-2027 ACTUAL COMPLETE REAL EXAM QUESTIONS
AND CORRECT ANSWERS (VERIFIED ANSWERS)
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A client with no history of heart disease has experienced acute
myocardial infarction and has been given thrombolytic therapy
with tissue plasminogen activator. What assessment finding
would the nurse identify as an indicator that the client is
experiencing complications of this therapy?
1. Tarry
stools
2. Nausea and
vomiting
3. Orange-colored
urine
4. Decreased urine output - ANSWER -
Tarry stools
Thrombolytic agents are used to dissolve existing thrombi, and
the nurse would
monitor the client for obvious or occult signs of
bleeding. This includes
assessment for obvious bleeding within the gastrointestinal
(GI) tract, urinary
,system, and skin. It also includes Hematest testing of
secretions for occult
blood. The correct option is the only one that indicates the
presence of blood.
A client has experienced an episode of pulmonary edema. The
nurse determines that the client's respiratory status is
improving after this episode if which breath sounds are noted?
1.
Ronchi
2.
Wheezes
3. Crackles in the
bases
4. Crackles throughout the lung fields - ANSWER -
Crackles in the base
Pulmonary edema is characterized by extreme breathlessness,
dyspnea, air hunger, and the production of frothy, pink-tinged
sputum. As the client's condition improves, the amount of fluid
in the alveoli decreases, which may be detected by crackles in
the bases. (Clear lung sounds indicate full resolution of the
episode.) Rhonchi and wheezes are not associated with
pulmonary edema. Auscultation of the lungs reveals crackles
throughout the lung fields.
A hospitalized client has been diagnosed with heart failure as a
complication of hypertension. In explaining the disease
,process to the client, the nurse identifies which chamber of the
heart as primarily responsible for the symptoms?
1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle - ANSWER -Left ventricle
Hypertension increases the workload of the left ventricle
because the ventricle has to pump the stroke volume against
increased resistance (afterload) in the major blood vessels.
Over time this causes the left ventricle to fail, leading to signs
and symptoms of heart failure. The remaining options are not
the chambers that are primarily responsible for this disease
process, although these chambers may be affected as the
disease becomes more chronic.
The registered nurse (RN) is educating a new nurse on mitral
stenosis. Which
statement by the new nurse indicates that the teaching has
been effective?
1. "Left ventricle to aorta narrowing will impede flow of blood."
2. "Left atrium to left ventricle narrowing will impede flow of
blood."
3. "Right atrium to right ventricle narrowing will impede flow of
blood."
, 4. "Right ventricle to pulmonary artery narrowing will impede
flow of blood." - ANSWER -"Left atrium to left ventricle
narrowing will impede flow of blood."
The mitral valve separates the left atrium from the left ventricle.
The remaining options describe impeded flow due to aortic,
tricuspid, and pulmonic stenosis, respectively.
The registered nurse (RN) is educating a new nurse about
aortic regurgitation.
Which statement by the new nurse indicates that the
teaching has been
effective?
1. "Failure of the aortic valve to close completely allows
blood to flow retrograde through the aorta to the left ventricle."
2. "Failure of the aortic valve to close completely allows
blood to flow retrograde through the left ventricle to the left
atrium."
3. "Failure of the aortic valve to close completely allows
blood to flow retrograde through the right ventricle to the right
atrium."
4. "Failure of the aortic valve to close completely allows
blood to flow retrograde through the pulmonary artery to the
right ventricle." - ANSWER -"Failure of the aortic valve to close
completely allows blood to flow retrograde through the aorta to
the left ventricle."