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Medical Surgical Nursing 6th Edition LeMone Burke Bauldoff Gubrud Test Bank

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Medical Surgical Nursing 6th Edition LeMone Burke Bauldoff Gubrud Test Bank

ISBN-13: 978-0133139433

ISBN-10: 0133139433

 

 

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Medical Surgical Nursing 6th Edition LeMone Burke Bauldoff Gubrud Test Bank

ISBN-13: 978-0133139433

ISBN-10: 0133139433

 

 

 

 

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Free Nursing Test Questions:

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank
Chapter 31

 

Question 1

Type: MCSA

The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound should the nurse expect to auscultate?

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

Correct Answer: 4

Rationale 1: Expiratory wheezes are not associated with chronic heart failure.

Rationale 2: Friction rub is not associated with chronic heart failure.

Rationale 3: Harsh vesicular sounds are not associated with chronic heart failure.

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

Global Rationale: Fluid accumulates in the alveolar spaces in 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 924

 

Question 2

Type: MCSA

The nurse is caring for a chronic heart failure patient with left-sided failure. Which documentation should the nurse expect to see in the medical record after this patient has a 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 923

 

Question 3

Type: MCSA

The nurse is caring for a patient with heart failure. What should the nurse expect when assessing this patient?

  1. S1, S2, and flat neck veins
  2. S3 and distended neck veins
  3. S2 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. Most patients have elements of both right- and left-sided heart failure.

Rationale 3: S1 and S2 sounds may be diminished in the heart failure patient and do 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. Most patients have elements of both right- and left-sided heart failure. 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 do 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 923-924

 

Question 4

Type: MCSA

The nurse is obtaining the health history of a patient who is being assessed for possible heart failure (HF). Which patient statement should the nurse identify as being associated with this condition?

  1. “I break out in a cold sweat when I eat a large meal.”
  2. “I am sleepy after I eat lunch every 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 is not related to a diagnosis of HF.

Rationale 2: Sleepiness after meals is not related to a diagnosis of HF.

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

Rationale 4: The effects of leg position are not related to a diagnosis of HF.

Global Rationale: Needing to prop oneself up with pillows at night to breathe describes orthopnea, which is consistent with heart failure (HF). HF produces a volume excess, congestion in the lungs, and dyspnea when the patient attempts to lie down. Diaphoresis and sleepiness after meals as well as the effects of leg position are not related to a diagnosis of HF.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 924

 

Question 5

Type: MCMA

A patient is admitted with acute heart failure. The nurse recognizes that this condition is associated with an abrupt onset of which health problems?

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 is associated with chronic heart failure.

Rationale 2: Valve disease is associated with chronic heart failure.

Rationale 3: Coronary heart disease (CHD) is associated with chronic heart failure.

Rationale 4: Acute failure is the abrupt onset of a myocardial injury (such as a massive MI) resulting in suddenly reduced cardiac function and signs of reduced cardiac output.

Rationale 5: Acute failure is the abrupt onset of a myocardial injury (such as a massive MI) resulting in suddenly reduced cardiac function and signs of reduced cardiac output.

Global Rationale: Acute failure is the abrupt onset of a myocardial injury (such as a massive MI) resulting in suddenly reduced cardiac function and signs of reduced cardiac output. 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.1. Explain the incidence, prevalence, risk factors, and pathophysiology for pump failure.

Page Number: 924

 

Question 6

Type: MCSA

Blood tests are ordered for a patient with suspected heart failure (HF). Which test result should the nurse review to support this medical diagnosis?

  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 tests are drawn but do not specifically identify problems in cardiac function.

Rationale 2: Urinalysis and blood urea nitrogen (BUN) may be performed but do not specifically identify problems in cardiac function.

Rationale 3: BNP tests 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: Serum electrolytes may be drawn but do not specifically identify problems in cardiac function.

Global Rationale: Liver function, urinalysis, blood urea nitrogen (BUN), and serum electrolytes may be performed but do not specifically identify problems in cardiac function. BNP tests 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 925-926

 

Question 7

Type: MCSA

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

  1. preventing infection at the catheter site by changing the dressing as prescribed
  2. setting alarm limits and turning monitor alarms on
  3. explaining to family members why the monitoring is in use
  4. coiling IV tubing on the bed

Correct Answer: 2

Rationale 1: Preventing 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 because they are silenced only when blood is drawn or tubing changed.

Rationale 3: Keeping family members informed about monitoring is important but is 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 because they are silenced only when blood is drawn or tubing changed. Keeping family members informed about monitoring and preventing infection by changing dressings are important but not the priority of care. Coiling the IV tubing on the bed is contraindicated.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 928

 

Question 8

Type: MCHS

A 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 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

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

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 928

 

Question 9

Type: MCSA

The nurse is caring for a patient in the critical care area whose fluid volume status needs to be closely assessed. Which type of monitoring should the nurse expect for this patient?

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

Correct Answer: 3

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

Rationale 2: Pulmonary artery pressure monitoring is used to evaluate left ventricular and overall cardiac function.

Rationale 3: CVP is used to monitor fluid volume status.

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

Global Rationale: CVP is used to monitor fluid volume status. Arterial pressure monitoring would not measure central venous pressure. Pulmonary artery pressure monitoring is used to evaluate left ventricular and overall cardiac function. An intra-aortic balloon pump is not used for pressure monitoring.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

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

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 927

 

Question 10

Type: MCSA

A patient has a pulmonary artery (PA) catheter placed. What should the nurse recognize as the purpose of this catheter?

  1. The patient cannot tolerate hemodynamic monitoring.
  2. The patient requires a peripheral intravenous catheter for medication administration.
  3. The patient would benefit from having the right ventricle pressures measured each shift.
  4. The patient 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 would not be used to administer medications as it is a central arterial catheter, not a peripheral line.

Rationale 3: The PA catheter does not measure right ventricular pressures.

Rationale 4: The PA catheter is used to evaluate left ventricular and overall cardiac function.

Global Rationale: The PA catheter is used to evaluate left ventricular and overall cardiac function. 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 as it is a central arterial catheter, not a peripheral line.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

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

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 928

 

Question 11

Type: MCSA

A patient is prescribed digoxin (Lanoxin). What is the nurse’s priority instruction to the patient about this medication?

  1. how to manage itchy skin
  2. foods that should be eaten while taking this drug
  3. the importance of not taking the medication if the pulse is under 60 beats per minute
  4. the need to check the pulse once a week and record the result on a notepad

Correct Answer: 3

Rationale 1: Itchy skin is not an adverse effect of this medication.

Rationale 2: The patient should be instructed to eat foods high in potassium; however, priority instruction concerning this medication.

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 if that occurs.

Rationale 4: The pulse should be assessed daily to determine if the medication can be taken.

Global Rationale: 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 if that occurs. The pulse should be assessed daily to determine if the medication can be taken. Itchy skin is not an adverse effect of this medication. The patient should be instructed to eat foods high in potassium; however, priority for this medication.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.8.3. Examine the treatment options for pump failure.

Page Number: 931

 

Question 12

Type: MCSA

An older patient was recently discharged to home after treatment for chronic heart failure. The patient experiences an increase in pulse rate from 80 beats per minute (bpm) to 102 bpm when walking from the kitchen to the utility room to do laundry. What should the home care nurse encourage the patient to do?

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

Correct Answer: 4

Rationale 1: Completing household tasks in the morning is not a practical strategy for an older patient with compromised heart function.

Rationale 2: Ignoring the pulse rate and becoming more active is not a practical strategy for an older patient with compromised heart function.

Rationale 3: All home activities should be performed at a pace that is comfortable 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. Completing household tasks in the morning, ignoring the pulse rate and becoming more active, and resting 30 minutes between loads of laundry are not practical strategies for an older patient with compromised heart function. All home activities should be performed at a pace that is comfortable for the patient.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.4. Utilize the nursing process in care of client.

Page Number: 934

 

Question 13

Type: MCSA

The nurse should recognize which finding as a sign of decreased cardiac output and tissue perfusion in a patient with heart failure?

  1. reduced 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 in this patient.

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 in this patient.

Global Rationale: A change in mentation is a common sign of decreased cardiac output and tissue perfusion. Urine output would decrease and 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: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 934

 

Question 14

Type: MCSA

A patient is exhibiting dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum. Which health problem should the nurse suspect is occurring in this patient?

  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.

Rationale 2: Dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink frothy sputum are signs and symptoms 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, crackles, and productive cough with pink frothy sputum are signs and symptoms 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 937

 

Question 15

Type: MCSA

A patient is diagnosed with pulmonary edema. What is a priority for this patient?

  1. inserting a peripheral intravenous catheter
  2. requesting a prescription to medicate the patient for comfort
  3. monitoring the blood glucose level
  4. placing a pulse oximeter and administering oxygen

Correct Answer: 4

Rationale 1: Inserting an IV would be the second priority, although often, if more than one caregiver is 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: Pulmonary edema is a medical emergency. Priority nursing actions focus on maintaining the airway and improving oxygenation, then breathing and circulation.

Global Rationale: Pulmonary edema 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, although often, if more than one caregiver is 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.3. Examine the treatment options for pump failure.

Page Number: 937


Question 16

Type: MCSA

The nurse is caring for a patient with possible endocarditis. What is important for the nurse to consider when caring for this patient?

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

Correct Answer: 4

Rationale 1: Endocarditis carries serious risks of damage to heart valves.

Rationale 2: Open heart surgery is not an appropriate treatment for this condition.

Rationale 3: Fever may be present in endocarditis.

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 of 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.12.1. Explain the incidence, risk factors, and pathophysiology for inflammatory heart disorders.

Page Number: 943

 

Question 17

Type: MCMA

The nurse suspects that a patient has pericarditis. What did the nurse assess to make this clinical decision?

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.

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

Rationale 3: Chest pain is a hallmark sign of pericarditis.

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. Abdominal discomfort, nausea, bradycardia, and distended neck veins are not associated with pericarditis.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.12.2. Differentiate the manifestations of inflammatory heart disorders.

Page Number: 946

 

Question 18

Type: MCSA

A patient is diagnosed with cardiac tamponade. What treatment should the nurse expect to be prescribed for this patient?

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

Correct Answer: 3

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

Rationale 2: Oxygen and rest may be indicated after the pericardiocentesis is performed.

Rationale 3: Cardiac tamponade is a medical emergency. Pericardiocentesis is performed to remove fluid or blood that has collected around the heart and is preventing the heart from pumping effectively.

Rationale 4: 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.12.3. Examine the diagnosis and treatment for inflammatory heart disorders.

Page Number: 948

 

Question 19

Type: MCSA

The nurse caring for a patient with coronary artery disease hears a murmur during auscultation of the heart. What should the nurse suspect is occurring in this patient?

  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 heart disorders interfere 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.7.2. Differentiate the manifestations of valvular disorders.

Page Number: 951

 

Question 20

Type: MCMA

The nurse suspects that a patient is experiencing paroxysmal nocturnal dyspnea (PND). What did the nurse assess to make this clinical decision?

Standard Text: Select all that apply.

  1. symptoms occurring 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, 4, 5

Rationale 1: PND is a condition in which the patient is awakened at night by acute shortness of breath.

Rationale 2: PND occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night, causing pulmonary congestion.

Rationale 3: PND is often a symptom of chronic heart failure, which is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses.

Rationale 4: Nocturia, or voiding more than once a night, is associated with PND.

Rationale 5: Daytime peripheral edema contributes to the development of PND.

Global Rationale: PND is a condition in which the patient is awakened at night 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. Nocturia, or voiding more than once a night, is associated with PND. Daytime peripheral edema contributes to the development of PND. PND is often a symptom of chronic heart failure, which is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 924

 

Question 21

Type: MCSA

Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which patient statement indicates 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 fat so I will have more energy.”
  3. “I will avoid brushing my teeth so often and quit using mouth rinse because I have gingivitis.”
  4. “If my joints start to hurt again, I need to slow down, but I won’t have to worry because I’m immune to rheumatic fever now.”

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. One episode of rheumatic fever does not confer immunity to future episodes.

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. One episode of rheumatic fever does not confer immunity to future episodes.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.12.4. Utilize the nursing process in care of client.

Page Number: 924

 

Question 22

Type: MCSA

The nurse is reviewing data collected on a group of patients. Which patient should the nurse realize is 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.

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

Rationale 3: High-output heart failure occurs in patients in hypermetabolic states such hyperthyroidism.

Rationale 4: Sedatives and analgesics slow metabolic function.

Global Rationale: High-output heart failure occurs in patients in hypermetabolic states such as anemia or hyperthyroidism. Hypertension is typically associated with low-output heart failure. Sedatives and analgesics slow metabolic function.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.1. Explain the incidence, prevalence, risk factors, and pathophysiology for pump failure.

Page Number: 924

 

Question 23

Type: MCMA

The nurse is caring for an older patient. The nurse recognizes that which factors place older adults at higher risk for development of heart failure?

Standard Text: Select all that apply.

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

Correct Answer: 1, 4

Rationale 1: Diastolic filling is impaired because of reduced 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: Diastolic filling is impaired because of reduced ventricular compliance.

Rationale 5: The heart becomes less responsive to sympathetic nervous system stimulation.

Global Rationale: Diastolic filling is impaired because of reduced 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: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.1. Explain the incidence, prevalence, risk factors, and pathophysiology for pump failure.

Page Number: 921

 

Question 24

Type: MCSA

An older patient with a history of heart failure is experiencing dyspnea, weight gain, chest pain, and increasing edema of the lower extremities. The patient’s blood pressure is elevated. What should the nurse ask to help determine 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 question is not relevant to determining the reason for exacerbation of the patient’s heart failure.

Rationale 2: This question is not relevant to determining the reason for exacerbation of the patient’s heart failure.

Rationale 3: This question is not relevant to determining the reason for exacerbation of the patient’s 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 anticipated.

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 questions are not relevant to determining the reason for exacerbation of the patient’s heart failure.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.1. Explain the incidence, prevalence, risk factors, and pathophysiology for pump failure.

Page Number: 921, 933

 

Question 25

Type: MCSA

The nurse is reviewing information received in report for a group of patients. Which patient should the nurse assess first?

  1. patient with occasional chest pain who has recently been diagnosed with gallbladder disease
  2. older patient with heart failure who was admitted with increasing edema of the lower extremities
  3. newly admitted patient complaining of substernal chest pain and whose father died recently from heart disease
  4. patient complaining of chest pain and 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 older patient with increasing edema of the extremities would need evaluation, but after another patient in the group.

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

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 and a family history of cardiac disease and initiate any interventions that are appropriate. This manifestation could indicate mitral valve prolapse. 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 older patient with increasing edema of the extremities would need evaluation, but after another patient in the group.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.7.2. Differentiate the manifestations of valvular disorders.

Page Number: 953

 

Question 26

Type: MCSA

The nurse is caring for patients on a cardiac unit. Which patient should the nurse assess first?

  1. patient with hypertrophic cardiomyopathy who is reporting dyspnea
  2. patient who had a cardiac catheterization and will be ambulating for the first time
  3. patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
  4. patient 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, another patient is the most emergent.

Rationale 2: The patient ambulating for the first time will be assessed by a nurse. However, another patient 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. However, another patient 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.7.2. Differentiate the manifestations of valvular disorders.

Page Number: 944

 

Question 27

Type: MCSA

A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first?

  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 and 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 performs another step.

Rationale 2: Elevating the leg above the heart could 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 develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, 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 develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, then notify the physician. Elevating the leg above the heart could 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: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.7.3. Examine the diagnosis and treatment of a valvular disorder.

Page Number: 944

 

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: There is no data indicating renal insufficiency; therefore creatinine level is not relevant.

Rationale 4: The 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. There is no data indicating 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: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

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

MNL Learning Outcome: 6.8.3. Examine the treatment options for pump failure.

Page Number: 930-931

 

Question 29

Type: MCSA

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

  1. sit and lean forward while the nurse auscultates at the left lower sternal border
  2. lie supine and breathe quietly while the nurse auscultates for expiratory wheezes
  3. sit upright while the nurse auscultates the outer aspects of the upper lobes for vesicular breath sounds
  4. sit and lean forward while the nurse auscultates 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 heard on expiration and may be constant or intermittent.

Rationale 2: Expiratory wheezes are not a pericardial friction rub, the characteristic sign of pericarditis.

Rationale 3: Auscultating lung sounds for vesicular breath sounds is done but does not focus on the pericardial friction rub, the characteristic sign of pericarditis.

Rationale 4: Auscultating at the second right intercostal space near the sternal border will not help determine the presence of a pericardial friction rub, the characteristic sign of pericarditis.

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 heard 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. Auscultating at the second right intercostal space near the sternal border will not help determine the presence of a pericardial friction rub.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.12.2. Differentiate the manifestations of inflammatory heart disorders.

Page Number: 930-931

 

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 on your surgeon. Ask her 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, usually when your mechanical prosthetic valve is healed and there is a 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: This does not address 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

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. The nurse should address the patient’s question.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.7.3. Examine the diagnosis and treatment of a valvular disorder.

Page Number: 957

 

Question 31

Type: MCSA

A patient is being started on enalapril (Vasotec). Which common adverse effect should the nurse review with the patient?

  1. increased thirst
  2. reduced urine output
  3. persistent cough
  4. loss of appetite

Correct Answer: 3

Rationale 1: Thirst is not a primary adverse effect of an ACE inhibitor.

Rationale 2: Reduced urine output is not a primary adverse effect of an ACE inhibitor.

Rationale 3: A primary adverse effect of an ACE inhibitor is a persistent cough.

Rationale 4: Loss of appetite is not a primary adverse effect of an ACE inhibitor.

Global Rationale: A primary adverse effect of an ACE inhibitor is a persistent cough. Thirst, reduced urine output, and loss of appetite are not primary adverse effects of this medication.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.8.3. Examine the treatment options for pump failure.

Page Number: 930

 

Question 32

Type: MCMA

 

The nurse suspects that a patient is experiencing a neuroendocrine response from low cardiac output in heart failure. What manifestations did the nurse assess to make this clinical decision?

 

Standard Text: Select all that apply.

 

  1. irregular heart rhythm
  2. gastrointestinal bleeding
  3. blood pressure 188/94 mmHg
  4. nausea, vomiting, and diarrhea
  5. heart rate 112 beats per minute

 

Correct Answer: 3, 5

 

Rationale 1: Dysrhythmias are not neuroendocrine responses to low cardiac output.

 

Rationale 2: Gastrointestinal bleeding is not a neuroendocrine response to low cardiac output.

 

Rationale 3: A neuroendocrine response to low cardiac output and decreased renal perfusion is the stimulation of the renin–angiotensin system, which leads to vasoconstriction and increased blood pressure.

 

Rationale 4: Nausea, vomiting, and diarrhea are not neuroendocrine responses to low cardiac output.

 

Rationale 5: A neuroendocrine response to low cardiac output is stimulation of the sympathetic nervous system and catecholamine release, leading to an increase in heart rate or tachycardia.

 

Global Rationale: A neuroendocrine response to low cardiac output is stimulation of the sympathetic nervous system and catecholamine release, leading to an increase in heart rate or tachycardia. A neuroendocrine response to low cardiac output and decreased renal perfusion is the stimulation of the renin–angiotensin system, which leads to vasoconstriction and increased blood pressure. Dysrhythmias, gastrointestinal bleeding, nausea, vomiting, and diarrhea are not neuroendocrine responses to low cardiac output.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure.

Page Number: 922

 

Question 33

Type: MCMA

 

A male patient of African-American descent is prescribed hydralazine and isosorbide (BiDil) as treatment for heart failure. What should the nurse instruct the patient about this medication?

 

Standard Text: Select all that apply.

 

  1. “Change positions slowly.”
  2. “Dizziness and fainting are expected adverse effects of this medication.”
  3. “You may have a headache when starting this medication, but it will subside.”
  4. “Notify the healthcare provider if you have chest pain while taking this medication.”
  5. “Do not take medications to treat erectile dysfunction while taking this medication.”

 

Correct Answer: 1, 3, 4, 5

 

Rationale 1: This drug can cause a drop in blood pressure, particularly when changing positions from lying to sitting or sitting to standing. The patient should change positions slowly and use caution to prevent falls.

 

Rationale 2: Dizziness and fainting should be reported to the healthcare provider as they may indicate a significant drop in blood pressure.

 

Rationale 3: Headache is a common adverse effect of this drug, particularly when first starting therapy. Headaches tend to subside with continued treatment.

 

Rationale 4: The doctor should be notified if chest pain develops while taking this medication.

 

Rationale 5: Drugs such as sildenafil (Viagra, Revatio), vardenafil (Levitra), and tadalafil (Cialis) are not to be taken while taking this medication because the combination may cause an extreme drop in blood pressure, leading to fainting, chest pain, or a heart attack.

 

Global Rationale: This drug can cause a drop in blood pressure, particularly when changing positions from lying to sitting or sitting to standing. The patient should change positions slowly and use caution to prevent falls. Headache is a common adverse effect of this drug, particularly when first starting therapy. Headaches tend to subside with continued treatment. The doctor should be notified if chest pain develops while taking this medication. Drugs such as sildenafil (Viagra, Revatio), vardenafil (Levitra), or tadalafil (Cialis) are not to be taken while taking this medication because the combination may cause an extreme drop in blood pressure, leading to fainting, chest pain, or a heart attack. Dizziness and fainting should be reported to the healthcare provider as they may indicate a significant drop in blood pressure.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.8.3. Examine the treatment options for pump failure.

Page Number: 932

 

Question 34

Type: MCMA

 

During a home visit the nurse suspects that a patient with heart failure needs additional teaching. What did the nurse observe to make this decision?

 

Standard Text: Select all that apply.

 

  1. The patient lifted an 18-month-old child off the floor.
  2. The patient’s lunch was a small salad and half a sandwich.
  3. The patient drank from a pitcher of water on the coffee table.
  4. The patient documented the frequency and amount of walking completed.
  5. Working in the kitchen, the patient was obviously sweating and short of breath.

 

Correct Answer: 1, 5

 

Rationale 1: Home activity guidelines for the patient with heart failure include no heavy lifting. An 18-month-old child would be considered heavy.

 

Rationale 2: Home activity guidelines for the patient with heart failure include eating six small meals a day.

 

Rationale 3: Home activity guidelines for the patient with heart failure include drinking plenty of water to avoid constipation.

 

Rationale 4: Home activity guidelines for the patient with heart failure include a graded exercise program.

 

Rationale 5: Home activity guidelines for the patient with heart failure include stopping any activity that causes sweating or shortness of breath.

 

Global Rationale: Home activity guidelines for the patient with heart failure include no heavy lifting. An 18-month-old child would be considered heavy. The patient should also stop any activity that causes sweating or shortness of breath. Other guidelines include eating up to six small meals per day, drinking water to prevent constipation, and participating in a graded exercise program.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.4. Utilize the nursing process in care of client.

Page Number: 935

 

Question 35

Type: MCMA

 

The nurse is reviewing medication orders for a patient with myocarditis caused by diphtheria. Which medications should the nurse question before administering them to the patient?

 

Standard Text: Select all that apply.

 

  1. antibiotic
  2. anticoagulant
  3. cardiac glycoside
  4. proton pump inhibitor
  5. antidysrhythmic agent

 

Correct Answer: 3, 4

 

Rationale 1: Myocarditis is an infection of the heart muscle. Antibiotics are indicated in the treatment of this condition.

 

Rationale 2: Emboli can occur with myocarditis. Anticoagulants would be indicated in the treatment of this condition.

 

Rationale 3: Patients with myocarditis often are particularly sensitive to the effects of digitalis, which is a cardiac glycosideRemember, it is used with caution. The nurse should question this medication.

 

Rationale 4: Proton pump inhibitors are used for gastrointestinal disorders. The nurse should question this medication.

 

Rationale 5: Dysrhythmias can occur with myocarditis. Antidysrhythmic agents are indicated in the treatment of this condition.

 

Global Rationale: Patients with myocarditis often are particularly sensitive to the effects of digitalis, which is a cardiac glycosideRemember, it is used with caution. Proton pump inhibitors are used for gastrointestinal disorders. The nurse should question this medication as well. Myocarditis is an infection of the heart muscle. Antibiotics are indicated in the treatment of this condition. Emboli can occur with myocarditis and would be treated with anticoagulants. Dysrhythmias can occur with myocarditis and would be treated with antidysrhythmic agents.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.12.3. Examine the diagnosis and treatment for inflammatory heart disorders.

Page Number: 946

 

Question 36

Type: MCMA

 

The nurse auscultates a heart murmur that is continuous and rumbling and increases in sound toward the end. Which conditions should the nurse suspect this patient might be experiencing?

 

Standard Text: Select all that apply.

 

  1. mitral stenosis
  2. tricuspid stenosis
  3. mitral regurgitation
  4. aortic regurgitation
  5. tricuspid regurgitation

 

Correct Answer: 1, 2

 

Rationale 1: The murmur associated with mitral stenosis is continuous and rumbling and increases in sound towards the end.

 

Rationale 2: The murmur associated with tricuspid stenosis is continuous and rumbling and increases in sound towards the end.

 

Rationale 3: The murmur associated with mitral regurgitation is continuous and occurs throughout systole.

 

Rationale 4: The murmur associated with aortic regurgitation is decrescendo and continuous.

 

Rationale 5: The murmur associated with tricuspid regurgitation is continuous and occurs throughout systole.

 

Global Rationale: The murmurs associated with mitral and tricuspid stenosis are continuous and rumbling and increase in sound towards the end. The murmurs associated with mitral and tricuspid regurgitation are continuous and occur throughout systole. The murmur associated with aortic regurgitation is decrescendo and continuous.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.7.2. Differentiate the manifestations of valvular disorders.

Page Number: 951

 

Question 37

Type: MCMA

 

A patient is undergoing diagnostic tests for aortic regurgitation. Which findings should the nurse expect to assess in this patient?

 

Standard Text: Select all that apply.

 

  1. dizziness
  2. head bobbing
  3. peripheral edema
  4. throbbing neck pulse
  5. palpitations in the supine position

 

Correct Answer: 1, 2, 4, 5

 

Rationale 1: Dizziness is a common manifestation of aortic regurgitation.

 

Rationale 2: In aortic regurgitation, the force of contraction may cause a characteristic head bob, or Musset’s sign, and shake the whole body.

 

Rationale 3: Peripheral edema is not a manifestation of aortic regurgitation.

 

Rationale 4: In aortic regurgitation a throbbing pulse may be visible in the arteries of the neck.

 

Rationale 5: In aortic regurgitation the increased stroke volume may cause complaints of persistent palpitations, especially when the patient is recumbent.

 

Global Rationale: Dizziness, head bobbing, throbbing neck pulse, and palpitations are common manifestations of aortic regurgitation. Peripheral edema is not a manifestation of aortic regurgitation.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritualRemember,cioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.7.2. Differentiate the manifestations of valvular disorders.

Page Number: 954

 

Question 38

Type: MCMA

 

A patient is scheduled for surgery to replace the mitral valve with a biologic heterograft valve. What should the nurse include when instructing the patient about this surgery?

 

Standard Text: Select all that apply.

 

  1. There will be an audible click with this valve.
  2. The valve will not need to be replaced.
  3. Long-term anticoagulation therapy is not necessary.
  4. The valve will likely need to be replaced in 15 years.
  5. Long-term antibiotic therapy is needed after the surgery.

 

Correct Answer: 3, 4

 

Rationale 1: An audible click is associated with a mechanical valve.

 

Rationale 2: Mechanical valves do not necessarily need to be replaced.

 

Rationale 3: Long-term anticoagulation therapy is not needed with a biologic valve.

 

Rationale 4: Biologic valves are less durable than mechanical valves; up to 50% must be replaced within 15 years.

 

Rationale 5: Long-term antibiotic therapy is not needed after valve replacement surgery.

 

Global Rationale: Long-term anticoagulation therapy is not needed with a biologic valve. Biologic valves are less durable than mechanical valves; up to 50% must be replaced within 15 years. An audible click is associated with a mechanical valve. Mechanical valves do not necessarily need to be replaced. Long-term antibiotic therapy is not needed after valve replacement surgery.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

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

MNL Learning Outcome: 6.7.3. Examine the diagnosis and treatment of a valvular disorder.

Page Number: 957

 

Question 39

Type: MCMA

 

The nurse is completing an assessment of a patient with hypertrophic cardiomyopathy. What interventions should the nurse identify to help this patient with feelings of fatigue?

 

Standard Text: Select all that apply.

 

  1. organizing care to allow for rest periods
  2. restricting fluids and measuring abdominal girth
  3. reviewing dietary restrictions for sodium intake
  4. assisting with activities of daily living as needed
  5. consulting with physical therapy for an activity plan

 

Correct Answer: 1, 4, 5

 

Rationale 1: The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should organize care to allow for rest periods.

 

Rationale 2: The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. Restricting fluids and measuring abdominal girth would be appropriate to help manage fluid balance.

 

Rationale 3: The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. Reviewing dietary restrictions would be appropriate to help manage fluid balance.

 

Rationale 4: The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should assist with activities of daily living as needed.

 

Rationale 5: The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should consult with physical therapy for an activity plan.

 

Global Rationale: The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should organize care to allow for rest periods, assist with activities of daily living as needed, and consult with physical therapy for an activity plan. Restricting fluids, measuring abdominal girth, and reviewing dietary restrictions would be appropriate to help manage fluid balance.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.8.4. Utilize the nursing process in care of client.

Page Number: 934, 962

 

Question 40

Type: MCMA

 

A patient with rheumatic heart disease is being discharged. What should the nurse include in the patient’s discharge instructions?

 

Standard Text: Select all that apply.

 

  1. “Perform dental hygiene several times a day.”
  2. “Complete the full course of prescribed antibiotics.”
  3. “Take antibiotics as prescribed before dental work.”
  4. “Restrict fluids and limit activity while taking medication.”
  5. “Notify the physician if you develop a sore throat or other infection.”

 

Correct Answer: 1, 2, 3, 5

 

Rationale 1: The patient with rheumatic heart disease should be instructed to perform dental hygiene to avoid gingival infections.

 

Rationale 2: The complete course of antibiotics should be taken as prescribed.

 

Rationale 3: Antibiotics may be prescribed before dental work.

 

Rationale 4: There is no need to restrict fluids and limit activity while taking medication.

 

Rationale 5: The physician should be notified if a sore throat or any other signs of infection develop.

 

Global Rationale: The patient with rheumatic heart disease should be instructed to perform dental hygiene to avoid gingival infections. The complete course of antibiotics should be taken as prescribed. Antibiotics may be prescribed before dental work. The physician should be notified if a sore throat or any other signs of infection develop. There is no need to restrict fluids or limit activity while taking medication.

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

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.

MNL Learning Outcome: 6.12.4. Utilize the nursing process in care of client.

Page Number: 941

 

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