NUR 372 Medical Surgical Q and A.docx
1.A A 60-year-old male client comes into the emergency department with complaints of crushing substernal chest pain that
radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infraction (MI). Immediateadmission
orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG),
and 2 mg of morphine sulfate given intravenously. The nurse should first:
a. Administer the morphine
b. Obtain a 12-lead ECG
c. Obtain the blood work
d. Order the chest radiograph
Ans: A – although obtaining the ECG, chest radiograph, and blood work are all important, the nurse’s priority action should
be to relieve the crushing chest pain. Therefore, administering morphine sulfate is priority action.
2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that thepurpose of
the drug is to:
a. Help keep him well hydrated
b. Dissolve clots that he may have
c. Prevent kidney failure
d. Treat potential cardiac dysrhythmias
Ans: B – thrombolytic drugs are administered within the first 6 hours after of myocardial infarction to lyse clots and
reduce the extent of myocardial damage.
3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs should the nurseexpect to
observe?
a. Oliguria
b. Bradycardia
c. Elevated blood pressure
d. Fever
Ans: A – oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typically signs of
cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine output, and signs ofdiminished blood
flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality
rate approaching 90%. Fever is not a typical sign of cardiogenic shock.
4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI. essential nursing action
include which of the following?
a. Obtaining an infusion pump for the medication
b. Monitoring blood pressure every 4 hours
c. Monitoring urine output hourly
d. Obtaining serum potassium levels daily
Ans: A – intravenous nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure
monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not
always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused by:
a. Left ventricular overload
b. Impending circulatory collapse
c. Extracellular electrolyte imbalances
d. Insufficient oxygen reaching the heart muscle
Ans: D – an MI interferes with or blocks circulation to the heart muscle. Decreased blood supply to the heart muscle
causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle
results in ischemic pain or angina.
6. Aspirin is administered to the client experiencing an MI because of its:
a. Antipyretic action
b. Antithrombotic action
c. Antiplatelet action
d. Analgesic action
Ans: B – aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason aspirin is administered to
the client experiencing an MI is its antithrombotic action. In clinical trials, the antithromboticaction of aspirin has been
thought to account for improved outcomes in clients with MI.
7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the cardiac monitor. The
client is receiving an intravenous infusion of 5% dextrose in water and oxygen at 2 L/minute. Thenurse’s first course of
action should be to:
a. Increase the intravenous infusion rate
b. Notify the physician promptly
c. Increase the oxygen concentration
d. Administer a prescribed analgesic
,a. Has minimal chest pain
b. Can identify risk factors for MI
c. Agrees to participate in a cardiac rehabilitation program
d. Can perform personal self-care activities without pain
Ans: D – by day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain.
Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to be able to agree to
participate in a cardiac rehabilitation program.
9. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would
include which outcome?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased PVCs
Ans: B – furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase blood pressure, decrease
pain, or decrease dysrhythmias.
10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This type of exercise is
recommended primarily to help:
a. Prepare the client for ambulation
b. Promote urinary and intestinal elimination
c. Prevent thrombophlebitis and blood clot formation
d. Decrease the likelihood of decubitus ulcer formation
Ans: C – although this type of exercise may decrease the likelihood of heel decubitus ulcer form formation, it is taught to
the MI client to prevent thrombophlebitis and blood clot formation. Movement of the lower extremities provides muscular
action and aids venous return. As a result, the activity helps prevent stasis of blood, which predisposes the client to
thrombophlebitis and blood clot formation. This type of exercise is not associated with promoting urinary and intestinal
elimination.
11. Which of the following reflects the principle on which a client’s diet will most likely be based during the acutephase of
MI?
a. Liquids as desired
b. Small, easily digested meals
c. Three regular meals per day
d. Nothing by mouth
Ans: B – recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily
digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed,
especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not
prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely linked to the
development of the disease?
a. Age
b. Medication usage
c. High cholesterol levels
d. Gender
Ans: C – high cholesterol levels are considered a controllable risk factor for CAD and appear most clearly linked to the
development of the disease. High cholesterol levels can be modified through diet, exercise, and medication. Age and gender
are uncontrollable risk factors for CAD. Medication usage is not considered a risk factor for CAD.
13. Which of the following is an uncontrollable risk factor that has been linked to the development of CAD?
a. Exercise
b. Obesity
c. Stress
d. Heredity
Ans: D – heredity has been linked to CAD and is an uncontrollable risk factor. Exercise, obesity, and stress are
controllable risk factor for CAD.
14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated fat, or leading a
sedentary lifestyle, technique of behavior modification may be used to help the client change behavior. The nurse can best
reinforce new adaptive behaviors by:
a. Explaining how the old behavior leads to poor health
b. Withholding praise until the new behavior is well established
c. Rewarding the client whenever the acceptable behavior is performed
d. Instilling mild fear into the client to extinguish the behavior
Ans: C – a basic principle of behavior modification is that behavior that is learned and continued is behavior thathas been
rewarded. Other reinforcement techniques have not been found to be as effective as reward.
,16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to:
a. Observe the client for chest pain
b. Monitor for fever
c. Monitor the 12-lead ECG every 4 hours
d. Monitor breath sounds
Ans: A – although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest
pain is the nursing assessment priority, because closure of the previously obstructed coronary artery may recur. Clients who
receive t-PA frequently receive heparin to prevent closure of the artery after t-PA. Carefulassessment for signs of bleeding
and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause
fever.
17. When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor vital signs and have
resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
a. Cardiac dysrhythmias
b. Hypertension
c. Seizure
d. Hypothermia
Ans: A – cardiac dysrhythmias are commonly observed with administration of t-PA. Cardiac dysrhythmias associated with
reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA.Seizures and hypothermia
are not generally associated with reperfusion of the cardiac tissue.
18. Contraindication to the administration of t-PA include which of the following?
a. Age greater than 60 years
b. History of cerebral hemorrhage
c. History of heart failure
d. Cigarette smoking
Ans: B – a past history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of
hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not
contraindications.
19. A client has driven himself into the emergency room. He is 50 years old, has a history of hypertension, and informs the
nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The
nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse’s next
action would be to:
a. Call for the doctor
b. Start an intravenous line
c. Obtain a portable chest radiograph
d. Draw blood for laboratory studies
Ans: B – advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the
antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing bloodfor the laboratory are
important but secondary to starting the intravenous line.
20. Crackles heard on lung auscultation indicate which of the following?
a. Cyanosis
b. Bronchospasm
c. Airway narrowing
d. Fluid-filled alveoli
Ans: D – crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to beassociated
with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.
21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness.
The first nursing action should be to:
a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness
b. Administer oxygen via nasal cannula
c. Offer pain medication for the chest heaviness
d. Inform the physician of the chest heaviness
Ans: A – further assessments is needed in this situation. It is premature to initiate other actions until further data have been
gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide
pertinent information to convey to the physician.
22. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician.
An increased myoglobin level suggests which of the following?
a. Cancer
b. Hypertension
c. Liver disease
d. Myocardial damage
Ans: D – detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin
, d. Pacemaker placement
Ans: A – in older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or
deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden able to
respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart
failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging
process. Irregular heartbeats are generally not associated with an older sedentary adult’s lifestyle. Peripheral vascular
occlusion of pacemaker placement should not affect response to stress.
The Client With Heart Failure
24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heartfailure
complicated by pulmonary edema. On admission of this client, which of the following should be assessed first?
a. Blood pressure
b. Skin breakdown
c. Serum potassium
d. Urine output
Ans: A – it is a priority to assess the blood pressure first, because people with pulmonary edema typically experience
severe hypertension that requires early intervention.
25. In which of the following should the nurse place a client with suspected heart failure?
a. Semi-sitting (Low Fowler’s position)
b. Lying on the right side (Sims’ position)
c. Sitting almost upright (High Fowler’s position)
d. Lying on the back with the head lowered (Trendelenburg position)
Ans: C – sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart,
thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler’s
position would be used if the client could not tolerate high Fowler’s position for some reason. Lying on the right side
would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg
position.
26. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonaryedema?
a. Risk for infection related to line placements
b. Impaired skin integrity related to pressure
c. Activity intolerance related to imbalance between oxygen supply and demand
d. Constipation related to immobility
Ans: C – activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased
cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea
and fatigue. The client could be at risk for infection related to line placements or impaired skin integrity related to pressure.
However, these are not the priority nursing diagnoses for the client with heart failure and pulmonary edema, nor is
constipation related to immobility.
27. The major goal of therapy for a client with heart failure and pulmonary edema would be to:
a. Increase cardiac output
b. Improve respiratory edema
c. Decrease peripheral edema
d. Enhance comfort
Ans: A – increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema.
Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be
improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with
pulmonary edema.
28. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to:
a. Dilate coronary arteries
b. Increase myocardial contractility
c. Decrease cardiac dysrhythmias
d. Decrease electrical conductivity in the heart
Ans: B – digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of
myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary
arteries. Although digoxin can be used to treat dysrhythmias and does decrease the electricalconductivity of the myocardium,
this is not the primary reason for its use in clients with heart failure and pulmonary edema.
29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with heartfailure
because it acts as a:
a. Vasopressor
b. Volume expander
c. Vasodilator
d. Potassium-sparing diuretic
Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive heart failure.
1.A A 60-year-old male client comes into the emergency department with complaints of crushing substernal chest pain that
radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infraction (MI). Immediateadmission
orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest radiograph, a 12-lead electrocardiogram (ECG),
and 2 mg of morphine sulfate given intravenously. The nurse should first:
a. Administer the morphine
b. Obtain a 12-lead ECG
c. Obtain the blood work
d. Order the chest radiograph
Ans: A – although obtaining the ECG, chest radiograph, and blood work are all important, the nurse’s priority action should
be to relieve the crushing chest pain. Therefore, administering morphine sulfate is priority action.
2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that thepurpose of
the drug is to:
a. Help keep him well hydrated
b. Dissolve clots that he may have
c. Prevent kidney failure
d. Treat potential cardiac dysrhythmias
Ans: B – thrombolytic drugs are administered within the first 6 hours after of myocardial infarction to lyse clots and
reduce the extent of myocardial damage.
3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs should the nurseexpect to
observe?
a. Oliguria
b. Bradycardia
c. Elevated blood pressure
d. Fever
Ans: A – oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typically signs of
cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine output, and signs ofdiminished blood
flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality
rate approaching 90%. Fever is not a typical sign of cardiogenic shock.
4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI. essential nursing action
include which of the following?
a. Obtaining an infusion pump for the medication
b. Monitoring blood pressure every 4 hours
c. Monitoring urine output hourly
d. Obtaining serum potassium levels daily
Ans: A – intravenous nitroglycerin infusion requires an infusion pump for precise control of the medication. Blood pressure
monitoring would be done with a continuous system, and more frequently than every 4 hours. Hourly urine outputs are not
always required. Obtaining serum potassium levels is not associated with nitroglycerin infusion.
5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused by:
a. Left ventricular overload
b. Impending circulatory collapse
c. Extracellular electrolyte imbalances
d. Insufficient oxygen reaching the heart muscle
Ans: D – an MI interferes with or blocks circulation to the heart muscle. Decreased blood supply to the heart muscle
causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to the cardiac muscle
results in ischemic pain or angina.
6. Aspirin is administered to the client experiencing an MI because of its:
a. Antipyretic action
b. Antithrombotic action
c. Antiplatelet action
d. Analgesic action
Ans: B – aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason aspirin is administered to
the client experiencing an MI is its antithrombotic action. In clinical trials, the antithromboticaction of aspirin has been
thought to account for improved outcomes in clients with MI.
7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the cardiac monitor. The
client is receiving an intravenous infusion of 5% dextrose in water and oxygen at 2 L/minute. Thenurse’s first course of
action should be to:
a. Increase the intravenous infusion rate
b. Notify the physician promptly
c. Increase the oxygen concentration
d. Administer a prescribed analgesic
,a. Has minimal chest pain
b. Can identify risk factors for MI
c. Agrees to participate in a cardiac rehabilitation program
d. Can perform personal self-care activities without pain
Ans: D – by day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain.
Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to be able to agree to
participate in a cardiac rehabilitation program.
9. When teaching a client about the expected outcomes after intravenous administration of furosemide, the nurse would
include which outcome?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased PVCs
Ans: B – furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase blood pressure, decrease
pain, or decrease dysrhythmias.
10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This type of exercise is
recommended primarily to help:
a. Prepare the client for ambulation
b. Promote urinary and intestinal elimination
c. Prevent thrombophlebitis and blood clot formation
d. Decrease the likelihood of decubitus ulcer formation
Ans: C – although this type of exercise may decrease the likelihood of heel decubitus ulcer form formation, it is taught to
the MI client to prevent thrombophlebitis and blood clot formation. Movement of the lower extremities provides muscular
action and aids venous return. As a result, the activity helps prevent stasis of blood, which predisposes the client to
thrombophlebitis and blood clot formation. This type of exercise is not associated with promoting urinary and intestinal
elimination.
11. Which of the following reflects the principle on which a client’s diet will most likely be based during the acutephase of
MI?
a. Liquids as desired
b. Small, easily digested meals
c. Three regular meals per day
d. Nothing by mouth
Ans: B – recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily
digested foods are better tolerated. Fluids are given according to the client’s needs, and sodium restrictions may be prescribed,
especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well. Clients are not
prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.
12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely linked to the
development of the disease?
a. Age
b. Medication usage
c. High cholesterol levels
d. Gender
Ans: C – high cholesterol levels are considered a controllable risk factor for CAD and appear most clearly linked to the
development of the disease. High cholesterol levels can be modified through diet, exercise, and medication. Age and gender
are uncontrollable risk factors for CAD. Medication usage is not considered a risk factor for CAD.
13. Which of the following is an uncontrollable risk factor that has been linked to the development of CAD?
a. Exercise
b. Obesity
c. Stress
d. Heredity
Ans: D – heredity has been linked to CAD and is an uncontrollable risk factor. Exercise, obesity, and stress are
controllable risk factor for CAD.
14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated fat, or leading a
sedentary lifestyle, technique of behavior modification may be used to help the client change behavior. The nurse can best
reinforce new adaptive behaviors by:
a. Explaining how the old behavior leads to poor health
b. Withholding praise until the new behavior is well established
c. Rewarding the client whenever the acceptable behavior is performed
d. Instilling mild fear into the client to extinguish the behavior
Ans: C – a basic principle of behavior modification is that behavior that is learned and continued is behavior thathas been
rewarded. Other reinforcement techniques have not been found to be as effective as reward.
,16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to:
a. Observe the client for chest pain
b. Monitor for fever
c. Monitor the 12-lead ECG every 4 hours
d. Monitor breath sounds
Ans: A – although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest
pain is the nursing assessment priority, because closure of the previously obstructed coronary artery may recur. Clients who
receive t-PA frequently receive heparin to prevent closure of the artery after t-PA. Carefulassessment for signs of bleeding
and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause
fever.
17. When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor vital signs and have
resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following?
a. Cardiac dysrhythmias
b. Hypertension
c. Seizure
d. Hypothermia
Ans: A – cardiac dysrhythmias are commonly observed with administration of t-PA. Cardiac dysrhythmias associated with
reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA.Seizures and hypothermia
are not generally associated with reperfusion of the cardiac tissue.
18. Contraindication to the administration of t-PA include which of the following?
a. Age greater than 60 years
b. History of cerebral hemorrhage
c. History of heart failure
d. Cigarette smoking
Ans: B – a past history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of
hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not
contraindications.
19. A client has driven himself into the emergency room. He is 50 years old, has a history of hypertension, and informs the
nurse that his father died from a heart attack at 60 years of age. The client is presently complaining of indigestion. The
nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per nasal cannula. The nurse’s next
action would be to:
a. Call for the doctor
b. Start an intravenous line
c. Obtain a portable chest radiograph
d. Draw blood for laboratory studies
Ans: B – advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the
antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing bloodfor the laboratory are
important but secondary to starting the intravenous line.
20. Crackles heard on lung auscultation indicate which of the following?
a. Cyanosis
b. Bronchospasm
c. Airway narrowing
d. Fluid-filled alveoli
Ans: D – crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to beassociated
with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.
21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain of chest heaviness.
The first nursing action should be to:
a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness
b. Administer oxygen via nasal cannula
c. Offer pain medication for the chest heaviness
d. Inform the physician of the chest heaviness
Ans: A – further assessments is needed in this situation. It is premature to initiate other actions until further data have been
gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide
pertinent information to convey to the physician.
22. The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician.
An increased myoglobin level suggests which of the following?
a. Cancer
b. Hypertension
c. Liver disease
d. Myocardial damage
Ans: D – detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin
, d. Pacemaker placement
Ans: A – in older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or
deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden able to
respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart
failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging
process. Irregular heartbeats are generally not associated with an older sedentary adult’s lifestyle. Peripheral vascular
occlusion of pacemaker placement should not affect response to stress.
The Client With Heart Failure
24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heartfailure
complicated by pulmonary edema. On admission of this client, which of the following should be assessed first?
a. Blood pressure
b. Skin breakdown
c. Serum potassium
d. Urine output
Ans: A – it is a priority to assess the blood pressure first, because people with pulmonary edema typically experience
severe hypertension that requires early intervention.
25. In which of the following should the nurse place a client with suspected heart failure?
a. Semi-sitting (Low Fowler’s position)
b. Lying on the right side (Sims’ position)
c. Sitting almost upright (High Fowler’s position)
d. Lying on the back with the head lowered (Trendelenburg position)
Ans: C – sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to the heart,
thus reducing myocardial workload. Also, the sitting position allows maximum space for lung expansion. Low Fowler’s
position would be used if the client could not tolerate high Fowler’s position for some reason. Lying on the right side
would not be a good position for the client in heart failure. The client in heart failure would not tolerate the Trendelenburg
position.
26. Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonaryedema?
a. Risk for infection related to line placements
b. Impaired skin integrity related to pressure
c. Activity intolerance related to imbalance between oxygen supply and demand
d. Constipation related to immobility
Ans: C – activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased
cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea
and fatigue. The client could be at risk for infection related to line placements or impaired skin integrity related to pressure.
However, these are not the priority nursing diagnoses for the client with heart failure and pulmonary edema, nor is
constipation related to immobility.
27. The major goal of therapy for a client with heart failure and pulmonary edema would be to:
a. Increase cardiac output
b. Improve respiratory edema
c. Decrease peripheral edema
d. Enhance comfort
Ans: A – increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema.
Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be
improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with
pulmonary edema.
28. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts to:
a. Dilate coronary arteries
b. Increase myocardial contractility
c. Decrease cardiac dysrhythmias
d. Decrease electrical conductivity in the heart
Ans: B – digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased strength of
myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin does not dilate coronary
arteries. Although digoxin can be used to treat dysrhythmias and does decrease the electricalconductivity of the myocardium,
this is not the primary reason for its use in clients with heart failure and pulmonary edema.
29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client with heartfailure
because it acts as a:
a. Vasopressor
b. Volume expander
c. Vasodilator
d. Potassium-sparing diuretic
Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive heart failure.
