Post by Nursing Board 101 on Aug 18, 2010 13:23:38 GMT -5
1. A 60-year-old male client comes into the emergency department with complaints of crushing substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infraction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given intravenously. The nurse should first:
a. Administer the morphine
b. Obtain a 12-lead ECG
c. Obtain the blood work
d. Order the chest radiograph
Ans: A – although obtaining the ECG, chest radiograph, and blood work are all important, the nurse’s priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is priority action.
2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of the drug is to:
a. Help keep him well hydrated
b. Dissolve clots that he may have
c. Prevent kidney failure
d. Treat potential cardiac dysrhythmias
Ans: B – thrombolytic drugs are administered within the first 6 hours after of myocardial infarction to lyse clots and reduce the extent of myocardial damage.
3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs should the nurse expect to observe?
a. Oliguria
b. Bradycardia
c. Elevated blood pressure
d. Fever
Ans: A – oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typically signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock.
4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI. essential nursing action include which of the following?
a. Obtaining an infusion pump for the medication
b. Monitoring blood pressure every 4 hours
c. Monitoring urine output hourly
d. Obtaining serum potassium levels daily
Ans: A – intravenous nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused by:
a. Left ventricular overload
b. Impending circulatory collapse
c. Extracellular electrolyte imbalances
d. Insufficient oxygen reaching the heart muscle
Ans: D – an MI interferes with or blocks circulation to the heart muscle. Decreased blood supply to the heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle results in ischemic pain or angina.
6. Aspirin is administered to the client experiencing an MI because of its:
a. Antipyretic action
b. Antithrombotic action
c. Antiplatelet action
d. Analgesic action
Ans: B – aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason aspirin is administered to the client experiencing an MI is its antithrombotic action. In clinical trials, the antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI.
7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and oxygen at 2 L/minute. The nurse’s first course of action should be to:
a. Increase the intravenous infusion rate
b. Notify the physician promptly
c. Increase the oxygen concentration
d. Administer a prescribed analgesic
Ans: B – PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than five or six per minute in the post-MI client, the physician should be notified immediately. More than six PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine hydrochloride. Increasing the intravenous infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse’s first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
8. Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? The client:
a. Has minimal chest pain
b. Can identify risk factors for MI
c. Agrees to participate in a cardiac rehabilitation program
d. Can perform personal self-care activities without pain
Ans: D – by day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to be able to agree to participate in a cardiac rehabilitation program.
9. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would include which outcome?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased PVCs
Ans: B – furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease dysrhythmias.
10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This type of exercise is recommended primarily to help:
a. Prepare the client for ambulation
b. Promote urinary and intestinal elimination
c. Prevent thrombophlebitis and blood clot formation
d. Decrease the likelihood of decubitus ulcer formation
Ans: C – although this type of exercise may decrease the likelihood of heel decubitus ulcer form formation, it is taught to the MI client to prevent thrombophlebitis and blood clot formation. Movement of the lower extremities provides muscular action and aids venous return. As a result, the activity helps prevent stasis of blood, which predisposes the client to thrombophlebitis and blood clot formation. This type of exercise is not associated with promoting urinary and intestinal elimination.
11. Which of the following reflects the principle on which a client’s diet will most likely be based during the acute phase of MI?
a. Liquids as desired
b. Small, easily digested meals
c. Three regular meals per day
d. Nothing by mouth
Ans: B – recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely linked to the development of the disease?
a. Age
b. Medication usage
c. High cholesterol levels
d. Gender
Ans: C – high cholesterol levels are considered a controllable risk factor for CAD and appear most clearly linked to the development of the disease. High cholesterol levels can be modified through diet, exercise, and medication. Age and gender are uncontrollable risk factors for CAD. Medication usage is not considered a risk factor for CAD.
13. Which of the following is an uncontrollable risk factor that has been linked to the development of CAD?
a. Exercise
b. Obesity
c. Stress
d. Heredity
Ans: D – heredity has been linked to CAD and is an uncontrollable risk factor. Exercise, obesity, and stress are controllable risk factor for CAD.
14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, technique of behavior modification may be used to help the client change behavior. The nurse can best reinforce new adaptive behaviors by:
a. Explaining how the old behavior leads to poor health
b. Withholding praise until the new behavior is well established
c. Rewarding the client whenever the acceptable behavior is performed
d. Instilling mild fear into the client to extinguish the behavior
Ans: C – a basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.
15. Alteplase recombinant. Or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of MI to:
a. Control chest pain
b. Reduce coronary artery vasospasm
c. Control the dysrhythmias associated with MI
d. Revascularize the blocked coronary artery
Ans: D – the thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset.
16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to:
a. Observe the client for chest pain
b. Monitor for fever
c. Monitor the 12-lead ECG every 4 hours
d. Monitor breath sounds
Ans: A – although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority, because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.
17. When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor vital signs and have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
a. Cardiac dysrhythmias
b. Hypertension
c. Seizure
d. Hypothermia
Ans: A – cardiac dysrhythmias are commonly observed with administration of t-PA. Cardiac dysrhythmias associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.
18. Contraindication to the administration of t-PA include which of the following?
a. Age greater than 60 years
b. History of cerebral hemorrhage
c. History of heart failure
d. Cigarette smoking
Ans: B – a past history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.
19. A client has driven himself into the emergency room. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse’s next action would be to:
a. Call for the doctor
b. Start an intravenous line
c. Obtain a portable chest radiograph
d. Draw blood for laboratory studies
Ans: B – advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the intravenous line.
20. Crackles heard on lung auscultation indicate which of the following?
a. Cyanosis
b. Bronchospasm
c. Airway narrowing
d. Fluid-filled alveoli
Ans: D – crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.
21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness. The first nursing action should be to:
a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness
b. Administer oxygen via nasal cannula
c. Offer pain medication for the chest heaviness
d. Inform the physician of the chest heaviness
Ans: A – further assessments is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.
22. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?
a. Cancer
b. Hypertension
c. Liver disease
d. Myocardial damage
Ans: D – detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours after physician.
23. An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:
a. Left ventricular atrophy
b. Irregular heart beats
c. Peripheral vascular occlusion
d. Pacemaker placement
Ans: A – in older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult’s lifestyle. Peripheral vascular occlusion of pacemaker placement should not affect response to stress.
The Client With Heart Failure
24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema. On admission of this client, which of the following should be assessed first?
a. Blood pressure
b. Skin breakdown
c. Serum potassium
d. Urine output
Ans: A – it is a priority to assess the blood pressure first, because people with pulmonary edema typically experience severe hypertension that requires early intervention.
25. In which of the following should the nurse place a client with suspected heart failure?
a. Semi-sitting (Low Fowler’s position)
b. Lying on the right side (Sims’ position)
c. Sitting almost upright (High Fowler’s position)
d. Lying on the back with the head lowered (Trendelenburg position)
Ans: C – sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler’s position would be used if the client could not tolerate high Fowler’s position for some reason. Lying on the right side would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg position.
26. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?
a. Risk for infection related to line placements
b. Impaired skin integrity related to pressure
c. Activity intolerance related to imbalance between oxygen supply and demand
d. Constipation related to immobility
Ans: C – activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue. The client could be at risk for infection related to line placements or impaired skin integrity related to pressure. However, these are not the priority nursing diagnoses for the client with heart failure and pulmonary edema, nor is constipation related to immobility.
27. The major goal of therapy for a client with heart failure and pulmonary edema would be to:
a. Increase cardiac output
b. Improve respiratory edema
c. Decrease peripheral edema
d. Enhance comfort
Ans: A – increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
28. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to:
a. Dilate coronary arteries
b. Increase myocardial contractility
c. Decrease cardiac dysrhythmias
d. Decrease electrical conductivity in the heart
Ans: B – digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias and does decrease the electrical conductivity of the myocardium, this is not the primary reason for its use in clients with heart failure and pulmonary edema.
29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with heart failure because it acts as a:
a. Vasopressor
b. Volume expander
c. Vasodilator
d. Potassium-sparing diuretic
Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.
30. Furosemide is administered intravenously to a client with heart failure. How soon after administration should the nurse begin to see evidence of the drug’s desired effect?
a. 5 to 10 minutes
b. 30 to 60 minutes
c. 2 to 4 hours
d. 6 to 8 hours
Ans: A – after intravenous injection of furosemide, diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given intravenously.
31. The nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary reason for this is to help:
a. Prevent electrolyte imbalances
b. Retard rapid drug absorption
c. Excrete excessive fluids accumulated during the night
d. Prevent sleep disturbances during the night
Ans: D – when diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night. Therefore, the client’s sleep will not be disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.
32. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse would suspect atrial fibrillation when palpation of the radial pulse reveals:
a. Two regular beats followed by one irregular
b. An irregular pulse rhythm
c. Pulse rate below 60 bpm
d. A weak, thready pulse
Ans: B – characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock.
33. When teaching the client about complications of atrial fibrillation, the nurse understands that the complications can be caused by:
a. Stasis of blood in the atria
b. Increased cardiac output
c. Decreased pulse rate
d. Elevated blood pressure
Ans: A – atrial fibrillation occurs when the sinoatrial node no longer functions as the heart’s pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate.
34. The nurse should teach the client that signs of digitalis toxicity include which of the following?
a. Skin rash over the chest and back
b. Increased appetite
c. Visual disturbances such as seeing yellow spots
d. Elevated blood pressure
Ans: C – colored vision and seeing yellow spots are symptoms of digitalis toxicity. Abdominal pain, anorexia, nausea, and vomiting are other common symptoms of digitalis toxicity. Additional signs of toxicity include dysrhythmias, such as atrial fibrillation or bradycardia. Skin rash, increased appetite, and elevated blood pressure are not associated with digitalis toxicity.
35. The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels indicate that the client has a:
a. Low sodium level
b. High glucose level
c. High calcium level
d. Low potassium level
Ans: D – a low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity. Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be prone to increased cardiac excitability.
36. Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-g sodium diet?
a. Apples
b. Tomato juice
c. Whole wheat bread
d. Beef tenderloin
Ans: B – canned foods and juices, such as tomato juice, are typically high in sodium and should be avoided in a sodium-restricted diet, canned foods and juices in which sodium has been removed or limited are available. The client should be taught to read labels carefully. Apples and whole wheat breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato juice.
37. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic should be encouraged to eat such foods as bananas, orange juice, and,
a. Spinach
b. Skimmed milk
c. Baked chicken
d. Brown rice
Ans: A – foods rich in potassium include bananas, orange juice, and green leafy vegetables such as spinach. Honeydew melon, cantaloupe, and watermelons are also rich in potassium. Other good sources of potassium are grapefruit juice, nectarines, potatoes, dried prunes, raisins, and figs. Skimmed milk, baked chicken, and brown rice are not considered high in potassium.
38. The nurse finds the apical impulses below the fifth intercostals space. The nurse suspects
a. Left atrial enlargement
b. Left ventricular enlargement
c. Right atrial enlargement
d. Right ventricular enlargement
Ans: B - a normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fifth intercostals space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostals space or lateral to the midclavicular line may indicate left ventricular enlargement.
39. The nurse is admitting a 69-year old man to the clinical unit. The client has a history of left ventricular enlargement. During the assessment the nurse notes +3 pitting edema of the ankles bilaterally. The client does not have chest pain. The nurse observes that the client does have dyspnea at rest. The nurse infers that the client may have
a. Arteriosclerosis
b. Congestive heart failure
c. Chronic bronchitis
d. Acute myocardial infarction
Ans: B – peripheral edema is a symptom of congestive heart failure. Congestive heart failure results when the heart chronically pumps against increased resistance or is unable to contract forcefully to pump the blood out into the systemic circulation. As a result, the ventricles become overfilled and there is an accumulation of volume within the closed system. The client’s symptoms do not indicate arteriosclerosis, chronic bronchitis, or acute MI.
40. The nurse’s discharge teaching plan for the client with congestive heart failure would stress the significance of which of the following?
a. Maintaining a high-fiber diet
b. Walking 2 miles every day
c. Obtaining daily weights at the same time each day
d. Remaining sedentary for most of the day
Ans: C – Congestive heart failure is a complex and chronic condition. Education should focus on health promotion and preventive care in the home environment. Signs and symptoms can be monitored by the client. Instructing the client to obtain daily weights at the same time each day is very important. The client should be told to call the physician if there has been a weight gain of 2 pounds or more. This may indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than waiting until the symptoms become life threatening. Following a high-fiber diet id beneficial, but it is not relevant to the teaching needs of the client with congestive heart failure. Prescribing an exercise program for the client, such as walking 2 miles everyday, would not be appropriate at discharge. The client’s exercise program would need to be planned in consultation with the physician and based on his history and the physical condition of the client. The client may require exercise tolerance testing before an exercise plan is laid out. Although the nurse does not pre-lifestyle should not be recommended.
41. A 70-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide. During the initial interview with the client, the nurse would most likely learn that the client’s childhood health history included:
a. Chicken pox
b. Poliomyelitis
c. Rheumatic fever
d. Meningitis
Ans: C – Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis. Chicken pox, poliomyelitis, and meningitis are not associated with mitral stenosis.
42. A client experiences some initial signs of excitation after having an intravenous infusion of lidocaine hydrochloride started. The nurse would assess that the client is demonstrating a typical adverse reaction to lidocaine hydrochloride when the client complains of:
a. Palpitations
b. Tinnitus
c. Urinary frequency
d. Lethargy
Ans: B – Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, convulsions, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine hydrochloride.
43. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary capillary wedge pressures. The purpose of this is to help assess the:
a. Degree of coronary artery stenosis
b. Peripheral arterial pressure
c. Pressure from fluid within the left ventricle
d. Oxygen and carbon dioxide concentrations in the blood
Ans: C – the pulmonary artery pressures are used to assess the heart’s ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricular end-diastolic pressure and guides the physician in determining fluid management for the client. The degree of coronary artery stenosis is assessed during a cardiac catheterization. The peripheral arterial pressure is assessed with an arterial line. The oxygen and carbon dioxide concentrations in the arterial blood can be measured by an arterial blood gas determination.
44. Which of the following signs and symptoms would most likely be found in a client with mitral regurgitation?
a. Exertional dyspnea
b. Confusion
c. Elevated creatine phosphokinase concentration
d. Chest pain
Ans: A – weight gain due to fluid retention and worsening heart failure cause exertional dyspnea in clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is transmitted backward to the pulmonary veins, capillaries, and arterioles and eventually to he right ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow. Confusion, elevated creatine phosphokinase concentration, and chest pain are not typically associated with mitral regurgitation.
45. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with congestion in the:
a. Aorta
b. Right atrium
c. Superior vena cava
d. Pulmonary circulation
Ans: D – when mitral stenosis is present, the left atrium has difficulty emptying its contents into the left ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the pulmonary circulation is under pressure. functioning of the aorta, right atrium, and superior vena cava is not immediately influenced by mitral stenosis.
46. Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses the client’s past compliance with medical regimens. Lack of compliance with which of the following regimens would pose the greatest health hazard to this client?
a. Medication therapy
b. Diet modification
c. Activity restrictions
d. Dental care
Ans: A – preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.
47. In preparing the client and the family for a postoperative stay in the intensive care unit after open heart surgery, the nurse should explain that:
a. The client will remain in the intensive care unit for 5 days
b. The client will sleep most of the time while in the intensive care unit
c. Noise and activity within the intensive care unit are minimal
d. The client will receive medication to relieve pain
Ans: D – management of postoperative pain is priority for the client after surgery, including valve replacement surgery, according to the Agency for Health Care Policy and Research. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the intensive care unit as long as monitoring and intensive care are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some environmental factors that affect recovery from valve replacement surgery.
48. A client who has undergone a mitral valve replacement experiences persistent bleeding from the surgical incision during the early postoperative period. Which of the following pharmaceutical agents should the nurse be prepared to administer to this client?
a. Vitamin C
b. Protamine sulfate
c. Quinidine sulfate
d. Warfarin sodium (Coumadin)
Ans: B – protamine sulfate is used to help combat persistent bleeding in a client who has had open heart surgery. Vitamin C and quinidine sulfate do not influence blood clotting. Warfarin sodium is an anticoagulant, as is heparin, and these two agents would tend to cause the client to bleed even more.
49. The most effective measure the nurse can use to prevent wound infection when changing a client’s dressing after coronary artery bypass surgery is to:
a. Observe careful handwashing procedures
b. Cleanse the incisional area with an antiseptic
c. Use prepackaged sterile dressings to cover the incision
d. Place soiled dressings in a waterproof bag before disposing of them
Ans: A – many factors help prevent wound infections, including washing hands carefully, using the sterile prepackaged supplies and equipment, cleansing the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful handwashing is also important in helping reduce other infections often acquired in hospitals, such as urinary tract and respiratory system infections.
50. For a client who excretes excessive amounts of calcium during the postoperative period after open surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
a. Ensure a liberal fluid intake
b. Provide an alkaline-ash diet
c. Prevent constipation
d. Enrich the client’s diet with dairy products
Ans: A – in an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.
51. The nurse teaches the client who is receiving warfarin sodium that:
a. Partial thromboplastin time values determine the dosage of warfarin sodium
b. Protamine sulfate is used to reverse the effects of warfarin sodium
c. The international normalized ration (INR) is used to assess effectiveness
d. Warfarin sodium will facilitate clotting of the blood
Ans: C - the INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium’s anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.
52. Good dental care is an important measure in reducing risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include demonstration of the proper use of:
a. A manual toothbrush
b. An electric toothbrush
c. An irrigation device
d. Dental floss
Ans: A – daily dental care and frequent checkups by a dentist who is informed about the client’s condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device, or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the bloodstream, increasing the risk of endocarditis.
53. Before a client’s disease discharge after mitral valve replacement surgery, the nurse should evaluate the client’s understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month-old postdischarge appointment with the surgeon?
a. Showering
b. Lifting anything heavier than 10 pounds
c. A program of gradually progressive walking
d. Light housework
Ans: B – most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.
54. Three days after mitral valve surgery, a 45-year-old woman comments that she hears a “ clicking” noise coming from her chest and her “ rather large” chest incision. The nurse’s response should reflect the understanding that the client may be experiencing which of the following?
a. Anxiety related to altered body image
b. Anxiety related to altered health status
c. Altered tissue perfusion
d. Lack of knowledge regarding the postoperative course
Ans: A – verbalized concerns from the client may stem from her anxiety over the changes her body has gone through after open heart surgery. Although the client may experience anxiety related to her altered health status or may have a lack of knowledge regarding her postoperative course, she is pointing out the changes in her body image. The client is not concerned about altered tissue perfusion.
The Client With Hypertension
55. An industrial health nurse at a large printing plant finds a male employee’s blood pressure to be elevated on two occasions 1 month apart and refers him to his provide physician. The employee is about 25 pounds overweight and has smoked a pack of cigarettes daily for more than 20 years. The client’s physician prescribes atenolol for the hypertension. The nurse should instruct the client to:
a. Avoid sudden discontinuation of the drug
b. Monitor the blood pressure annually
c. Follow a 2-g sodium diet
d. Discontinue the medication if severe headaches develop
Ans: A – atenolol is -adrenergic antagonists indicated for management of hypertension. Sudden discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should not be discontinued without a doctor’s order. Blood pressure needs to be monitored more frequently than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually placed on a 2-g sodium diet for hypertension.
56. The nurse teaches her client, who has recently been diagnosed with hypertension, about his dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client’s?
a. Mixed green salad with blue cheese dressing, crackers, and cold cuts
b. Ham sandwich on rye bread and an orange
c. Baked chicken, an apple, and a slice of white bread
d. Hot dogs, baked beans, and celery and carrot sticks
Ans: C – processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both and fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement\ with clients who are basically asymptomatic.
57. A client’s job involves working in a warm, dry room, frequently bending and crouching to check the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should assess the client for which of the following?
a. Muscle aches
b. Thirst
c. Lethargy
d. Postural hypotension
Ans: D – possible dizziness from postural hypotension when rising a crouched or bent position increases the client’s risk of being injured by the equipment. The nurse should assess the client’s blood pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle aches, or thirst from working in a warm, dry room, but these are not as potentially dangerous as postural hypotension. The client should not be experiencing lethargy.
58. An exercise program is prescribed for the client with hypertension. Which intervention would be most likely to assist the client in maintaining an exercise program?
a. Giving the client a written exercise program.
b. Explaining the exercise program to the client’s spouse.
c. Reassuring the client that he or she can do the exercise program.
d. Tailoring a program to the client’s needs and abilities.
Ans: D – tailoring or individualizing a program to the client’s lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client’s spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.
59. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
a. Review the negative effects of smoking on the body.
b. Discuss the effects of passive smoking on environmental pollution.
c. Established the client’s smoking pattern.
d. Explain how smoking worsens high blood pressure.
Ans: C - a plan to reduce or stop smoking begins with establishing the client’s personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risk, but this knowledge has not been shown to help clients change their smoking behavior.
60. Essential Hypertension would be diagnosed in a 40-year-old man whose blood pressure readings were consistently at or above which of the following?
a. 120/90 mmHg
b. 130/85 mmHg
c. 140/90 mmHg
d. 160/80 mmHg
Ans: C – Heart Center of the Philippines standards define hypertension as a consistent systolic blood pressure level greater than 140 mmHg and a consistent diastolic blood pressure level greater than 90 mmHg.