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ATI Med-Surg Practice Test Cardio P2 Questions and Answers with Explanations,100% Correct, Download to Score A

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ATI Med-Surg Practice Test Cardio P2 Questions and Answers with Explanations Congestive Heart Failure 1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive ... heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupnea. 4. Radial pulse rate of 90 and CRT less than three (3) seconds. 2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of “decreased cardiac output related to inability of the heart to pump effectively” is written. Which short-term goal would be best for the client? 1. The client will be able to ambulate in the hall by date of discharge. 2. The client will have an audible S1 and S2 with no S3 heard by end of shift. 3. The client will turn, cough, and deep breathe every two (2) hours. 4. The client will have a SaO2 reading of 98% by day two (2) of care. 3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify the health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside. 3. Instruct the client to remove the saltshaker from the dinner table. 4. Encourage the client to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime. 4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client’s forehead. 2. Obtain a pulse oximetry reading. 3. Take the client’s vital signs. 4. Assist the client to a sitting position. 5. The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client’s peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention. 6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan. 7. The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with congestive heart failure. Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food. 8. The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level. 9. The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit (ICU) via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done. 10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain on inspiration and a nonproductive cough. 11. The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client’s potassium level and assess the client’s intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily. 12. The nurse has written an outcome goal “demonstrates tolerance for increased activity” for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)g sodium diet. 3. Weigh the client daily. 4. Plan for frequent rest periods. Angina/Myocardial Infarction 13. Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs). 14. Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool, clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema. 15. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram (ECG). 3. Have the client sit down immediately. 4. Assess the client’s vital signs. 16. The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously. 17. The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriatefor the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy. 18. The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client’s chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client’s telemetry monitor. 19. The client diagnosed with a myocardial infarction is six (6) hours post–right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client’s right pedal pulse is 3+ and bounding. 20. The intensive care department nurse is assessing the client who is 12 hours post–myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client’s bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously. 21. The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client’s apical pulse is 64. 2. The client’s calcium level is elevated. 3. The client’s telemetry shows occasional PVCs. 4. The client’s blood pressure is 90/58. 22. The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move the legs. 4. Take no action concerning the UAP’s behavior. 23. The client diagnosed with a myocardial infarction asks the nurse, “Why do I have to rest and take it easy? My chest doesn’t hurt anymore.” Which statement would be the nurse’s best response? 1. “Your heart is damaged and needs about four (4) to six (6) weeks to heal.” 2. “There is necrotic myocardial tissue that puts you at risk for dysrhythmias.” 3. “Your doctor has ordered bedrest. Therefore, you must stay in the bed.” 4. “Just because your chest doesn’t hurt anymore doesn’t mean you are out of danger.” 24. The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client’s BP is 110/70 and pulse is 90. 2. The client’s groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling. Coronary Artery Disease 25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. “I should keep the tablets in the dark-colored bottle they came in.” 2. “If the tablets do not burn under my tongue, they are not effective.” 3. “I should keep the bottle with me in my pocket at all times.” 4. “If my chest pain is not gone with one tablet, I will go to the ER.” 26. The client with coronary artery disease asks the nurse, “Why do I get chest pain?” Which statement would be the most appropriate response by the nurse? 1. “Chest pain is caused by decreased oxygen to the heart muscle.” 2. “There is ischemia to the myocardium as a result of hypoxemia.” 3. “The heart muscle is unable to pump effectively to perfuse the body.” 4. “Chest pain occurs when the lungs cannot adequately oxygenate the blood.” 27. The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client’s neurovascular status. 3. Keep the client in high Fowler’s position. 4. Assess the gag reflex prior to feeding the client. 28. The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client’s potassium level is 4.5 mEq/L. 29. Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client’s radial pulse. 2. Assess the client’s serum potassium level. 3. Assess the client’s glucometer reading. 4. Assess the client’s pulse oximeter reading. 30. Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet. 31. The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. “Do you have a daily bowel movement?” 2. “Do you get yearly chest x-rays (CXRs)?” 3. “Are you sexually active?” 4. “Have you had any weight change?” 32. The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40°F. 4. Wear open-toed shoes when ambulating. 33. The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately. 34. The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct the client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor. 35. Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. “I will not eat more than six (6) eggs a week.” 2. “I should bake or grill any meats I eat.” 3. “I will drink eight (8) ounces of whole milk a day.” 4. “I should not eat any type of pork products.” 36. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain. Valvular Heart Disease 37. A client is being seen in the clinic to rule out (R/O) mitral valve stenosis. Which assessment data would be most significant? 1. The client complains of shortness of breath when walking. 2. The client has jugular vein distention and 3+ pedal edema. 3. The client complains of chest pain after eating a large meal. 4. The client’s liver is enlarged and the abdomen is edematous. 38. Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency? 1. A loud S1, S2 split, and a mitral opening snap. 2. A holosystolic murmur heard best at the cardiac apex. 3. A midsystolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the third left intercostal space. 39. The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity. 40. The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological tissue valve replacement? 1. The client must take lifetime anticoagulant therapy. 2. The client’s infections are easier to treat. 3. There is a low incidence of thromboembolism. 4. The valve has to be replaced frequently. 41. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client’s INR is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (AquaMephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding. 42. Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. 4. Pericardial friction rub. 5. Pulsus paradoxus. 43. The client is being evaluated for valvular heart disease. Which information would be most significant? 1. The client has a history of coronary artery disease. 2. There is a family history of valvular heart disease. 3. The client has a history of smoking for 10 years. 4. The client has a history of rheumatic heart disease. 44. The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the Post Anesthesia Care Unit nurse implement? 1. Assess the client’s chest tube output. 2. Monitor the client’s chest dressing. 3. Evaluate the client’s endotracheal (ET) lip line. 4. Keep the client’s affected leg straight. 45. The client with a mechanical valve replacement asks the nurse, “Why do I have to take antibiotics before getting my teeth cleaned?” Which response by the nurse is most appropriate? 1. “You are at risk of developing an infection in your heart.” 2. “Your teeth will not bleed as much if you have antibiotics.” 3. “This procedure may cause your valve to malfunction.” 4. “Antibiotics will prevent vegetative growth on your valves.” 46. The client had open-heart surgery to replace the mitral valve. Which intervention should the intensive care unit nurse implement? 1. Restrict the client’s fluids as ordered. 2. Keep the client in the supine position. 3. Maintain oxygen saturation at 90%. 4. Monitor the total parenteral nutrition. 47. Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60-year-old female with congestive heart failure. 2. A 23-year-old male with Marfan’s syndrome. 3. An 80-year-old male with atrial fibrillation. 4. A 33-year-old female with Down syndrome. 48. The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse to assign to a new graduate who just completed orientation to the medical floor? 1. The client admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) days post–myocardial infarction being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation who has an INR of five (5). Dysrhythmias and Conduction Problems 49. The telemetry nurse is unable to read the telemetry monitor at the nurse’s station. Which intervention should the telemetry nurse implement first? 1. Go to the client’s room to check the client. 2. Instruct the primary nurse to assess the client. 3. Contact the client on the client call system. 4. Request the nursing assistant to take the crash cart to the client’s room. 50. The client shows ventricular fibrillation on the telemetry at the nurse’s station. Which action should the telemetry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3. Call a STAT code. 4. Start cardiopulmonary resuscitation (CPR). 51. The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the healthcare provider to order for this client? 1. Amiodarone. 2. Atropine. 3. Digoxin. 4. Adenosine. 52. The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticipate being implemented? 1. Administer a thrombolytic medication. 2. Assess the client’s cardiovascular status. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion. 53. Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout “all clear” prior to defibrillating the client. 54. The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion. 55. The client is exhibiting ventricular tachycardia. Which intervention should the nurse implement first? 1. Administer amiodarone, an antidysrhythmic, IVP. 2. Prepare to defibrillate the client. 3. Assess the client’s apical pulse and blood pressure. 4. Start basic cardiopulmonary resuscitation. 56. The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider. 57. The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP. 58. The client who is one (1) day postoperative coronary artery bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client’s cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain. 59. The client’s telemetry reading shows a P wave before each QRS complex and the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client’s cardiac enzymes. 60. Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance. Inflammatory Cardiac Disorders 61. The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration. 62. The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub. 63. The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. “Have you had a sore throat in the last month?” 2. “Did you have rheumatic fever as a child?” 3. “Do you have a family history of carditis?” 4. “What over-the-counter (OTC) medications do you take?” 64. The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around “8.” 65. The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client’s urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer. 66. The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client’s heart and lung sounds. 67. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs moreteaching concerning the discharge teaching? 1. “I must take all the prescribed antibiotics.” 2. “I may get a vaginal yeast infection with penicillin.” 3. “I will have no problems as long as I take my medication.” 4. “My throat culture was positive for a streptococcal infection.” 68. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus (PE). 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis. 69. Which nursing diagnosis would be priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle function. 70. The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer the client to outpatient occupational therapy. 3. Maintain oxygen via nasal cannula at two (2) L/min. 4. Discuss upcoming valve replacement surgery. 71. The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client’s heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client’s cardiac rhythm. 5. Keep the client in the supine position. 72. The client with infective endocarditis is admitted to the medical department. Which health- care provider’s order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges. CONCEPTS The concepts covered in this chapter focus on the cardiac-related areas of nursing; perfusion- related problems of myocardial infarction, dysrhythmias, heart failure, and hypertension; and the interrelated concepts of the nursing process and critical thinking. The concept of nursing process is displayed throughout the questions. The concept of critical thinking is presented in any prioritizing or “first” question. 73. The nurse enters the client’s room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first? 1. Notify the health care provider. 2. Call a rapid response team (RRT). 3. Determine the telemetry monitor reading. 4. Push the Code Blue button. 74. The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client’s BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first? 1. “Do you have the money to buy your medication?” 2. “Does the medication give unwanted side effects?” 3. “Did you quit taking the medications because you don’t feel bad?” 4. “Can you tell me why you stopped taking the medication?” 75. The nurse identifies the concept of altered tissue perfusion related to a client admitted with atrial fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Monitor the client’s blood pressure and apical rate every four (4) hours. 2. Place the client on intake and output every shift. 3. Require the client to sleep with the head of the bed elevated. 4. Teach the patient to perform Buerger Allen exercises daily. 5. Determine if the client is on an antiplatelet or anticoagulant medication. 6. Assess the client’s neurological status every shift and prn. 76. The nurse identifies the concept of perfusion for a client diagnosed with congestive heart failure. Which assessment data support this concept? 1. The client has a large abdomen and a positive tympanic wave. 2. The client has paroxysmal nocturnal dyspnea. 3. The client has 2+ glucose in the urine. 4. The client has a comorbid condition of myocardial infarction. 77. The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge? 1. Carry your nitroglycerin tablets in a brown bottle. 2. Swallow a nitroglycerin tablet at the first sign of angina. 3. If one nitroglycerin tablet does not work in 10 minutes, take another. 4. Nitroglycerin tablets have a fruity odor if they are potent. 78. The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first? 1. Call a Code Blue. 2. Assess the telemetry reading. 3. Take the client’s apical pulse. 4. Have the client sit down. 79. The client’s telemetry reading is below. Which should the nurse implement? 1. Take the client’s apical pulse and blood pressure. 2. Prepare to administer amiodarone IVPB. 3. Continue to monitor. 4. Place oxygen on the client via a nasal cannula. 80. The nurse is functioning in the role of medication nurse during a code. Which should the nurse implement when administering amiodarone for ventricular tachycardia? 1. Mix the medication in 100 mL of fluid and administer rapidly. 2. Push the amiodarone directly into the nearest IV port and raise the arm. 3. Question the physician’s order because it is not ACLS recommended. 4. Administer via an IV pump based on mg/kg/min. 81. The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first? 1. Notify the health care provider (HCP). 2. Assess what the client ate at the last meal. 3. Request a STAT 12 lead electrocardiogram. 4. Administer furosemide IVP. 82. The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse question? 1. Furosemide IVP to a client with a potassium level of 3.6 mEq/L. 2. Digoxin orally to a client diagnosed with rapid atrial fibrillation. 3. Enalapril orally to a client whose BP is 86/64 and apical pulse is 65. 4. Morphine IVP to a client complaining of chest pain and who is diaphoretic. 83. The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority? 1. Sleep, rest, activity. 2. Comfort. 3. Oxygenation. 4. Perfusion. 84. The home health nurse is assigned a client diagnosed with heart failure. Which should the nurse implement? Select all that apply. 1. Request a dietary consult for a sodium-restricted diet. 2. Instruct the client to elevate the feet during the day. 3. Teach the client to weigh every morning wearing the same type of clothing. 4. Assess for edema in dependent areas of the body. 5. Encourage the client to drink at least 3,000 mL of fluid per day. 6. Have the client repeat back instructions to the nurse. 85. The telemetry monitor tech notifies the nurse of the strip shown below. Which should the nurse implement first? 1. Instruct the unlicensed assistive personnel (UAP) to check the client. 2. Go to the client’s room and assess the client personally. 3. Have the monitor tech check the client using a different lead. 4. Call for the Code Blue team and perform cardiopulmonary resuscitation. 86. The nurse is working with a group of new graduates on a medical-surgical unit. Which should the nurse explain about completing first morning rounds on clients? 1. Perform a “down and dirty” assessment on each client soon after receiving report. 2. Determine which client should have a bath and inform the unlicensed assistive personnel. 3. Give all the clients a wet wash to wash the face and a toothbrush and toothpaste. 4. Pick up any paper on the floor and get the room ready for morning physician rounds. 87. The nurse has received shift report. Which client should the nurse assess first? 1. The client diagnosed with coronary artery disease complaining of severe indigestion. 2. The client diagnosed with congestive heart failure who has 3+ pitting edema. 3. The client diagnosed with atrial fibrillation whose apical rate is 110 and irregular. 4. The client diagnosed with sinus bradycardia who is complaining of being constipated. 88. The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instruction(s) should the nurse teach the client? 1. Call the health care provider (HCP) if any chest pain happens. 2. Discuss when the client can resume sexual activity. 3. Explain the pharmacology of nitroglycerin tablets. 4. Encourage the client to sleep with the head of the bed elevated. 89. The nurse is administering morning medications. Which medication should be administered first? 1. The cardiac glycoside medication, digoxin, to a client diagnosed with heart failure and who has 2+ edema of the feet. 2. The sliding scale insulin to a client with a fasting blood glucose of 345 mg/dL who is demanding breakfast. 3. The loop diuretic, furosemide, to a client with a 24-hour intake of 986 mL and an output of 1,400 mL. 4. The ARB medication to a client whose blood pressure was reported by the unlicensed assistive personnel as 142/76. 90. The nurse identifies the concept of tissue perfusion as a client problem. Which is an antecedent of tissue perfusion? 1. The client has a history of coronary artery disease (CAD). 2. The client has a history of diabetes insipidus (DI). 3. The client has a history of chronic obstructive pulmonary disease (COPD). 4. The client has a history of multiple fractures from a motor-vehicle accident. PRACTICE QUESTIONS ANSWERS AND RATIONALES Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Analysis: Concept –Perfusion. 2. 1. Ambulating in the hall by day of discharge would be a more appropriate goal for an activity-intolerance nursing diagnosis. 2. Audible S1 and S2 sounds are normal for a heart with adequate output. An audible S3 sound might indicate left ventricular failure, which could be life threatening. 3. This is a nursing intervention, not a short-term goal, for this client. 4. A pulse oximeter reading would be a goal for impaired gas exchange, not for cardiac output. TEST-TAKING HINT: When reading a nursing diagnosis or problem, the test taker must be sure that the answer selected addresses the problem. An answer option may be appropriate care for the disease process but may not fit with the problem or etiology. Remember, when given an etiology in a nursing diagnosis, the answer will be doing something about the problem (etiology). In this question the test taker should look for an answer that addresses the ability of the heart to pump blood. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 3. 1. The client should notify the HCP of weight gain of more than two (2) or three (3) pounds in one (1) day. 2. The client should not take digoxin if the radial pulse is less than 60. 3. The client should be on a low-sodium diet to prevent water retention. 4. The color of the urine should not change to a dark color; if anything, it might become lighter and the amount will increase with diuretics. 5. Instruct the client to take the diuretic in the morning to prevent nocturia. TEST-TAKING HINT: This is an alternative-type question—in this case, “Select all that apply.” If the test taker missed this statement, it is possible to jump at the first correct answer. This is one reason that it is imperative to read all options before deciding on the correct one(s). This could be a clue to reread the question for clarity. Another hint that this is an alternative question is the number of options. The other questions have four potential answers; this one has five. Numbers in an answer option are always important. Is one (1) pound enough to indicate a problem that should be brought to the attention of the health-care provider? Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Nursing Roles. 4. 1. Sponging dry the client’s forehead would be appropriate, but it is not the first intervention. 2. Obtaining a pulse oximeter reading would be appropriate, but it is not the first intervention. 3. Taking the vital signs would be appropriate, but it is not the first intervention. 4. The nurse must first put the client in a sitting position to decrease the workload of the heart by decreasing venous return and maximizing lung expansion. Then, the nurse could take vital signs and check the pulse oximeter and then sponge the client’s forehead. TEST-TAKING HINT: In a question that asks the nurse to set priorities, all the answer options can be appropriate actions by the nurse for a given situation. The test taker should apply some guidelines or principles, such as Maslow’s hierarchy, to determine what will give the client the most immediate assistance. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 5. 1. Pitting edema changing from 3+ to 4+ indicates a worsening of the CHF. 2. The client’s ability to take the radial pulse would evaluate teaching, not medical treatment. 3. Being able to perform activities of daily living (ADLs) without shortness of breath (dyspnea) would indicate the client’s condition is improving. The client’s heart is a more effective pump and can oxygenate the body better without increasing fluid in the lungs. 4. Any jugular vein distention indicates that the right side of the heart is failing, which would not indicate effective medical treatment. TEST-TAKING HINT: When asked to determine whether treatment is effective, the test taker must know the signs and symptoms of the disease being treated. An improvement in the signs and symptoms indicates effective treatment. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 6. 1. BNP is a specific diagnostic test. Levels higher than normal indicate congestive heart failure, with the higher the number, the more severe the CHF. 2. An elevated CK-MB would indicate a myocardial infarction, not severe CHF. CK-MB is an isoenzyme. 3. A positive D-dimer would indicate a pulmonary embolus. 4. A positive ventilation/perfusion (V/Q) scan (ratio) would indicate a pulmonary embolus. TEST-TAKING HINT: This question requires the test taker to discriminate among CHF, MI, and PE. If unsure of the answer of this type of question, the test taker should eliminate any answer options that the test taker knows are wrong. For example, the test taker may not know about pulmonary embolus but might know that CK-MB data are used to monitor MI and be able to eliminate option “2” as a possibility. Then, there is a 1:3 chance of getting the correct answer. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 7. 1. If a cough develops, the client should notify the health-care provider because this is an adverse reaction and the HCP will discontinue the medication. 2. Orthostatic hypotension may occur with ACE inhibitors as a result of vasodilation. Therefore, the nurse should instruct the client to rise slowly and sit on the side of the bed until equilibrium is restored. 3. ACE inhibitors may cause the client to retain potassium; therefore, the client should not increase potassium intake. 4. An ACE inhibitor should be taken one (1) hour before meals or two (2) hours after a meal to increase absorption of the medication. TEST-TAKING HINT: If the test taker knows that an ACE inhibitor is also given for hypertension, then looking at answer options referring to hypotension would be appropriate. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Synthesis: Concept – Perfusion. 8. 1. An S3 heart sound indicates left ventricular failure, and the nurse must assess this client first because it is an emergency situation. 2. The nurse would expect a client with CHF to have sacral edema of 4+; the client with an S3 would be in a more life-threatening situation. 3. A pulse oximeter reading of greater than 93% is considered normal. 4. An elevated creatinine level is expected in a client diagnosed with chronic renal failure. TEST-TAKING HINT: Because the nurse will be assessing each client, the test taker must determine which client is a priority. A general guideline for this type of question is for the test taker to ask “Is this within normal limits?” or “Is this expected for the disease process?” If the answer is yes to either question, then the test taker can eliminate these options and look for abnormal data that would make that client a priority. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Evaluation:Concept – Perfusion. 9. 1. Allowing the UAP to take a client down to smoke is not cost effective and is not supportive of the medical treatment regimen that discourages smoking. 2. The client going to the ICU would be unstable, and the nurse should not delegate to a UAP any nursing task that involves an unstable client. 3. The nurse cannot delegate teaching. 4. The UAP can assist the x-ray technician in positioning the client for the portable x- ray. This does not require judgment. TEST-TAKING HINT: The test taker must be knowledgeable about the individual state’s Nurse Practice Act regarding what a nurse may delegate to unlicensed assistive personnel. Generally, the answer options that require higher level of knowledge or ability are reserved for licensed staff. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Nursing Roles. 10. 1. This client is stable because discharge is scheduled for the following day. Therefore, this client does not need to be assigned to the most experienced registered nurse. 2. This client is more in need of custodial nursing care than care from the most experienced registered nurse. Therefore, the charge nurse could assign a less experienced nurse to this client. 3. This client is exhibiting signs/symptoms of shock, which makes this client the most unstable. An experienced nurse should care for this client. 4. These complaints usually indicate muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration. This client does not require the care of an experienced nurse as much as does the client with signs of shock. TEST-TAKING HINT: When deciding on an answer for this type of question, the test taker should reason as to which client is stable and which has a potentially higher level of need. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 11. 1. The client with peripheral edema will experience calf tightness but would not have leg cramping, which is the result of low potassium levels. The timing of the diuretic will not change the side effect of leg cramping resulting from low potassium levels. 2. The most probable cause of the leg cramping is potassium excretion as a result of diuretic medication. Bananas and orange juice are foods that are high in potassium. 3. Weight gain is monitored in clients with CHF, and elevating the legs would decrease peripheral edema by increasing the rate of return to the central circulation, but these interventions would not help with leg cramps. 4. Ambulating frequently and performing leg-stretching exercises will not be effective in alleviating the leg cramps. TEST-TAKING HINT: The timing “at night” in this question was not important in answering the question, but it could have made the test taker jump at option “1.” Be sure to read all answer options before deciding on an answer. Answering this question correctly requires knowledge of the side effects of treatments used for CHF. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Application:Concept – Perfusion. 12. 1. Measuring the intake and output is an appropriate intervention to implement for a client with CHF, but it does not address getting the client to tolerate activity. 2. Dietary sodium is restricted in clients with CHF, but this is an intervention for decreasing fluid volume, not for increasing tolerance for activity. 3. Daily weighing monitors fluid volume status, not activity tolerance. 4. Scheduling activities and rest periods allows the client to participate in his or her own care and addresses the desired outcome. TEST-TAKING HINT: With questions involving nursing diagnoses or goals and outcomes, the test taker should realize that all activities referred to in the answer options may be appropriate for the disease but may not be specific for the desired outcome. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Perfusion. Angina/Myocardial Infarction 13. 1. CK-MB elevates in 12 to 24 hours. 2. Lactic dehydrogenase (LDH) elevates in 24 to 36 hours. 3. Troponin is the enzyme that elevates within 1 to 2 hours. 4. WBCs elevate as a result of necrotic tissue, but this is not a cardiac enzyme. TEST-TAKING HINT: The test taker should be aware of the words “cardiac enzyme,” which would eliminate option “4” as a possible answer. The word in the stem is “first.” This question requires the test taker to have knowledge of laboratory values. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 14. 1. Midepigastric pain would support a diagnosis of peptic ulcer disease; pyrosis is belching. 2. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin. 3. Intermittent claudication is leg pain secondary to decreased oxygen to the muscle, and pallor is paleness of the skin as a result of decreased blood supply. Neither is an early sign of MI. 4. Jugular vein distension (JVD) and dependent edema are signs/symptoms of congestive heart failure, not of MI. TEST-TAKING HINT: The stem already addresses chest pain; therefore, the test taker could eliminate option “1” as a possible answer. Intermittent claudication, option “3,” is the classic sign of arterial occlusive disease, and JVD is very specific to congestive heart failure. The nurse must be able to identify at least two or three signs/symptoms of disease processes. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 15. 1. The nurse must assume the chest pain is secondary to decreased oxygen to the myocardium and administer a sublingual nitroglycerin tablet, which is a coronary vasodilator, but this is not the first action. 2. An ECG should be ordered, but it is not the first intervention. 3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain. 4. Assessment is often the first nursing intervention, but when the client has chest pain and a possible MI, the nurse must first take care of the client. Taking vital signs would not help relieve chest pain. TEST-TAKING HINT: Whenever the test taker wants to select an assessment intervention, be sure to think about whether that intervention will help the client, especially if the client is experiencing pain. Do not automatically select the answer option that is assessment. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 16. 1. Morphine should be administered intravenously, not intramuscularly. 2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain. 4. The supine position will increase respiratory effort, which will increase myocardial oxygen consumption; the client should be in the semi-Fowler’s position. 5. Nitroglycerin, a coronary vasodilator, is administered sublingually, not subcutaneously. TEST-TAKING HINT: This is an alternate-type question that requires the test taker to select all options that are applicable. The test taker must identify all correct answer options to receive credit for a correct answer; no partial credit is given. Remember to read the question carefully—it is not meant to be tricky. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Analysis:Concept – Perfusion. 17. 1. The social worker addresses financial concerns or referrals after discharge, which are not indicated for this client. 2. Physical therapy addresses gait problems, lower extremity strength building, and assisting with transfer, which are not required for this client. 3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors. 4. Occupational therapy assists the client in regaining activities of daily living and covers mainly fine motor activities. TEST-TAKING HINT: The test taker must be familiar with the responsibilities of the other members of the health-care team. If the test taker had no idea which would be the most appropriate referral, the word “cardiac,” which means “heart,” should help the test taker in deciding that this is the most sensible option because the client had a myocardial infarction, a “heart attack.” Content – Medical: Integrated Nursing Process – Planning: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Collaboration. 18. 1. The nurse should medicate the client as needed, but it is not the first intervention. 2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery. 3. Turning will help decrease complications from immobility, such as pneumonia, but it will not help relieve the client’s pain. 4. The nurse, not a machine, should always take care of the client. TEST-TAKING HINT: The stem asks the nurse to identify the first intervention that should be implemented. Therefore, the test taker should apply the nursing process and select an assessment intervention. Both options “2” and “4” involve assessment, but the nurse—not a machine or diagnostic test—should always assess the client. Content – Surgical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Synthesis:Concept – Assessment. 19. 1. After PTCA, the client must keep the right leg straight for at least six (6) to eight (8) hours to prevent any arterial bleeding from the insertion site in the right femoral artery. 2. A pressure dressing is applied to the insertion site to help prevent arterial bleeding. 3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot. 4. A bounding pedal pulse indicates that adequate circulation is getting to the right foot; therefore, this would not require immediate intervention. TEST-TAKING HINT: This question requires the test taker to identify abnormal, unexpected, or life-threatening data. The nurse must know that a PTCA is performed by placing a catheter in the femoral artery and that internal or external bleeding is the most common complication. Content – Surgical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 20. 1. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction. 2. Elevating the head of the bed will not do anything to help a failing heart. 3. This is not a normal finding; it indicates heart failure. 4. Morphine is administered for chest pain, not for heart failure, which is suggested by the S3 sound. TEST-TAKING HINT: There are some situations in which the nurse must notify the healthcare provider, and the test taker should not automatically eliminate this as a possible correct answer. The test taker must decide if any of the other three options will help correct a life-threatening complication. Normal assessment concepts should help identify the correct option. The normal heart sounds are S1 and S2 (“lubb-dupp”); S3 is abnormal. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Synthesis:Concept – Perfusion. 21. 1. The apical pulse is within normal limits—60 to 100 beats per minute. 2. The serum calcium level is not monitored when calcium channel blockers are given. 3. Occasional PVCs would not warrant immediate intervention prior to administering this medication. 4. The client’s blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out. TEST-TAKING HINT: The test taker must know when to question administering medications. The test taker is trying to select an option that, if the medication is administered, would cause serious harm to the client. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Analysis: Concept – Medication. 22. 1. Leg movement is an appropriate action, and the UAP should not be told to stop encouraging it. 2. This behavior is not unsafe or dangerous and should not be reported to the charge nurse. 3. The nurse should praise and encourage UAPs to participate in the client’s care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring. 4. The nurse should praise subordinates for appropriate behavior, especially when it is helping to prevent life-threatening complications. TEST-TAKING HINT: This is a management question. The test taker must know the chain of command and when to report behavior. The test taker could eliminate options “1” and “2” with the knowledge that moving the legs is a safe activity for the client. When having to choose between options “3” and “4,” the test taker should select doing something positive, instead of taking no action. This is a management concept. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Nursing Roles. 23. 1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form. 2. The nurse should talk to the client in layperson’s terms, not medical terms. Medical terminology is a foreign language to most clients. 3. This is not answering the client’s question. The nurse should take any opportunity to teach the client. 4. This is a condescending response, and telling the client that he or she is not out of danger is not an appropriate response. TEST-TAKING HINT: When attempting to answer a client’s question, the nurse should provide factual information in simple, understandable terms. The test taker should select the answer option that provides this type of information. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Application:Concept – Nursing Roles. 24. 1. These vital signs are within normal limits and would not require any immediate intervention. 2. The groin dressing should be dry and intact. 3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention. 4. The nurse must check the neurovascular assessment, and paresthesia would warrant immediate intervention, but no numbness and tingling is a good sign. TEST-TAKING HINT: “Warrants immediate intervention” means the nurse should probably notify the health-care provider or do something independently because a complication may occur. Therefore, the test taker must select an answer option that is abnormal or unsafe. In the data listed, there are three normal findings and one abnormal finding. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. Coronary Artery Disease 25. 1. If the tablets are not kept in a dark bottle, they will lose their potency. 2. The tablets should burn or sting when put under the tongue. 3. The client should keep the tablets with him in case of chest pain. 4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911. TEST-TAKING HINT: This question is an “except” question, requiring the test taker to identify which statement indicates the client doesn’t understand the teaching. Sometimes the test taker could restate the question and think which statement indicates the client understands the teaching. Content – Medical: Integrated Nursing Process – Evaluation: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Application: Concept – Perfusion. 26. 1. This is a correct statement presented in layman’s terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain. 2. This is the explanation in medical terms that should not be used when explaining medical conditions to a client. 3. This explains congestive heart failure but does not explain why chest pain occurs. 4. Respiratory compromise occurs when the lungs cannot oxygenate the blood, such as occurs with altered level of consciousness, cyanosis, and increased respiratory rate. TEST-TAKING HINT: The nurse must select the option that best explains the facts in terms a client who does not have medical training can understand. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Application:Concept – Perfusion. 27. 1. The client’s right leg should be kept straight to prevent arterial bleeding from the femoral insertion site for the catheter used to perform the catheterization. 2. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor. 3. The head of the bed should be elevated no more than 10 degrees. The client should be kept on bedrest, flat with the affected extremity straight, to help decrease the chance of femoral artery bleeding. 4. The gag reflex is assessed if a scope is inserted down the trachea (bronchoscopy) or esophagus (endoscopy) because the throat is numbed when inserting the scope. A catheter is inserted in the femoral or brachial artery when performing a cardiac catheterization. TEST-TAKING HINT: The nurse should apply the nursing process when determining the correct answer. Therefore, either option “2” or option “4” could possibly be the correct answer. The test taker then should apply anatomy concepts—where is the left femoral artery? Neurovascular assessment is performed on extremities. Content – Surgical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Synthesis: Concept – Perfusion. 28. 1. This blood pressure is normal and the nurse would administer the medication. 2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate. 3. A headache will not affect administering the medication to the client. 4. The potassium level is within normal limits, but it is usually not monitored prior to administering a beta blocker. TEST-TAKING HINT: If the test taker does not know when to question the use of a certain medication, the test taker should evaluate the options to determine if any options include abnormal data based on normal parameters. This would make the test taker select option “2” because the normal apical pulse in an adult is 60 to 100. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Analysis: Concept – Medication. 29. 1. The nurse should always assess the apical (not radial) pulse, but the pulse is not affected by a loop diuretic. 2. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client’s potassium level, and if the client is hypokalemic, the nurse should question administering this medication. 3. The glucometer provides a glucose level, which is not affected by a loop diuretic. 4. The pulse oximeter reading evaluates peripheral oxygenation and is not affected by a loop diuretic. TEST-TAKING HINT: Knowing that diuretics increase urine output would lead the test taker to eliminate glucose level and oxygenation (options “3” and “4”). In very few instances does the nurse assess the radial pulse; the apical pulse is assessed. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level – Application: Concept – Medication. 30. 1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. 2. Walking will help increase collateral circulation. 3. Salt should be restricted in the diet of a client with hypertension, not coronary artery disease. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system. TEST-TAKING HINT: This is an alternate-type question where the test taker must select all interventions that are applicable to the situation. Coronary artery disease is a common disease, and the nurse must be knowledgeable about ways to modify risk factors. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Nursing Roles. 31. 1. Bowel movements are important, but they are not pertinent to coronary artery disease. 2. Chest x-rays are usually done for respiratory problems, not for coronary artery disease. 3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client’s being elderly should not affect the nurse’s assessment of the client’s concerns about sexual activity. 4. Weight change is not significant in a client with coronary artery disease. TEST-TAKING HINT: Remember, if the client is described with an adjective such as “elderly,” this may be the key to selecting the correct answer. The nurse must not be judgmental about the elderly, especially about issues concerning sexual activity. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 32. 1. Isometric exercises are weight lifting-type exercises. A client with CAD should perform isotonic exercises, which increase muscle tone, not isometric exercises. 2. The client should walk at least 30 minutes a day to increase collateral circulation. 3. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside. 4. The client should wear good, supportive tennis shoes when ambulating, not sandals or other open-toed shoes. TEST-TAKING HINT: The test taker should be aware of adjectives such as “isometric,” which makes option “1” incorrect, and “open-toed,” which makes option “4” incorrect. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Application:Concept – Perfusion. 33. 1. The client should take the coronary vasodilator nitroglycerin sublingually, but it is not the first intervention. 2. Stopping the activity decreases the heart’s need for oxygen and may help decrease the angina (chest pain). 3. The client should keep a diary of when angina occurs, what activity causes it, and how many nitroglycerin tablets are taken before chest pain is relieved. 4. If the chest pain (angina) is not relieved with three (3) nitroglycerin tablets, the client should call 911 or have someone take him to the emergency department. Notifying the HCP may take too long. TEST-TAKING HINT: The question is asking which action the client should take first. This implies that more than one of the answer options could be appropriate for the chest pain, but that only one is done first. The test taker should select the answer that will help the client directly and quickly—and that is stopping the activity. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Perfusion. 34. 1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity. 2. The Holter monitor should not be removed for any reason. 3. All medications should be taken as prescribed. 4. The client should perform all activity as usual while wearing the Holter monitor so the HCP can get an accurate account of heart function during a 24-hour period. TEST-TAKING HINT: In some instances, the test taker must be knowledgeable about diagnostic tests and there are no test-taking hints. The test taker might eliminate option “3” by realizing that, unless the client is NPO for a test or surgery, medications are usually taken. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Application:Concept – Perfusion. 35. 1. According to the American Heart Association, the client should not eat more than three (3) eggs a week, especially the egg yolk. 2. The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat. 3. The client should drink low-fat milk, not whole milk. 4. Pork products (bacon, sausage, ham) are high in sodium, which is prohibited in a low-salt diet, not a low-cholesterol, low-fat diet. TEST-TAKING HINT: The test taker must be knowledgeable of prescribed diets for specific disease processes. This is mainly memorizing facts. There is no test-taking hint to help eliminate any of the options. Content – Medical: Integrated Nursing Process – Evaluation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Analysis: Concept –Nutrition. 36. 1. This client is at high risk for complications related to necrotic myocardial tissue and will need extensive teaching, so this client should not be assigned to a new graduate. 2. Unstable angina means this client is at risk for life-threatening complications and should not be assigned to a new graduate. 3. A new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory. 4. Chest pain means this client could be having a myocardial infarction and should not be assigned to a new graduate. TEST-TAKING HINT: “New graduate” is the key to answering this question correctly. What type of client should be assigned to an inexperienced nurse? The test taker should not assign the new graduate a client who is unstable or at risk for a life- threatening complication. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Nursing Roles. Valvular Heart Disease 37. 1. Dyspnea on exertion (DOE) is typically the earliest manifestation of mitral valve stenosis. 2. Jugular vein distention (JVD) and 3+ pedal edema are signs/symptoms of right-sided heart failure and indicate worsening of the mitral valve stenosis. These signs would not be expected in a client with early manifestations of mitral valve stenosis. 3. Chest pain rarely occurs with mitral valve stenosis. 4. An enlarged liver and edematous abdomen are late signs of right-sided heart failure that can occur with long-term untreated mitral valve stenosis. TEST-TAKING HINT: Whenever the test taker reads “rule out,” the test taker should look for data that would not indicate a severe condition of the body system that is affected. Chest pain, JVD, and pedal edema are late signs of heart problems. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 38. 1. This would be expected with mitral valve stenosis. 2. The murmur associated with mitral valve insufficiency is loud, high pitched, rumbling, and holosystolic (occurring throughout systole) and is heard best at the cardiac apex. 3. This would be expected with mitral valve prolapse. 4. This would be expected with aortic regurgitation. TEST-TAKING HINT: This is a knowledge-based question and there is no test-taking hint to help the test taker rule out distracters. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 39. 1. Prophylactic antibiotics before invasive procedures prevent infectious endocarditis. 2. The client is undergoing anticoagulant therapy and should use a soft-bristle toothbrush to help prevent gum trauma and bleeding. 3. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) interfere with clotting and may potentiate the effects of the anticoagulant therapy, which the client with a mechanical valve will be prescribed. Therefore, the client should not take aspirin daily. 4. The client should alternate rest with activity to prevent fatigue to help decrease the workload of the heart. TEST-TAKING HINT: The stem asks the test taker to identify which behavior means the client does not understand the teaching. Therefore, the test taker should select the distracter that does not agree with the condition. There is no condition for which alternating rest with activity would not be recommended. Content – Medical: Integrated Nursing Process – Evaluation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept – Perfusion. 40. 1. An advantage of having a biological valve replacement is that no anticoagulant therapy is needed. Anticoagulant therapy is needed with a mechanical valve replacement. 2. This is an advantage of having a biological valve replacement; infections are harder to treat in clients with mechanical valve replacement. 3. This is an advantage of having a biological valve replacement; there is a high incidence of thromboembolism in clients with mechanical valve replacement. 4. Biological valves deteriorate and need to be replaced frequently; this is a disadvantage of them. Mechanical valves do not deteriorate and do not have to be replaced often. TEST-TAKING HINT: This is an “except” question. The test taker might reverse the question and ask, “Which is an advantage of a biological valve?”—which might make answering the question easier. Content – Medical: Integrated Nursing Process – Diagnosis: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Knowledge: Concept – Perfusion. 41. 1. The therapeutic range for most clients’ INR is 2 to 3, but for a client with a mechanical valve replacement it is 2 to 3.5. The medication should be given as ordered and not withheld. 2. Vitamin K is the antidote for an overdose of warfarin, but 2.7 is within the therapeutic range. 3. This laboratory result is within the therapeutic range, INR 2 to 3, and the medication does not need to be withheld. 4. There is no need for the nurse to assess for bleeding because 2.7 is within the therapeutic range. TEST-TAKING HINT: The test taker has to know the therapeutic range for the INR to be able to answer this question correctly. The test taker should keep a list of normal and therapeutic laboratory values that must be remembered. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level – Analysis: Concept – Medication. 42. 1. Paroxysmal nocturnal dyspnea is a sudden attack of respiratory distress, usually occurring at night because of the reclining position, and occurs in valvular disorders. 2. This is an abnormal condition in which a client must sit or stand to breathe comfortably and occurs in valvular disorders. 3. Coughing occurs when the client with long-term valvular disease has difficulty breathing when walking or performing any type of activity. 4. Pericardial friction rub is a sound auscultated in clients with pericarditis, not valvular heart disease. 5. Pulsus paradoxus is a marked decrease in amplitude during inspiration. It is a sign of cardiac tamponade, not valvular heart disease. TEST-TAKING HINT: The test taker should notice that options “1,” “2,” and “3” are all signs/symptoms that have something to do with the lungs. It would be a good choice to select these three as correct answers. They are similar in description. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 43. 1. An acute myocardial infarction can damage heart valves, causing tearing, ischemia, or damage to heart muscles that affects valve leaflet function, but coronary heart disease does not cause valvular heart disease. 2. Valvular heart disease does not show a genetic etiology. 3. Smoking can cause coronary artery disease, but it does not cause valvular heart disease. 4. Rheumatic heart disease is the most common cause of valvular heart disease. TEST-TAKING HINT: The test taker could rule out option “1” because of knowledge of anatomy: Coronary artery disease has to do with blood supply to heart muscle, whereas the valves are a part of the anatomy of the heart. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 44. 1. Percutaneous balloon valvuloplasty is not an open-heart surgery; therefore, the chest will not be open and the client will not have a chest tube. 2. This is not an open-heart surgery; therefore, the client will not have a chest dressing. 3. The endotracheal (ET) tube is inserted if the client is on a ventilator, and this surgery does not require putting the client on a ventilator. 4. In this invasive procedure, performed in a cardiac catheterization laboratory, the client has a catheter inserted into the femoral artery. Therefore, the client must keep the leg straight to prevent hemorrhaging at the insertion site. TEST-TAKING HINT: If the test taker knows that the word “percutaneous” means “via the skin,” then options “1” and “2” could be eliminated as possible correct answers. Content – Surgical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Application:Concept – Perfusion. 45. 1. The client is at risk for developing endocarditis and should take prophylactic antibiotics before any invasive procedure. 2. Antibiotics have nothing to do with how much the teeth bleed during a cleaning. 3. Teeth cleaning will not cause the valve to malfunction. 4. Vegetation develops on valves secondary to bacteria that cause endocarditis, but the client may not understand “vegetative growth on your valves”; therefore, this is not the most appropriate answer. TEST-TAKING HINT: The test taker should select an option that answers the client’s question in the easiest and most understandable terms, not in medical jargon. This would cause the test taker to eliminate option “4” as a possible correct answer. The test taker should know antibiotics do not affect bleeding and so can eliminate option “2.” Content – Surgical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Application:Concept – Perfusion. 46. 1. Fluid intake may be restricted to reduce the cardiac workload and pressures within the heart and pulmonary circuit. 2. The head of the bed should be elevated to help improve alveolar ventilation. 3. Oxygen saturation should be no less than 93%; 90% indicates an arterial oxygen saturation of around 60 (normal is 80 to 100). 4. Total parenteral nutrition would not be prescribed for a client with mitral valve replacement. It is ordered for clients with malnutrition, gastrointestinal disorders, or conditions in which increased calories are needed, such as burns. TEST-TAKING HINT: A client with a heart or lung problem should never have the head of the bed in a flat (supine) position; therefore, option “2” should be eliminated as a possible correct answer. The test taker must know normal values for monitoring techniques such as pulse oximeters and keep a list of normal values. Content – Surgical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Perfusion. 47. 1. Congestive heart failure does not predispose the female client to having a mitral valve prolapse. 2. Clients with Marfan’s syndrome have life-threatening cardiovascular problems, including mitral valve prolapse, progressive dilation of the aortic valve ring, and weakness of the arterial walls, and they usually do not live past the age of 40 because of dissection and rupture of the aorta. 3. Atrial fibrillation does not predispose a client to mitral valve prolapse. 4. A client with Down syndrome may have congenital heart anomalies but not mitral valve prolapse. TEST-TAKING HINT: The test taker could eliminate options “1” and “3” based on knowledge that these are commonly occurring cardiovascular problems, and the nurse should know that possible complications of these problems do not include mitral valve prolapse. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Analysis: Concept –Perfusion. 48. 1. This client requires teaching and an understanding of the preprocedure interventions for diagnostic tests; therefore, a more experienced nurse should be assigned to this client. 2. Because this client is being discharged, it would be an appropriate assignment for the new graduate. 3. Supraventricular tachycardia (SVT) is not life threatening, but the client requires intravenous medication and close monitoring and therefore should be assigned to a more experienced nurse. 4. A client with atrial fibrillation is usually taking the anticoagulant warfarin (Coumadin), and the therapeutic INR is 2 to 3. An INR of 5 is high and the client is at risk for bleeding. TEST-TAKING HINT: The test taker must realize that a new graduate must be assigned the least critical client. Remember, teaching is a primary responsibility of the nurse; physical care is not always the criterion that should be used when making client assignments. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Nursing Roles. Dysrhythmias and Conduction Problems 49. 1. The telemetry nurse should not leave the monitors unattended at any time. 2. The telemetry nurse must have someone go assess the client, but this is not the first intervention. 3. If the client answers the call light and is not experiencing chest pain, then there is probably a monitor artifact, which is not a life-threatening emergency. After talking with the client, send a nurse to the room to check the monitor. 4. The crash cart should be taken to a room when the client is experiencing a code. TEST-TAKING HINT: When the test taker sees the word “first,” the test taker must realize that more than one answer option may be a possible intervention but that only one should be implemented first. The test taker should try to determine which intervention directly affects the client. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 50. 1. There are many interventions that should be implemented prior to administering medication. 2. The treatment of choice for ventricular fibrillation is defibrillation, but it is not the first action. 3. The nurse must call a code that activates the crash cart being brought to the room and a team of health-care providers that will care for the client according to an established protocol. 4. The first person at the bedside should start cardiopulmonary resuscitation (CPR), but the telemetry nurse should call a code so that all necessary equipment and personnel are at the bedside. TEST-TAKING HINT: The test taker must realize that ventricular fibrillation is life threatening and immediate action must be implemented. Remember, when the question asks “first,” all options could be appropriate interventions but only one should be implemented first. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 51. 1. Amiodarone suppresses ventricular ectopy and is the drug of choice for ventricular dysrhythmias. 2. Atropine decreases vagal stimulation and is the drug of choice for asystole. 3. Digoxin slows heart rate and increases cardiac contractility and is the drug of choice for atrial fibrillation. 4. Adenosine is the drug of choice for supraventricular tachycardia. TEST-TAKING HINT: This is a knowledge-based question, and the test taker must know the answer. The nurse must know what medications treat specific dysrhythmias. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Synthesis: Concept – Medication. 52. 1. A thrombolytic medication is administered for a client experiencing a myocardial infarction. 2. Assessment is an independent nursing action, not a collaborative treatment. 3. The client is symptomatic and will require a pacemaker. 4. Synchronized cardioversion is used for ventricular tachycardia with a pulse or atrial fibrillation. TEST-TAKING HINT: The key to answering this question is the adjective “collaborative,” which means the treatment requires obtaining a health-care provider’s order or working with another member of the health-care team. This would cause the test taker to eliminate option “2” as a possible correct answer. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Synthesis: Concept – Perfusion. 53. 1. The adult client should be defibrillated at 360 joules. 2. The oxygen source should be removed to prevent any type of spark during defibrillation. 3. The nurse should use defibrillator pads or defibrillator gel to prevent any type of skin burns while defibrillating the client. 4. If any member of the health-care team is touching the client or the bed during defibrillation, that person could possibly be shocked. Therefore, the nurse should shout “all clear.” TEST-TAKING HINT: The test taker should always consider the safety of the client and the health-care team. Options “2” and “3” put the client at risk for injury during defibrillation. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Perfusion. 54. 1. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use a soft-bristle toothbrush. 2. The client will need a regularly scheduled INR to determine the therapeutic level for the anticoagulant warfarin (Coumadin); PTT levels are monitored for heparin. 3. A client with symptomatic sinus bradycardia, not a client with atrial fibrillation, may need a pacemaker. 4. Synchronized cardioversion may be prescribed for new-onset atrial fibrillation but not for chronic atrial fibrillation. TEST TAKING HINT: In order to choose the correct answer for this question the test taker must recognize the disease process, then know what complications are possible, and finally the test-taker must know how the client can possibly be treated so that the complication does not occur. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Nursing Roles. 55. 1. Amiodarone is the drug of choice for ventricular tachycardia, but it is not the first intervention. 2. Defibrillation may be needed, but it is not the first intervention. 3. The nurse must assess the apical pulse and blood pressure to determine if the client is in cardiac arrest and then treat as ventricular fibrillation. If the client’s heart is beating, the nurse would then administer lidocaine. 4. CPR is only performed on a client who is not breathing and does not have a pulse. The nurse must establish if this is occurring first prior to taking any other action. TEST-TAKING HINT: When the stem asks the test taker to select the first intervention, all answer options could be plausible interventions, but only one is implemented first. The test taker should use the nursing process to answer the question and select the intervention that addresses assessment, which is the first step in the nursing process. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 56. 1. A pacemaker will have to be inserted, but it is not the first intervention. 2. Atropine will decrease vagal stimulation and increase the heart rate. Therefore, it is the first intervention. 3. A STAT ECG may be done, but the telemetry reading shows complete heart block, which is a life-threatening dysrhythmia and must be treated. 4. The HCP will need to be notified but not prior to administering a medication. The test taker must assume the nurse has the order to administer medication. Many telemetry departments have standing protocols. TEST-TAKING HINT: The test taker must select the intervention that should be implemented first and will directly affect the dysrhythmia. Medication is the first intervention, and then pacemaker insertion. The test taker should not eliminate an option because the test taker thinks there is not an order by a health-care provider. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 57. 1. Ventricular fibrillation indicates the client does not have a heartbeat. Therefore, CPR should be instituted. 2. Adenosine, an antidysrhythmic, is the drug of choice for supraventricular tachycardia, not for ventricular fibrillation. 3. Defibrillation is the treatment of choice for ventricular fibrillation. 4. The crash cart has the defibrillator and is used when performing advanced cardiopulmonary resuscitation. 5. Amiodarone is an antidysrhythmic that is used in ventricular dysrhythmias. TEST-TAKING HINT: This is an alternate-type question that requires the test taker to possibly select more than one option. To receive credit, the test taker must select all correct options; partial credit is not given for this type of question. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Analysis:Concept – Perfusion. 58. 1. The telemetry reading is accurate, and there is no need for the nurse to assess the client’s heart rate. 2. There is no reason to notify the surgeon for a client exhibiting sinus tachycardia. 3. Synchronized cardioversion is prescribed for clients in acute atrial fibrillation or ventricular fibrillation with a pulse. 4. Sinus tachycardia means the sinoatrial node is the pacemaker, but the rate is greater than 100 because of pain, anxiety, or fever. The nurse must determine the cause and treat appropriately. There is no specific medication for sinus tachycardia. TEST-TAKING HINT: The test taker must use the nursing process to determine the correct option and select an option that addresses assessment, the first step of the nursing process. Because both option “1” and option “4” address assessment, the test taker must determine which option is more appropriate. How will taking the apical pulse help treat sinus tachycardia? Determining the cause for sinus tachycardia is the most appropriate intervention. Content – Surgical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Perfusion. 59. 1. The P wave represents atrial contraction, and the QRS complex represents ventricular contraction—a normal telemetry reading. A rate between 60 and 100 indicates normal sinus rhythm. Therefore, the nurse should document this as normal sinus rhythm and not take any action. 2. A 12-lead ECG should be requested for chest pain or abnormal dysrhythmias. 3. Digoxin is used to treat atrial fibrillation. 4. Cardiac enzymes are monitored to determine if the client has had a myocardial infarction. Nothing in the stem indicates the client has had an MI. TEST-TAKING HINT: The test taker must know normal sinus rhythm, and there are no test-taking hints to help eliminate incorrect options. The test taker should not automatically select assessment as the correct answer, but if the test taker had no idea of the answer, remember assessment of laboratory data is not the same as assessing the client. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Perfusion. 60. 1. Not every cardiac dysrhythmia causes alteration in comfort; angina is caused by decreased oxygen to the myocardium. 2. Any abnormal electrical activity of the heart causes decreased cardiac output. 3. Impaired gas exchange is the result of pulmonary complications, not cardiac dysrhythmias. 4. Not all clients with cardiac dysrhythmias have activity intolerance. TEST-TAKING HINT: Option “2” has the word “cardiac,” which refers to the heart. Therefore, even if the test taker had no idea what the correct answer was, this would be an appropriate option. The test taker should use medical terminology to help identify the correct option. Content – Medical: Integrated Nursing Process – Diagnosis: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Analysis: Concept – Perfusion. Inflammatory Cardiac Disorders 61. 1. Pulsus paradoxus is the hallmark of cardiac tamponade; a paradoxical pulse is markedly decreased in amplitude during inspiration. 2. Fatigue and arthralgias are nonspecific signs/symptoms that usually occur with myocarditis. 3. Petechiae on the trunk, conjunctiva, and mucous membranes and hemorrhagic streaks under the fingernails or toenails occur with endocarditis. 4. Chest pain is the most common symptom of pericarditis, usually has an abrupt onset, and is aggravated by respiratory movements (deep inspiration, coughing), changes in body position, and swallowing. TEST-TAKING HINT: The test taker who has no idea what the answer is should apply the test-taking strategy of asking which body system is affected. In this case, it is the cardiac system, specifically the outside of the heart. The test taker should select the option that has something to do with the heart, which is either option “1” or option “4.” Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 62. 1. Acute pericardial effusion interferes with normal cardiac filling and pumping, causing venous congestion and decreased cardiac output. Muffled heart sounds, indicative of acute pericarditis, must be reported to the health-care provider. 2. Distended, not nondistended, jugular veins would warrant immediate intervention. 3. Decreasing quality of peripheral pulses, not bounding peripheral pulses, would warrant immediate intervention. 4. A pericardial friction rub is a classic symptom of acute pericarditis, but it would not warrant immediate intervention. TEST-TAKING HINT: This is a priority setting question, the test taker should determine if the data provided is abnormal or expected for the the disease process. If so, then the test taker can consider the option as being the correct answer. If the data is within normal limits aor expected for the disease process then the option is not a priority. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 63. 1. A sore throat in the last month would not support the diagnosis of carditis. 2. Rheumatic fever, a systemic inflammatory disease caused by an abnormal immune response to pharyngeal infection by group A beta-hemolytic streptococci, causes carditis in about 50% of people who develop it. 3. Carditis is not a genetic or congenital disease process. 4. This is an appropriate question to ask any client, but OTC medications do not cause carditis. TEST-TAKING HINT: This is a knowledge-based question, but the test taker could eliminate option “4,” realizing this is a question to ask any client, and the stem asks which question will support the diagnosis of carditis. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 64. 1. Steroids, such as prednisone, not NSAIDs, must be tapered off to prevent adrenal insufficiency. 2. NSAIDs will not make clients drowsy. 3. NSAIDs must be taken with food, milk, or antacids to help decrease gastric distress. NSAIDs reduce fever, inflammation, and pericardial pain. 4. NSAIDs should be taken regularly around the clock to help decrease inflammation, which, in turn, will decrease pain. TEST-TAKING HINT: The test taker must remember NSAIDs and steroids cause gastric distress to the point of causing peptic ulcer disease. These medications are administered for a variety of conditions and diseases. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Synthesis: Concept – Medication. 65. 1. Oxygen may be needed, but it is not the first intervention. 2. This would be appropriate to determine if the urine output is at least 30 mL/hr, but it is not the first intervention. 3. The nurse must assess the client to determine if the pain is expected secondary to pericarditis or if the pain is indicative of a complication that requires intervention from the health-care provider. 4. Using the incentive spirometer will increase the client’s alveolar ventilation and help prevent atelectasis, but it is not the first intervention. TEST-TAKING HINT: The test taker must apply the nursing process when determining the correct answer and select the option that addresses the first step in the nursing process—assessment. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level – Synthesis:Concept – Perfusion. 66. 1. A pericardiocentesis removes fluid from the pericardial sac and is the emergency treatment for cardiac tamponade. 2. Cardiac enzymes may be slightly elevated because of the inflammatory process, but evaluation of these would not be ordered to treat or evaluate cardiac tamponade. 3. A 12-lead ECG would not help treat the medical emergency of cardiac tamponade. 4. Assessment by the nurse is not collaborative; it is an independent nursing action. TEST-TAKING HINT: “Collaborative” means another member of the health-care team must order or participate in the intervention. Therefore, option “4” could be eliminated as a possible correct answer. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Synthesis: Concept – Perfusion. 67. 1. The full course of antibiotics must be taken to help ensure complete destruction of streptococcal infection. 2. Antibiotics kill bacteria but also destroy normal body flora in the vagina, bowel, and mouth, leading to a superinfection. 3. Even with antibiotic treatment for rheumatic fever, the client may experience bacterial endocarditis in later years and should know this may occur. 4. A throat culture is taken to diagnose group A beta-hemolytic streptococcus and is positive in 25% to 40% of clients with acute rheumatic fever. TEST-TAKING HINT: The question is asking the test taker to identify which statement indicates the client does not understand the teaching; this is an “except” question. The test taker can ask which statement indicates the teaching is effective and choose the one option that is not appropriate. Content – Medical: Integrated Nursing Process – Evaluation: Client Needs – Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level –Synthesis: Concept – Medication. 68. 1. Pulmonary embolus would occur with an embolization of vegetative lesions from the tricuspid valve on the right side of the heart. 2. Bacteria enter the bloodstream from invasive procedures, and sterile platelet-fibrin vegetation forms on heart valves. The mitral valve is on the left side of the heart and, if the vegetation breaks off, it will go through the left ventricle into the systemic circulation and may lodge in the brain, kidneys, or peripheral tissues. 3. Coughing up blood (hemoptysis) occurs when the vegetation breaks off the tricuspid valve in the right side of the heart and enters the pulmonary artery. 4. Deep vein thrombosis is a complication of immobility, not of a vegetative embolus from the left side of the heart. TEST-TAKING HINT: If the test taker does not know the answer, knowledge of anatomy may help determine the answer. The mitral valve is on the left side of the heart and any emboli would not enter the lung first, thereby eliminating options “1” and “3” as possible correct answers. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Reduction of Risk Potential: Cognitive Level – Analysis: Concept – Perfusion. 69. 1. Anxiety is a psychosocial nursing diagnosis, which is not a priority over a physiological nursing diagnosis. 2. Antibiotic therapy does not result in injury to the client. 3. Myocarditis does not result in valve damage (endocarditis does), and there would be decreased, not increased, cardiac output. 4. Activity intolerance is priority for the client with myocarditis, an inflammation of the heart muscle. Nursing care is aimed at decreasing myocardial work and maintaining cardiac output. TEST-TAKING HINT: If the test taker has no idea which is the correct answer, then “myo,” which refers to muscle, and “card,” which refers to the heart, should lead the test taker to the only option which has both muscle and heart in it, option “4.” Content – Medical: Integrated Nursing Process – Diagnosis: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Analysis: Concept –Perfusion. 70. 1. Uninterrupted rest and sleep help decrease the workload of the heart and help ensure the restoration of physical and emotional health. 2. Occupational therapy addresses activities of daily living. The client should be referred to physical therapy to develop a realistic and progressive plan of activity. 3. The client with pericarditis is not usually prescribed oxygen, and 2 L/min is a low dose of oxygen that is prescribed for a client with chronic obstructive pulmonary disease (COPD). 4. Endocarditis, not pericarditis, may lead to surgery for valve replacement. TEST-TAKING HINT: A concept that the test taker must remember with any client being discharged from the hospital should be to alternate rest with activity to avoid problems associated with immobility. If the test taker does not know the answer to a question, using basic concepts is the best option. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Nursing Roles. 71. 1. The nurse should monitor the vital signs for any client who has just undergone surgery. 2. A pericardiocentesis involves entering the pericardial sac. Assessing heart and lung sounds allows assessment for cardiac failure. 3. The pericardial fluid is documented as output. 4. Evaluating the client’s cardiac rhythm allows the nurse to assess for cardiac failure, which is a complication of pericardiocentesis. 5. The client should be in the semi-Fowler’s position, not in a flat position, which increases the workload of the heart. TEST-TAKING HINT: This is an alternate-type question that requires the test taker to select possibly more than one option as a correct answer. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Safe Effective Care Environment, Management of Care: Cognitive Level –Application: Concept – Perfusion. 72. 1. The nurse must obtain blood cultures prior to administering antibiotics. 2. Blood cultures must be done before administering antibiotics so that an adequate number of organisms can be obtained to culture and identify. 3. An echocardiogram allows visualization of vegetations and evaluation of valve function. However, antibiotic therapy is a priority before diagnostic tests, and blood cultures must be obtained before administering medication. 4. Bedrest should be implemented, but the first intervention should be obtaining blood cultures so that antibiotic therapy can be started as soon as possible. TEST-TAKING HINT: The test taker must identify the first of the HCP’s orders to be implemented. “Infective” should indicate that this is an infection, which requires antibiotics, but the nurse should always assess for allergies and obtain cultures prior to administering any antibiotic. CONCEPTS 73. 1. The HCP will be notified but the first action is to call for the Code Blue team and initiate CPR. 2. A Rapid Response Team is called to prevent an arrest situation from occurring. This client is in an arrest situation. 3. The client has clinical signs of death; CPR must be initiated and the code team notified. 4. The first action is to immediately notify the code team and initiate CPR per protocol. TEST-TAKING HINT: The test taker should remember “If in stress do not assess.” The nurse has enough information given in the stem of the question to initiate an action. The question asks for a first; all of the options may be implemented but only one is first. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis:Concept – Perfusion. 74. 1. Although this might be the cause of noncompliance, actual side effects of antihypertensive medications may be more likely. Evidence indicates that the side effect of erectile dysfunction is a major reason of noncompliance for males. 2. This is a mild way of introducing the subject of side effects to a client not wishing to admit the medication causes unwanted effects. It opens the door to more probing assessment questions. The nurse should bring up the subject in order to allow the client to be forthcoming with the issues of why he is not taking his medication. 3. This would be the second question to ask if the client denies any problems with side effects. 4. Although in this case the nurse can ask “why” because it is an interview question and not therapeutic conversation being requested in the stem, a more direct question will open the conversation up better. TEST-TAKING HINT: To answer this question the test taker must remember that all medications have potential side effects. Antihypertensive medications can cause erectile dysfunction in males, frequently resulting in noncompliance with the medication regimen. The issue is a psychological as well as a physiological one. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Pharmacologic Integrity: Cognitive Level – Analysis: Concept – Perfusion/Medication. 75. 1. The client should be monitored for any cardiovascular changes. 2. The client should be monitored for the development of heart failure as a result of increased strain on the heart from the atria not functioning as they should. 3. There is no evidence that the client requires to sleep in the orthopneic position. 4. Buerger Allen exercises are useful for clients who have peripheral artery disease but do not have an effect on atrial fibrillation. 5. Clients who have been diagnosed with atrial fibrillation are at risk for developing emboli from the stasis of blood in the atria. If an emboli breaks loose from the lining of the atria then it can travel to the lungs (right) or to the brain (left). 6. Clients who have been diagnosed with atrial fibrillation are at risk for developing emboli from the stasis of blood in the atria. If an emboli breaks loose from the lining of the atria then it can travel to the lungs (right) or to the brain (left). TEST-TAKING HINT: To answer “Select all that apply” questions the test taker should look at each option independently of the others. Each option becomes a true/false question. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Pharmacologic Integrity: Cognitive Level – Analysis: Concept –Perfusion/Medication. 76. 1. This indicates ascites, which can happen in heart failure but does not necessarily do so; it can also be liver failure or another issue. 2. Dyspnea occurring at night when the client is in a recumbent position indicates that the cardiac muscle is not able to compensate for extra fluid returning to the heart during sleep. 3. This could indicate diabetes but not heart failure. 4. The client is at risk for heart failure as a result of the MI, but it does not happen with all MI clients and does not support the diagnosis. TEST-TAKING HINT: The test taker should read the stem of the question carefully. It is asking for assessment data to support the client is in heart failure. Three of the answer options give assessment data; therefore, option “4” can be eliminated. Only one of the other three gives an option that only occurs with heart failure. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept – Perfusion. 77. 1. Nitroglycerin tablets are dispensed in small brown bottles to preserve the potency. The client should not change the tablets to another container. 2. The tablets are placed under the tongue to dissolve and thereby work more rapidly. 3. The client is taught to take one (1) tablet every 5 minutes and if the angina is not relieved to call 911. 4. The tablets do not have a fruity odor; they sting when placed under the tongue if they are potent. TEST-TAKING HINT: The test taker should be knowledgeable of common medications and what to teach the client. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis:Concept – Perfusion. 78. 1. The client has not arrested. The nurse might call the rapid response team (RRT) but not a code blue. 2. The client is in distress; the nurse should implement a procedure that will alleviate the distress. 3. The client is in distress; the nurse should implement a procedure that will alleviate the distress. 4. The client began to have a problem during physical exertion. Stopping the exertion should be the first action taken by the nurse. TEST-TAKING HINT: The test taker should remember “If in stress do not assess.” The nurse has enough information given in the stem of the question to initiate an action. The question asks for a first. All of the options may be implemented but only one is first. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis:Concept – Perfusion. 79. 1. This strip indicates normal sinus rhythm; there is no need for further action based on the strip. 2. This strip indicates normal sinus rhythm; there is no need for further action based on the strip. 3. This strip indicates normal sinus rhythm; there is no need for further action based on the strip. The nurse should continue to monitor the client. 4. This strip indicates normal sinus rhythm; there is no need for further action based on the strip. TEST-TAKING HINT: The test taker should recognize normal values and results in order to recognize abnormals. A normal result can rule out an answer in a “which do you assess first” question; an abnormal value automatically elevates the need to see that client before another one. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis:Concept – Perfusion. 80. 1. Amiodarone is administered during a code rapidly after being mixed in 100 mL of fluid. 2. Amiodarone is not pushed; lidocaine is administered by this method. Amiodarone is replacing the use of lidocaine during a code because of evidence-based practice. 3. Amiodarone is ACLS recommended. 4. Dopamine is administered via mg/kg/min. The time to calculate this kind of dosage is not taken until after the code is concluded and the client is placed on a vasopressor medication such as dopamine. TEST-TAKING HINT: The test taker should be knowledgeable of common medications and basic rules of administration. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Pharmacological Adaptation: Cognitive Level – Synthesis: Concept –Perfusion/Medication. 81. 1. “Has developed” indicates a new issue; the nurse should notify the HCP of the assessment findings, which indicate that the client has developed heart failure. 2. What the client ate has no bearing on the new development of the clinical manifestations of heart failure. 3. A 12-lead ECG will not treat heart failure. 4. A diuretic may need to be administered but notifying the HCP is first. TEST-TAKING HINT: The test taker should read every word in the stem of the question; “has developed” indicates a newly occurring situation for the client. The nurse must notify the HCP when new issues occur in order to intervene before a failure to rescue issue occurs. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis:Concept – Perfusion. 82. 1. The potassium level is within normal range; this medication would not be questioned. 2. Digoxin is given to clients with rapid atrial fibrillation to slow the heart rate; this medication would not be questioned. 3. Enalapril, an ACE inhibitor, will lower the blood pressure even more. The nurse should hold the medication and notify the HCP that the medication is being held. 4. This would be the first medication to be administered because it indicates a potential cardiac muscle perfusion issue. TEST-TAKING HINT: The test taker should recognize normal values and results in order to recognize abnormals. A normal result can rule out an answer in “Which do you assess first?” or “Which would the nurse question?” An abnormal value indicates a need for some action on the part of the nurse. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Pharmacological Integrity: Cognitive Level – Synthesis: Concept –Perfusion/Medication. 83. 1. Activity intolerance is a result of lack of perfusion of the cardiac muscle, but the priority is to get the muscle perfused. 2. Pain does not kill anyone; the reason behind the pain could. In the case of chest pain the cardiac muscle is not being perfused, which causes the pain. 3. The problem is not having enough oxygen available to the body but that the oxygen is not being perfused to the cardiac muscle. 4. The cardiac muscle is not perfused when there is a narrowing of the arteries caused by CAD or when an embolus or a thrombus occludes the artery. Adequate perfusion will supply oxygen to the cardiac muscle, allow for increased activity, and decrease pain. TEST-TAKING HINT: The test taker should remember basic pathophysiology to answer this priority question. The other three interrelated concepts are based on the issue of tissue perfusion. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Perfusion. 84. 1. A dietitian can assist the nurse in explaining the sodium restrictions to the client as well as hidden sources of sodium. 2. This will help the client’s body to return excess fluid to the heart for removal from the body by the kidneys. 3. The client should weigh himself/herself every morning in the same type of clothing (gown, underwear, jeans, etc.) and report a weight gain of 3 pounds in a week to the HCP. 4. The nurse should not assess for edema in the feet and lower legs, but if the client is in bed the lowest part of the body may be in the sacral area. Whichever area is dependent is where the nurse should look for edema. 5. The client should drink enough fluids to maintain body function, but 3,000 mL is excessive. 6. Whenever the nurse is instructing a client, the nurse should determine if the client heard and understood the instructions. Having the client repeat the instructions is one way of determining “hearing.” Having the client return demonstrate is a method of determining understanding. TEST-TAKING HINT: The new NCLEX-RN test plan report states that “Select all that apply” questions may have five (5) to six (6) options, and one option must be correct but all may be correct. In order to answer a “Select all that apply” question each option is considered separately as a true/false question. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Perfusion. 85. 1. This could be nothing serious (artifact) but from the appearance of the strip, the nurse cannot tell if the client is in an arrest situation; the nurse must personally assess the situation. The nurse cannot delegate an unstable client. 2. The nurse must determine the situation personally; this could be artifact or ventricular fibrillation. 3. This could be nothing serious (artifact) but from the appearance of the strip, the nurse cannot tell if the client is in an arrest situation; the nurse must personally assess the situation. Telemetry monitoring is accomplished using lead II; the monitor tech does not have the ability to change the lead placement. 4. The nurse must assess the client prior to making a decision as to whether to notify the code team or not. TEST-TAKING HINT: The rules for delegation are the nurse cannot delegate an unstable client, teaching, assessment, evaluation, or medication administration to a UAP. This would eliminate option “1.” Calling a code without assessing the client would eliminate option “4.” Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis:Concept – Perfusion/Collaboration. 86. 1. “Down and dirty” rounds include assessing each client for the main focus of the client’s admission or any new issue that is reported from the shift report and assessing all lines and tubes going into or coming out of the client. Once this is done the nurse knows then that the client is stable and a full head-to-toe assessment can be done at a later time. 2. The UAP will determine when and how to accomplish the job; the nurse may assist the UAP by informing the UAP of situations which may impact the timing of the baths, but this is not the purpose of morning rounds. 3. This is the UAP’s job. 4. This is not the purpose of morning rounds. TEST-TAKING HINT: Option “3” has the word “all,” which could eliminate it from consideration because rarely does an “all” apply. Options “2” and “3” are doing the UAP’s job and option “4” is the housekeeping’s job. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept – Perfusion/Collaboration. 87. 1. A complaint of indigestion could be cardiac chest pain. The nurse should assess this client because of the diagnosis of CAD and the word “severe” in the option. 2. Edema is expected for the client diagnosed with heart failure, and it is not life threatening. 3. An irregular heart rate is not life threatening, and 110 is abnormal but also not life threatening. 4. Constipation is not life threatening albeit uncomfortable. TEST-TAKING HINT: A first makes the test taker determine which client has the greatest need. Expected and not life-threatening issues do not require being a priority. Content – Medical: Integrated Nursing Process – Assessment: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept – Perfusion. 88. 1. The word “any” makes this a wrong option. The nurse should teach the client what to do if chest pain occurs. Take one nitroglycerin tablet every 5 minutes times three (3), and if not relieved call 911. 2. The nurse should make sure the client is aware of when sexual activity can be safely resumed. 3. The client needs to know how to take nitroglycerin but not the pharmacology of how the medication works. 4. The client can sleep in any position of comfort. TEST-TAKING HINT: The test taker should recognize certain words such as “any,” “all,” “never,” or “always.” These absolutes will determine if an option is incorrect or correct. Content – Medical: Integrated Nursing Process – Planning: Client Needs – Physiological Integrity, Physiological Adaptation: Cognitive Level – Synthesis: Concept –Perfusion. 89. 1. Digoxin is a routine medication that will be administered at 0900 in most hospitals. 2. The client intends on eating breakfast and this is a scheduled medication for before meals. 3. This client is showing that the diuretic is doing what it should do. This medication will be given at 0900. 4. This is a slightly abnormal blood pressure but is in acceptable range for someone prescribed an ARB, angiotensin receptor blocker. The medication can be administered at 0900. TEST-TAKING HINT: The test taker should be knowledgeable of common medications and the basic rules of administration. Content – Medical: Integrated Nursing Process – Implementation: Client Needs – Pharmacological Adaptation: Cognitive Level – Synthesis: Concept –Perfusion/Medication. 90. 1. CAD narrows the arteries of the heart, causing the tissues not to be perfused, especially when an embolus or a thrombus occurs. 2. DI is a disease of the pituitary gland or the kidneys; it is not a perfusion issue. 3. COPD is an oxygenation issue, not a perfusion one. 4. Multiple fractures do not cause perfusion issues unless an interrelated issue occurs. TEST-TAKING HINT: The test taker should remember basic pathophysiology and the resulting problems associated with different pathology. [Show More]

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