1) A client is scheduled for a cardiac catherization using
4. Allergy to iodine or shellfish
a radiopaque dye. Which of the following assessments is
most critical before the procedure?
This procedure requires an informed consent because it
1. Intake and output
involves injection of a radiopaque dye into the blood ves-
2. Baseline peripheral pulse rates
sel. The risk of allergic reaction and possible anaphylaxis
3. Height and weight
is serious and must be assessed before the procedure.
4. Allergy to iodine or shellfish
2) A client with no history of cardiovascular disease comes
into the ambulatory clinic with flulike symptoms. The client
suddenly complains of chest pain. Which of the following 3."Does the pain get worse when you breathe in?"
questions would best help a nurse to discriminate pain
caused by a non-cardiac problem? Chest pain is assessed by using the standard pain assess-
1. "Have you ever had this pain before?" ment parameters. Options 1, 2, and 4 may or may not help
2. "Can you describe the pain to me?" discriminate the origin of pain. Pain of pleuropulmonary
3. "Does the pain get worse when you breathe in?" origin usually worsens on inspiration.
4. "Can you rate the pain on a scale of 1-10, with 10 being
the worst?"
3) A client with myocardial infarction has been transferred
from a coronary care unit to a general medical unit with
2. Bathroom privileges and self-care activities
cardiac monitoring via telemetry. A nurse plans to allow
for which of the following client activities?
On transfer from the CCU, the client is allowed self-care
1. Strict bed rest for 24 hours after transfer
activities and bathroom privileges. Supervised ambulation
2. Bathroom privileges and self-care activities
for brief distances are encouraged, with distances gradu-
3. Unsupervised hallway ambulation with distances under
ally increased (50, 100, 200 feet).
200 feet
4. Ad lib activities because the client is monitored.
A nurse notes 2+ bilateral edema in the lower extremities 1. Review the intake and output records for the last 2 days
of a client with myocardial infarction who was admitted
2 days ago. The nurse would plan to do which of the Edema, the accumulation of excess fluid in the interstitial
following next? spaces, can be measured by intake greater than output
, 1. Review the intake and output records for the last 2 days
2. Change the time of diuretic administration from morn- and by a sudden increase in weight. Diuretics should be
ing to evening given in the morning whenever possible to avoid nocturia.
3. Request a sodium restriction of 1 g/day from the physi- Strict sodium restrictions are reserved for clients with se-
cian. vere symptoms.
4. Order daily weights starting the following morning.
A client is wearing a continuous cardiac monitor, which
begins to sound its alarm. A nurse sees no electrocar- 1. Check the client status and lead placement
diogram complexes on the screen. The first action of the
nurse is to: Sudden loss of electrocardiogram complexes indicates
1. Check the client status and lead placement ventricular asystole or possible electrode displacement.
2. Press the recorder button on the electrocardiogram Accurate assessment of the client and equipment is neces-
console. sary to determine the cause and identify the appropriate
3. Call the physician intervention.
4. Call a code blue
4.Taking a blood pressure within 15 minutes after nicotine
6) A nurse is assessing the blood pressure of a client or catteine ingestion
diagnosed with primary hypertension. The nurse ensures
accurate measurement by avoiding which of the follow- BP should be taken with the client seated with the arm
ing? bared, positioned with support and at heart level. The
1. Seating the client with arm bared, supported, and at client should sit with the legs on the floor, feet uncrossed,
heart level. and not speak during the recording. The client should
2. Measuring the blood pressure after the client has been not have smoked tobacco or taken in catteine in the 30
seated quietly for 5 minutes. minutes preceding the measurement. The client should
3. Using a cutt with a rubber bladder that encircles at least rest quietly for 5 minutes before the reading is taken.
80% of the limb. The cutt bladder should encircle at least 80% of the limb
4. Taking a blood pressure within 15 minutes after nicotine being measured. Gauges other than a mercury sphygmo-
or catteine ingestion. manometer should be calibrated every 6 months to ensure
accuracy
7) IV heparin therapy is ordered for a client. While im-
plementing this order, a nurse ensures that which of the