. Which of the following should be included in this patient’s discharge instructions?

  1. Slight bleeding from the nose is expected.
  2. Contact the physician’s office for follow-up laboratory studies.
  3. Pain in the limb is a sign of healing.
  4. Take two doses of the prescribed anticoagulant if a dose is missed one day.

Correct Answer: 2

Rationale 1: Nasal bleeding is not expected.

Rationale 2: When preparing the patient and family for home or community-based care related to an acute arterial occlusion, discuss the following topics as necessary: incision care; manifestations of complications to be reported, including symptoms of infection or occlusion of the graft or artery; long-term anticoagulant therapy, including the reason, prescribed dose, follow-up laboratory testing and appointments, interactions with other drugs, and manifestations of excessive bleeding; any activity restrictions or dietary modifications; lifestyle modifications to slow atherosclerosis and control hypertension; and measures to promote peripheral circulation and maintain tissue integrity.

Rationale 3: Pain in the limb could indicate another clot has formed.

Rationale 4: Anticoagulant medications should never be “doubled” even in the case of a missed dose. The patient would be encouraged to notify the physician if a dose is missed.

Global Rationale: When preparing the patient and family for home or community-based care related to an acute arterial occlusion, discuss the following topics as necessary: incision care; manifestations of complications to be reported, including symptoms of infection or occlusion of the graft or artery; long-term anticoagulant therapy, including the reason, prescribed dose, follow-up laboratory testing and appointments, interactions with other drugs, and manifestations of excessive bleeding; any activity restrictions or dietary modifications; lifestyle modifications to slow atherosclerosis and control hypertension; and measures to promote peripheral circulation and maintain tissue integrity. Nasal bleeding is not expected. Pain in the limb could indicate another clot has formed. Anticoagulant medications should never be “doubled” even in the case of a missed dose. The patient would be encouraged to notify the physician if a dose is missed.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 43

Type: MCMA

.A patient is demonstrating signs of thrombophlebitis. With this disorder, the nurse realizes that which three mechanisms occur to cause this condition?

Standard Text: Select all that apply.

  1. pooling of blood in the vessel
  2. blood hypercoagulation
  3. sluggish blood flow
  4. elevated systemic blood pressure
  5. vessel damage

Correct Answer: 2,3,5

Rationale 1: Blood does not pool in the vessel, it is restricted.

Rationale 2: Three pathologic factors, called Virchow’s triad, are associated with thrombophlebitis: stasis of blood, vessel damage, and increased blood coagulability.

Rationale 3: Three pathologic factors, called Virchow’s triad, are associated with thrombophlebitis: stasis of blood, vessel damage, and increased blood coagulability.

Rationale 4: Systemic blood pressure elevation is not a mechanism of this problem.

Rationale 5: Three pathologic factors, called Virchow’s triad, are associated with thrombophlebitis: stasis of blood, vessel damage, and increased blood coagulability.

Global Rationale: Three pathologic factors, called Virchow’s triad, are associated with thrombophlebitis: stasis of blood, vessel damage, and increased blood coagulability. Blood does not pool in the vessel, it is restricted. Systemic blood pressure elevation is not a mechanism of this problem.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 44

Type: MCSA

A patient is seen for increasing edema in his left lower extremity, erythema, and pain in the limb with ambulation. Which of the following disorders do these symptoms suggest?

  1. arterial occlusion
  2. deep vein thrombosis
  3. superficial vein thrombosis (SVT)
  4. varicose veins

Correct Answer: 2

Rationale 1: A DVT is not an arterial or a primary superficial vein problem.

Rationale 2: The manifestations of deep vein thrombosis (DVT) are primarily due to the inflammatory process that accompanies the thrombus. Calf pain is the most common symptom, and it may be described as tightness or a dull, aching pain in the affected extremity, particularly upon walking. Tenderness, swelling, warmth, and erythema may be noted along the course of involved veins. The affected extremity may be cyanotic and often is edematous. Rarely, a cord may be palpated over the affected vein. A positive Homan’s sign is an unreliable indicator of DVT.

Rationale 3: A DVT is not an arterial or a primary superficial vein problem.

Rationale 4: Varicose veins are tortuous veins with valve insufficiency.

Global Rationale: The manifestations of deep vein thrombosis (DVT) are primarily due to the inflammatory process that accompanies the thrombus. Calf pain is the most common symptom, and it may be described as tightness or a dull, aching pain in the affected extremity, particularly upon walking. Tenderness, swelling, warmth, and erythema may be noted along the course of involved veins. The affected extremity may be cyanotic and often is edematous. Rarely, a cord may be palpated over the affected vein. A positive Homan’s sign is an unreliable indicator of DVT. A DVT is not an arterial or a primary superficial vein problem. Varicose veins are tortuous veins with valve insufficiency.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 45

Type: MCSA

A patient with a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. The nurse anticipates that oral warfarin sodium should be prescribed

  1. the same day the heparin is discontinued.
  2. the day before the heparin is discontinued.
  3. four to five days before the heparin is discontinued.
  4. the day the patient is discharged.

Correct Answer: 3

Rationale 1: Anticoagulation with warfarin may be initiated concurrently with heparin therapy.

Rationale 2: Anticoagulation with warfarin may be initiated concurrently with heparin therapy.

Rationale 3: Oral anticoagulation with warfarin may be initiated concurrently with heparin therapy. Overlapping heparin and warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, and it may actually promote clotting during the first few days of therapy.

Rationale 4: Overlapping heparin and warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, and it may actually promote clotting during the first few days of therapy.

Global Rationale: Oral anticoagulation with warfarin may be initiated concurrently with heparin therapy. Overlapping heparin and warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, and it may actually promote clotting during the first few days of therapy.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 46

Type: MCSA

The nurse is planning care for a patient who was diagnosed with deep vein thrombosis (DVT). Which of the following should be included in the patient’s plan of care?

  1. activity as tolerated
  2. measure and apply graduated compression stockings
  3. encourage patient to sit out of bed several hours every day
  4. assist patient with putting on tight-fitting pants

Correct Answer: 2

Rationale 1: The plan of care for a patient with deep vein thrombosis (DVT) includes possible bed rest, the duration of which is determined by the extent of leg edema.

Rationale 2: The plan of care for a patient with deep vein thrombosis (DVT) includes possible bed rest, the duration of which is determined by the extent of leg edema; elevate legs 15 to 20 degrees, with the knees slightly flexed, above the level of the heart to promote venous return and discourage venous pooling; elastic antiembolism/compression stockings or pneumatic compression devices are also frequently ordered to stimulate the muscle-pumping mechanism that promotes the return of blood to the heart; when permitted, walking is encouraged; avoid prolonged standing or sitting; avoid leg crossing and tight-fitting garments or stockings that bind.

Rationale 3: Walking is encouraged but the patient should avoid prolonged standing or sitting and avoid leg crossing.

Rationale 4: The patient should avoid tight-fitting garments or stockings that bind.

Global Rationale: The plan of care for a patient with deep vein thrombosis (DVT) includes possible bed rest, the duration of which is determined by the extent of leg edema; elevate legs 15 to 20 degrees, with the knees slightly flexed, above the level of the heart to promote venous return and discourage venous pooling; elastic antiembolism/compression stockings or pneumatic compression devices are also frequently ordered to stimulate the muscle-pumping mechanism that promotes the return of blood to the heart; when permitted, walking is encouraged; avoid prolonged standing or sitting; avoid leg crossing and tight-fitting garments or stockings that bind.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 47

Type: MCSA

A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath. Which of the following should the nurse do first?

  1. Elevate the head of the bed and begin oxygen therapy.
  2. Obtain a 12-lead EKG and notify the physician.
  3. Measure the patient’s blood pressure.
  4. Assess the extremity with the thrombosis and heart sounds.
  5. Assess the pulses on the extremity with the thrombosis and check the PT/INR level .

Correct Answer: 1

Rationale 1: Immediately report patient complaints of chest pain and shortness of breath, anxiety, or a sense of impending doom. The manifestations of pulmonary embolism are similar to those of myocardial infarction. Prompt intervention to restore pulmonary blood flow can reduce the risk of significant adverse effects. Initiate oxygen therapy, elevate the head of the bed, and reassure the patient who is experiencing manifestations of pulmonary embolism. Oxygen therapy and elevating the head of the bed promote ventilation and gas exchange in those alveoli that are well-perfused, and help to maintain tissue oxygenation.

Rationale 2: This intervention is not the priority and would delay the initiation of required interventions in this situation.

Rationale 3: This intervention is not the priority and would delay the initiation of required interventions in this situation.

Rationale 4: This intervention is not the priority and would delay the initiation of required interventions in this situation.

Rationale 5: This intervention is not the priority and would delay the initiation of required interventions in this situation.

Global Rationale: Immediately report patient complaints of chest pain and shortness of breath, anxiety, or a sense of impending doom. The manifestations of pulmonary embolism are similar to those of myocardial infarction. Prompt intervention to restore pulmonary blood flow can reduce the risk of significant adverse effects. Initiate oxygen therapy, elevate the head of the bed, and reassure the patient who is experiencing manifestations of pulmonary embolism. Oxygen therapy and elevating the head of the bed promote ventilation and gas exchange in those alveoli that are well-perfused, and help to maintain tissue oxygenation. The other interventions are not the priority and would delay the initiation of required interventions in this situation.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 48

Type: MCSA

A 75-year-old patient is diagnosed with chronic venous insufficiency. Which of the following instructions are appropriate for this patient?

  1. Keep legs in a dependent position as much as possible.
  2. Avoid the use of knee-high hose or girdles.
  3. Limit ambulation.
  4. Dangle legs over the side of the bed several times per day.

Correct Answer: 2

Rationale 1: Nursing care for the patient with chronic venous insufficiency includes elevating the legs while resting and during sleep.

Rationale 2: Nursing care for the patient with chronic venous insufficiency includes elevating the legs while resting and during sleep; walking as much as possible, but avoiding sitting or standing for long periods of time; when sitting, do not cross legs or allow pressure on the back of the knees, such as sitting on the side of the bed; do not wear anything that pinches legs, such as knee-high hose, garters, or girdles; wear elastic hose as prescribed; and keep the skin on the feet and legs cleanRemember,ft, and dry.

Rationale 3: Nursing care for the patient with chronic venous insufficiency includes walking as much as possible, but avoiding sitting or standing for long periods of time.

Rationale 4: Nursing care for the patient with chronic venous insufficiency includes not crossing legs or allowing pressure on the back of the knees, such as sitting on the side of the bed.

Global Rationale: Nursing care for the patient with chronic venous insufficiency includes elevating the legs while resting and during sleep; walking as much as possible, but avoiding sitting or standing for long periods of time; when sitting, do not cross legs or allow pressure on the back of the knees, such as sitting on the side of the bed; do not wear anything that pinches legs, such as knee-high hose, garters, or girdles; wear elastic hose as prescribed; and keep the skin on the feet and legs cleanRemember,ft, and dry.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Explain risk factors and preventive measures for cardiac disorders such as heart failure, inflammatory disorders, and valve disorders.

 

Question 49

Type: MCSA

An elderly patient is prescribed elastic graduated compression stockings. The nurse should instruct this patient to do which of the following?

  1. Wear the stockings continuously, except when showering.
  2. Expect areas of skin breakdown under the stockings.
  3. Wear the stockings primarily while sleeping.
  4. Remove the stockings once per day and while sleeping.

Correct Answer: 4

Rationale 1: The patient who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, and remove them once during the daytime and while sleeping.

Rationale 2: Skin breakdown is not anticipated with wearing the stockings and would need to be reported to the physician.

Rationale 3: The patient who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, and remove them once during the daytime and while sleeping.

Rationale 4: The patient who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, and remove them once during the daytime and while sleeping.

Global Rationale: The patient who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, and remove them once during the daytime and while sleeping. Skin breakdown is not anticipated with wearing the stockings and would need to be reported to the physician.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss indications for and management of patients with hemodynamic monitoring.

 

Question 50

Type: MCSA

The nurse is preparing to assess a patient’s hematologic, peripheral vascular, and lymphatic systems. Which of the following assessment techniques is not typically utilized for this assessment?

  1. inspection.
  2. palpation
  3. percussion
  4. auscultation

Correct Answer: 3

Rationale 1: The techniques used to assess these systems include inspection of the skin for such changes as edema, ulcerations, or alterations in color and temperature; auscultation of blood pressure; and palpation of the major pulse points of the body and lymph nodes.

Rationale 2: The techniques used to assess these systems include inspection of the skin for such changes as edema, ulcerations, or alterations in color and temperature; auscultation of blood pressure; and palpation of the major pulse points of the body and lymph nodes.

Rationale 3: Percussion is not typically used to assess the hematologic, peripheral vascular, and lymphatic systems.

Rationale 4: The techniques used to assess these systems include inspection of the skin for such changes as edema, ulcerations, or alterations in color and temperature; auscultation of blood pressure; and palpation of the major pulse points of the body and lymph nodes.

Global Rationale: Percussion is not typically used to assess the hematologic, peripheral vascular, and lymphatic systems. The techniques used to assess these systems include inspection of the skin for such changes as edema, ulcerations, or alterations in color and temperature; auscultation of blood pressure; and palpation of the major pulse points of the body and lymph nodes.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

Question 51

Type: MCSA

During the assessment, a patient’s pedal pulses are increased. The nurse should document this finding as which of the following?

  1. +1
  2. +2
  3. +3
  4. +4

Correct Answer: 3

Rationale 1: 1+ = diminished

Rationale 2: 2+ = normal

Rationale 3: The correct documentation for this finding is +3. Pulses should be described as increased, normal, diminished, or absent. Scales that range from 0 to 4+ are sometimes used as follows: 0 = absent; 1+ = diminished; 2+ = normal; 3+ = increased; and 4+ = bounding.

Rationale 4: 4+ = bounding

Global Rationale: The correct documentation for this finding is +3. Pulses should be described as increased, normal, diminished, or absent. Scales that range from 0 to 4+ are sometimes used as follows: 0 = absent; 1+ = diminished; 2+ = normal; 3+ = increased; and 4+ = bounding.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Describe nursing care for the patient undergoing cardiac surgery or cardiac transplant.

 

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