NUR 257 EXAM 2 FINAL
EXAM QUESTIONS WITH VERIFIED AND
DETAILED ANSWERS LATEST UPDATE
GRADED A+ TESTED AND APPROVED
The nurse is educating a client about the care related to a new diagnosis of
mitral valve prolapse. What statement made by the client demonstrates
understanding of the teaching?
"I will take antibiotics before getting my teeth cleaned."
"I can get my tongue pierced at a store in the shopping mall."
"I will avoid caffeine, alcohol, and smoking."
"I can get a tattoo at a local parlor." - ANSWER>>"I will avoid caffeine,
alcohol, and smoking."
A nurse is caring for a client with aortic stenosis whose compensatory
mechanisms of the heart have begun to fail. The nurse will monitor the
client carefully for which initial symptoms?
Dizziness, nausea, diarrhea
Exertional dyspnea, orthopnea, pulmonary edema
Syncope, fever, vomiting
Nausea, vomiting, exertional fatigue - ANSWER>>Exertional dyspnea,
orthopnea, pulmonary edema
The nurse is assessing a client admitted with infective endocarditis. Which
manifestation would the nurse expect to find?
Bruising on the palms of the hands and soles of the feet
Raised red rash on the trunk and face
Involuntary muscle movements of the extremities
Small painful lesions on the pads of the fingers and toes -
ANSWER>>Small painful lesions on the pads of the fingers and toes
During assessment of a client admitted for cardiomyopathy, the nurse notes
Page 1 of 39
,the following symptoms: dyspnea on exertion, fatigue, fluid retention, and
nausea. The initial appropriate nursing diagnosis is which of the following?
Ineffective airway clearance
Disturbed sensory perception
Decreased cardiac output
Autonomic dysreflexia - ANSWER>>Decreased cardiac output
A nurse and a nursing student are performing a physical assessment of a
client with pericarditis. The client has an audible pericardial friction rub on
auscultation. When leaving the room, the student asks the nurse what
causes the sound. The nurse's best response is which of the following?
"The layers of the heart become loose from each other and rub together
with each heart beat."
"The lung surfaces lose their lubrication and rub against the myocardium
with each heart beat."
"The great vessels rub against the pericardium with each heart beat." "The
pericardial surfaces lose their lubricating fluid because of inflammation and
rub against each other." - ANSWER>>"The pericardial surfaces lose their
lubricating fluid because of inflammation and rub against each other."
The nurse determines that a patient has a characteristic symptom of
pericarditis. What symptom does the nurse recognize as significant for this
diagnosis?
Dyspnea
Fatigue lasting more than 1 month
Uncontrolled restlessness
Constant chest pain - ANSWER>>Constant chest pain
A patient is being seen in a clinic to rule out mitral valve stenosis. Which
assessment data would be most significant?
The patient's has an enlarged liver and edematous abdomen.
The patient reports chest pain after eating a large meal.
The patient has jugular vein distention and 3+ pedal edema.
The patient reports shortness of breath when walking. - ANSWER>>The
patient reports shortness of breath when walking.
Page 2 of 39
,A nurse is teaching a client about valve replacement surgery. Which
statement by the client indicates an understanding of the benefit of an
autograft replacement valve?
"The valve is mechanical, and it will not deteriorate or need replacing." "The
valve is made from a pig tissue, and I will not need to take any
bloodthinning drugs when I am discharged."
"The valve is from a tissue donor, and I will not need to take any
bloodthinning drugs when I am discharged."
"The valve is made from my own heart valve, and I will not need to take any
blood-thinning drugs when I am discharged." - ANSWER>>"The valve is
made from my own heart valve, and I will not need to take any blood-
thinning drugs when I am discharged."
A patient is undergoing a pericardiocentesis. Following withdrawal of
pericardial fluid, which assessment by the nurse indicates that cardiac
tamponade has been relieved?
Increase in CVP
Absence of cough
Decrease in blood pressure
Decrease in central venous pressure (CVP) - ANSWER>>Decrease in
central venous pressure (CVP)
A client who was admitted to the hospital with a diagnosis of
thrombophlebitis 1 day ago suddenly reports chest pain and shortness of
breath and is visibly anxious. The nurse immediately assesses the client for
other signs and symptoms of pulmonary embolism. myocardial infarction.
pneumonia. pulmonary edema. - ANSWER>>pulmonary embolism.
A client with a confirmed DVT is being discharged from the ED. Which
client statement indicates that the client has received proper nursing
instruction and understands how to manage this condition? "I should try
not to drink too much during the daytime."
"I should lie on my side with my knees bent when sleeping."
"I need to ice my leg every 2 hours for about 20 minutes."
"I need to do my leg exercises five times or more every hour." -
ANSWER>>"I need to do my leg exercises five times or more every hour."
Page 3 of 39
, A nurse is caring for a client who had an aortic balloon valvuloplasty. The
nurse should inspect the surgical insertion site closely for which
complication(s)?
Bleeding and infection
Bleeding and wound dehiscence
Thrombosis and infection
Evisceration - ANSWER>>Bleeding and infection
A client who recently had a myocardial infarction develops pericarditis and
complains of chest pain rated 6 (on a scale of 0-10) with deep breathing.
Which ordered pro re nata medications is most appropriate for the nurse to
administer?
Morphine sulfate 6 mg IVP every 2-4 hours
Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours
Acetaminophen 650 mg PO every 4 hours
Ibuprofen 800 mg PO every 8 hours - ANSWER>>Ibuprofen 800 mg PO
every 8 hours
The nurse instructs a client recovering from mechanical valve replacement
surgery. Which client statement indicates that teaching has been effective?
"I can play soccer in a week or two."
"I will not drive until informed by my health care provider."
"I have a low risk of developing an infection in my heart."
"I will not need to take anticoagulant medication every day." - ANSWER>>"I
will not drive until informed by my health care provider."
A nurse is caring for a client receiving warfarin therapy following a
mechanical valve replacement. The client had a prothrombin time and
International Normalized Ratio (INR) drawn before breakfast. The
laboratory report shows the client's INR reading was 4. What is the nurse's
first priority ?
Assess the client for bleeding and notify the health care provider of the
results.
Notify the next nurse on afternoon shift to hold the evening dose of
warfarin.
Notify the health care provider to request an increase in the warfarin dose.
Be prepared to administer an I.M. vitamin K injection and notify the
Page 4 of 39
EXAM QUESTIONS WITH VERIFIED AND
DETAILED ANSWERS LATEST UPDATE
GRADED A+ TESTED AND APPROVED
The nurse is educating a client about the care related to a new diagnosis of
mitral valve prolapse. What statement made by the client demonstrates
understanding of the teaching?
"I will take antibiotics before getting my teeth cleaned."
"I can get my tongue pierced at a store in the shopping mall."
"I will avoid caffeine, alcohol, and smoking."
"I can get a tattoo at a local parlor." - ANSWER>>"I will avoid caffeine,
alcohol, and smoking."
A nurse is caring for a client with aortic stenosis whose compensatory
mechanisms of the heart have begun to fail. The nurse will monitor the
client carefully for which initial symptoms?
Dizziness, nausea, diarrhea
Exertional dyspnea, orthopnea, pulmonary edema
Syncope, fever, vomiting
Nausea, vomiting, exertional fatigue - ANSWER>>Exertional dyspnea,
orthopnea, pulmonary edema
The nurse is assessing a client admitted with infective endocarditis. Which
manifestation would the nurse expect to find?
Bruising on the palms of the hands and soles of the feet
Raised red rash on the trunk and face
Involuntary muscle movements of the extremities
Small painful lesions on the pads of the fingers and toes -
ANSWER>>Small painful lesions on the pads of the fingers and toes
During assessment of a client admitted for cardiomyopathy, the nurse notes
Page 1 of 39
,the following symptoms: dyspnea on exertion, fatigue, fluid retention, and
nausea. The initial appropriate nursing diagnosis is which of the following?
Ineffective airway clearance
Disturbed sensory perception
Decreased cardiac output
Autonomic dysreflexia - ANSWER>>Decreased cardiac output
A nurse and a nursing student are performing a physical assessment of a
client with pericarditis. The client has an audible pericardial friction rub on
auscultation. When leaving the room, the student asks the nurse what
causes the sound. The nurse's best response is which of the following?
"The layers of the heart become loose from each other and rub together
with each heart beat."
"The lung surfaces lose their lubrication and rub against the myocardium
with each heart beat."
"The great vessels rub against the pericardium with each heart beat." "The
pericardial surfaces lose their lubricating fluid because of inflammation and
rub against each other." - ANSWER>>"The pericardial surfaces lose their
lubricating fluid because of inflammation and rub against each other."
The nurse determines that a patient has a characteristic symptom of
pericarditis. What symptom does the nurse recognize as significant for this
diagnosis?
Dyspnea
Fatigue lasting more than 1 month
Uncontrolled restlessness
Constant chest pain - ANSWER>>Constant chest pain
A patient is being seen in a clinic to rule out mitral valve stenosis. Which
assessment data would be most significant?
The patient's has an enlarged liver and edematous abdomen.
The patient reports chest pain after eating a large meal.
The patient has jugular vein distention and 3+ pedal edema.
The patient reports shortness of breath when walking. - ANSWER>>The
patient reports shortness of breath when walking.
Page 2 of 39
,A nurse is teaching a client about valve replacement surgery. Which
statement by the client indicates an understanding of the benefit of an
autograft replacement valve?
"The valve is mechanical, and it will not deteriorate or need replacing." "The
valve is made from a pig tissue, and I will not need to take any
bloodthinning drugs when I am discharged."
"The valve is from a tissue donor, and I will not need to take any
bloodthinning drugs when I am discharged."
"The valve is made from my own heart valve, and I will not need to take any
blood-thinning drugs when I am discharged." - ANSWER>>"The valve is
made from my own heart valve, and I will not need to take any blood-
thinning drugs when I am discharged."
A patient is undergoing a pericardiocentesis. Following withdrawal of
pericardial fluid, which assessment by the nurse indicates that cardiac
tamponade has been relieved?
Increase in CVP
Absence of cough
Decrease in blood pressure
Decrease in central venous pressure (CVP) - ANSWER>>Decrease in
central venous pressure (CVP)
A client who was admitted to the hospital with a diagnosis of
thrombophlebitis 1 day ago suddenly reports chest pain and shortness of
breath and is visibly anxious. The nurse immediately assesses the client for
other signs and symptoms of pulmonary embolism. myocardial infarction.
pneumonia. pulmonary edema. - ANSWER>>pulmonary embolism.
A client with a confirmed DVT is being discharged from the ED. Which
client statement indicates that the client has received proper nursing
instruction and understands how to manage this condition? "I should try
not to drink too much during the daytime."
"I should lie on my side with my knees bent when sleeping."
"I need to ice my leg every 2 hours for about 20 minutes."
"I need to do my leg exercises five times or more every hour." -
ANSWER>>"I need to do my leg exercises five times or more every hour."
Page 3 of 39
, A nurse is caring for a client who had an aortic balloon valvuloplasty. The
nurse should inspect the surgical insertion site closely for which
complication(s)?
Bleeding and infection
Bleeding and wound dehiscence
Thrombosis and infection
Evisceration - ANSWER>>Bleeding and infection
A client who recently had a myocardial infarction develops pericarditis and
complains of chest pain rated 6 (on a scale of 0-10) with deep breathing.
Which ordered pro re nata medications is most appropriate for the nurse to
administer?
Morphine sulfate 6 mg IVP every 2-4 hours
Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours
Acetaminophen 650 mg PO every 4 hours
Ibuprofen 800 mg PO every 8 hours - ANSWER>>Ibuprofen 800 mg PO
every 8 hours
The nurse instructs a client recovering from mechanical valve replacement
surgery. Which client statement indicates that teaching has been effective?
"I can play soccer in a week or two."
"I will not drive until informed by my health care provider."
"I have a low risk of developing an infection in my heart."
"I will not need to take anticoagulant medication every day." - ANSWER>>"I
will not drive until informed by my health care provider."
A nurse is caring for a client receiving warfarin therapy following a
mechanical valve replacement. The client had a prothrombin time and
International Normalized Ratio (INR) drawn before breakfast. The
laboratory report shows the client's INR reading was 4. What is the nurse's
first priority ?
Assess the client for bleeding and notify the health care provider of the
results.
Notify the next nurse on afternoon shift to hold the evening dose of
warfarin.
Notify the health care provider to request an increase in the warfarin dose.
Be prepared to administer an I.M. vitamin K injection and notify the
Page 4 of 39
