Cardiac Disorders NCLEX Questions And Answers (Graded A+!!!!

Cardiac Disorders NCLEX QuCardiac Disorders NCLEX The nurse is assessing a pt w/ chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate? 1. expiratory wheezes 2. friction rub 3. harsh vesicular 4. crackles - ANS Answer: 4 Rationale 1, 2, 3: Expiratory wheezes, friction rub, & harsh vesicular sounds are not associated w/ chronic heart failure. Rationale 4: Fluid accumulates in the alveolar spaces w/ left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration. When caring for a chronic heart failure pt w/ left-sided failure, the nurse would most likely note the following statement in the physician's written report following cardiac catheterization? 1. "Pressures in the left ventricle & atrium are increased." 2. "Pressures in the left ventricle & atrium are decreased." 3. "Pressures in the right ventricle & atrium match the ventricle pressures." 4. "Pressures in the right ventricle reflect functioning of all heart chambers." - ANS Answer: 1 Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume. Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume. Rationale 3: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. Rationale 4: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. A nurse caring for a pt w/ heart failure would expect to find which of the following during assessment of the pt? 1. S1, S2 & flat neck veins 2. S3 & distended neck veins 3. S2 is heard the loudest & followed by S1 4. S4 & flat neck veins - ANS Answer: 2 Rationale 1: S1 & S2 are normal heart sounds; flat neck veins are considered a normal finding. Rationale 2: The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle & the neck veins distend because of the increased venous pressure. Rationale 3: S1 & S2 sounds may be diminished in the heart failure pt & not vary in intensity. Rationale 4: S4 (gallop) may be present but neck veins would be distended. When obtaining the health history of a pt who is being assessed for possible congestive heart failure, it is significant when the pt says which of the following? 1. "I break out in a cold sweat when I eat a large meal." 2. "I am sleepy after I eat lunch each day." 3. "I have to prop myself up on three pillows to sleep at night, otherwise I can't breathe." 4. "I feel better w/ my legs down when I sit in my favorite chair." - ANS Answer: 3 Rationale 1: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF. Rationale 2: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF. Rationale 3: Needing to prop oneself up w/ pillows at night in order to breathe describes orthopnea, which is consistent w/ congestive heart failure (CHF). Congestive heart failure produces a volume excess, congestion in the lungs, & dyspnea when attempting to lie down. Rationale 4: Diaphoresis & sleepiness after meals & comfort when legs are dependent are all notable findings but not related to a diagnosis of CHF. A pt is admitted w/ acute heart failure. The nurse realizes that acute heart failure is associated w/ an abrupt onset of which of the following? Select all that apply. 1. cardiomyopathy 2. heart valve disease 3. coronary heart disease (CHD) 4. massive infarction (MI)) 5. myocardial injury - ANS Correct Answer: 4,5 Rationale 1,2,3: Cardiomyopathy, valve disease, & coronary heart disease (CHD) are all associated w/ chronic heart failure. Rationale 4,5: Pts often present for care w/ signs of acute heart failure when they have had an abrupt onset of myocardial injury such as a massive myocardial infarction (MI). Blood tests are ordered for a pt who is diagnosed w/ possible congestive heart failure (CHF). The nurse underst&s which of the following lab tests indicates heart failure? The most specific test(s) to accurately indicate CHF would be which of the following? 1. liver function 2. urinalysis & blood urea nitrogen (BUN) 3. brain natriuretic peptide (BNF). 4. serum electrolytes - ANS Correct Answer: 3 Rationale: Liver function, urinalysis, blood urea nitrogen (BUN)), & serum electrolytes are appropriate tests for this diagnosis but brain natriuretic peptide (BNP) provides the strongest indicator. BNP have been shown to positively correlate w/ pressures in the left ventricle & pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase. The nurse is caring for a pt who has invasive hemodynamic monitoring. The highest priority of care for this pt is which of the following? 1. Prevent infection at the catheter site by changing the dressing as prescribed. 2. Set alarm limits & turn monitor alarms on. 3. Explain to family members why the monitoring is in use. 4. Coil IV tubing on the bed. - ANS Answer: 2 Rationale 1: Prevention of infection by changing dressings is important but not the priority of care. Rationale 2: Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. Alarms should always be investigated since they are suspended only when drawing blood or changing tubing. Rationale 3: Keeping family members informed about monitoring is important, but again, not the priority of care. Rationale 4: Coiling the IV tubing on the bed is contraindicated. The nurse is caring for a pt in the critical care area whose fluid volume status needs to be assessed closely. The most likely type of monitoring that will be used is which of the following? 1. arterial pressure monitoring 2. pulmonary artery pressure monitoring 3. central venous pressure monitoring 4. intra-aortic balloon pump monitoring - ANS Answer: 3 Rationale 1: Arterial pressure monitoring would not measure central venous pressure. Rationale 2: Central venous pressure (CVP) monitoring can be accomplished w/ a central IV line & an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status. If the pt is acutely ill w/ a cardiac condition, then CVP can be obtained from a pulmonary artery pressure monitoring system as well. Rationale 3: Central venous pressure (CVP) monitoring can be accomplished w/ a central IV line & an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status. If the pt is acutely ill w/ a cardiac condition, then CVP can be obtained from a pulmonary artery pressure monitoring system as well. Rationale 4: An intra-aortic balloon pump not be used for pressure monitoring. A pulmonary artery (PA) catheter is used in critical care pts who 1. cannot tolerate hemodynamic monitoring. 2. requires a peripheral intravenous catheter for meds administration. 3. would benefit from having the right ventricle pressures measured each shift. 4. requires evaluation of left ventricular pressures each shift. - ANS Answer: 4 Rationale 1: PA catheters are a form of hemodynamic monitoring. Rationale 2,3: The PA catheter does not measure right ventricular pressures & would not be used to administer meds since it is a central arterial catheter, not a peripheral line. Rationale 4: Pulmonary artery (PA) catheters can be used to evaluate pulmonary artery pressures, left ventricular pressures, measure cardiac output, & manipulate fluid volume status in acutely ill pts. The nurse should instruct a pt who is prescribed digoxin (Lanoxin) on which of the following info? 1. How to manage nausea that can be associated w/ taking digoxin. 2. Foods that should be eaten while taking this drug. 3. Do not take the meds & to not take it if the pulse is under 60 beats per minute. 4. Checking the pulse for one minute each day & recording the result on a notepad. - ANS Answer: 3 Rationale 1,2: This is necessary but is not priority. All four answers include important teaching information but the highest priority is for the pt to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) & to contact the physician. Rationale 3: The highest priority is for the pt to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) & to contact the physician. Rationale 4: This is necessary but is not priority. All four answers include important teaching information but the highest priority is for the pt to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) & to contact the physician. An elderly pt was recently discharged to home after treatment for chronic heart failure. The pt experiences a pulse rate increase from 80 bpm to 102 bpm when walking from the kitchen to the utility room to do laundry. Which of the following are appropriate nursing actions for the home health nurse? 1. Encourage the pt to complete tasks such as laundry early in the morning before fatigue is an issue. 2. Recommend that the pt ignore the pulse rate & become more active to build stamina. 3. Encourage the pt to rest for 30 minutes between completing each load of laundry. 4. Encourage the pt to rest on a chair in the utility room & sit & rest when the pt feels his pulse rate increase. - ANS Answer: 4 Rationale 1: Recommending that the pt complete household tasks in the morning, to ignore the pulse rate & become more active, & to rest 30 minutes between loads of laundry are not practical strategies for an elderly pt w/ compromised heart function. Rationale 2: Recommending that the pt complete household tasks in the morning, to ignore the pulse rate & become more active, & to rest 30 minutes between loads of laundry are not practical strategies for an elderly pt w/ compromised heart function. Rationale 3: All home activities should be performed at a comfortable pace for the pt. Rationale 4: The increase in pulse rate indicates that activity is not being tolerated. Rest should help to bring the heart rate down to the pre-exercise level. The nurse recognizes which of the following as a sign of decreased cardiac output & tissue perfusion in a pt w/ heart failure? 1. decreased mental alertness 2. increased urine output 3. abdominal distention 4. strong peripheral pulses - ANS Correct Answer: 1 Rationale 1: A change in mentation is a common sign of decreased cardiac output & tissue perfusion. Rationale 2: Urine output would decrease. Rationale 3: Abdominal distention a sign of right-sided failure which is a problem w/ venous return, not cardiac output or tissue perfusion. Rationale 4: Pulses would weaken The nurse is assessing a pt who is demonstrating dyspnea, orthopnea, cyanosis, clammy skin, a productive cough w/ pink, frothy sputum, & crackles. The nurse realizes that the pt likely has which of the following conditions? 1. chronic heart failure 2. pulmonary edema 3. endocarditis 4. angina - ANS Answer: 2 Rationale 1: Not all pts w/ chronic heart failure have pink, frothy sputum. The presence of this symptom differentiates pulmonary edema from chronic heart failure. Rationale 2: Dyspnea, orthopnea, cyanosis, clammy skin, productive cough w/ pink frothy sputum, & crackles are signs & symptoms indicative of pulmonary edema which is considered a medical emergency. Rationale 3: Endocarditis would manifest w/ pain & potentially fever. Rationale 4: Angina is chest pain. The priority nursing action the nurse would implement for the pt who is admitted w/ pulmonary edema would be to do which of the following? 1. Insert a peripheral intravenous catheter. 2. Seek a prescription to medicate the pt for comfort. 3. Monitor the blood glucose level. 4. Place a pulse oximeter & administer oxygen. - ANS Answer: 4 Rationale 1: Inserting an IV would be second, but often, if there is more than one caregiver present, this action can be done simultaneously. Rationale 2: Meds would not be given until the ABCs have been addressed. Rationale 3: The blood glucose level is not related to pulmonary edema. Rationale 4: Since this is a medical emergency, priority nursing actions focus on maintaining the airway & improving oxygenation, then breathing & circulation. Which of the following is important to consider when caring for pts w/ possible endocarditis? 1. Endocarditis does not pose a high risk for damage to affected heart valves. 2. Pts w/ this disorder can be treated by open heart surgery to clean the heart valves. 3. The condition is unrelated to fever so medicate pts w/ the prescribed antipyretic & observe. 4. Endocarditis can be prevented in pts at risk by administering antibiotics prior to procedures. - ANS Answer: 4 Rationale 1: Endocarditis does not pose a high risk for damage to affected heart valves. Rationale 2: Endocarditis can be treated by open heart surgery to clean the heart valves. Rationale 3: Endocarditis does not cause fever but administer an antipyretic & observe. Rationale 4: Endocarditis can be prevented in pts at risk by administering antibiotics prior to procedures. The nurse would assess which of the following as clinical signs & symptoms of pericarditis? Select all that apply. 1. pericardial friction rub 2. abdominal discomfort & nausea 3. chest pain 4. bradycardia 5. distended neck veins - ANS Correct Answer: 1,3 Rationale 1: Pericardial friction is a hallmark sign of pericarditis in addition to fever. Rationale 2: Abdominal discomfort & nausea are not associated w/ pericarditis. Rationale 3: Chest pain is a hallmark sign of pericarditis in addition to fever. Rationale 4: Bradycardia is not associated w/ pericarditis. Rationale 5: Distended neck veins are not associated w/ pericarditis. The nurse, caring for a pt diagnosed w/ cardiac tamponade, realizes treatment would be w/ which of the following? 1. antidysrhythmic drugs & oxygen 2. oxygen & rest 3. pericardiocentesis 4. antibiotics - ANS Answer: 3 Rationale 1,2: Antidysrhythmic drugs, oxygen, rest, & antibiotics may be indicated after the pericardiocentesis is performed. Rationale 3: When cardiac tamponade occurs, it is considered a medical emergency. Pericardiocentesis is performed to removed fluid or blood that has collected around the heart & is preventing the heart from pumping effectively. Rationale 4: Antidysrhythmic drugs, oxygen, rest, & antibiotics may be indicated after the pericardiocentesis is performed. A nurse caring for a pt w/ coronary artery disease hears a murmur during auscultation of the heart. The nurse suspects the a pt has which of the following? 1. valvular heart disease 2. pericarditis 3. cardiac tamponade 4. heart failure - ANS Answer: 1 Rationale 1: Valvular disorders interfere w/ the smooth flow of blood through the heart. The flow becomes turbulent, causing a murmur, a characteristic manifestation of valvular disease. Rationale 2: The heart sound characteristic of pericarditis is a pericardial friction rub Rationale 3: Distant & muffled heart sounds are typical of cardiac tamponade. Rationale 4: Extra heart sounds S3 & S4 are heard in heart failure The nurse realizes that a pt is experiencing paroxysmal nocturnal dyspnea (PND) when which of the following is assessed? Select all that apply. 1. Symptoms occur at night 2. pulmonary congestion 3. improving cardiac reserve 4. voiding more than 1 time per night 5. daytime peripheral edema - ANS Correct Answer: 1,2,5 Rationale 1,2,5: PND is a condition in which the pt is awakened at night & frightened by acute shortness of breath. It occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night causing pulmonary congestion. Rationale 3: Chronic HF is characterized by decreasing cardiac reserve & dependent edema that worsens as the day progresses. Rationale 4: Nocturia is the term that describes voiding more than 1 time per night. Home care teaching is being completed by the nurse for a pt recovering from rheumatic fever. Which of the following statements by the pt would indicate that the teaching has been effective? 1. "I will be sure to tell my dentist that I had rheumatic fever." 2. "I will try to focus on eating less protein & more fat, so I will have more energy." 3. "I will avoid brushing my teeth so often & quit using mouth rinse since I have gingivitis." 4. "I know that if my joints start to hurt again, I need to slow down, but I won't have to worry since I'm immune to getting rheumatic fever again." - ANS Answer: 1 Rationale 1: Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the pt recovering from rheumatic fever. Rationale 2: Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing & combat fatigue. Rationale 3: Maintaining good oral hygiene & preventive dental care are important to preventing gingival infections, which can lead to recurrence of the disease. Rationale 4: Rheumatic fever is manifested by joint pain. Immunity is not conferred by having had an episode of rheumatic fever. The nurse realizes that which of the following persons are at risk for high-output heart failure? 1. a pt w/ chronic anemia 2. a person w/ untreated hypertension 3. an individual w/ untreated hypothyroidism 4. someone who abuses sedatives & analgesics - ANS Answer: 1 Rationale 1: High-output heart failure occurs in pts in hypermetabolic states such as anemia, hyperthyroidism, pregnancy, & infection, which require increased cardiac output to maintain blood flow & oxygen to tissues. Rationale 2: Hypertension is typically associated w/ low-output heart failure. Rationale 3: High-output heart failure occurs in pts in hypermetabolic states such as anemia, hyperthyroidism, pregnancy, & infection, which require increased cardiac output to maintain blood flow & oxygen to tissues. Rationale 4: Sedatives & analgesics slow metabolic function. The nurse, caring for an elderly pt, realizes that aging adults are at higher risk for development of heart failure due to which of the following? Select all that apply. 1. impaired diastolic filling 2. increased cardiac reserve 3. increased maximal heart rate 4. decreased ventricular compliance 5. high responsiveness to sympathetic nervous system stimulation - ANS Answer: 1,4 Rationale 1: Impaired diastolic filling occurs due to decreased ventricular compliance. Rationale 2: W/ aging, cardiac function is less responsive to increased stress because cardiac reserve decreases. Rationale 3: Maximal heart rate is reduced. Rationale 4: The heart becomes less responsive to sympathetic nervous system stimulation. An elderly pt arrives at the clinic complaining of dyspnea, weight gain, chest pain, & increasing edema of the lower extremities. The pt's blood pressure is elevated. The nurse discovers the pt has a history of heart failure. Which of the following questions by the nurse may best help w/ determining why the pt is currently having health problems? 1. "Are you married?" 2. "Have you been out of the country lately?" 3. "Do you have gr&children that you babysit?" 4. "Have you attended any recent family or social gatherings?" - ANS Correct Answer: 4 Rationale 1,2,3: This doesn't apply to help determine why the pt may suddenly be experiencing an exacerbation of the HF. Rationale 4: If the pt has attended a recent family or social gathering in which food was served, it is possible that the sodium content of the food was higher than the pt anticipating Which of the following pts should the nurse assess first? 1. the pt w/ occasional chest pain who has recently been diagnosed w/ gallbladder disease 2. the elderly pt w/ heart failure who was admitted w/ increasing edema of the lower extremities 3. the newly admitted pt complaining of substernal chest pain. Pt has recently had a father die from heart disease 4. the pt complaining of chest pain & is hyperventilating after a family member leaves the room following an argument - ANS Answer: 3 Rationale 1: The pt w/ gallbladder disease may have chest pain that is not cardiac related. Rationale 2: The elderly pt w/ increasing edema of the extremities would need evaluation, but after the newly admitted pt. Rationale 3: The nurse would want to assess the newly admitted pt w/ substernal chest pain w/ a family history of cardiac disease & initiate any interventions that are appropriate. Rationale 4: The pt who is hyperventilating could be having an anxiety attack, but needs to be assessed as soon as possible. The nurse caring for pts on a cardiac unit should plan to see which of the following assigned pts first? 1. a pt w/ hypertrophic cardiomyopathy who is reporting dyspnea 2. a pt who had a cardiac catheterization & will be ambulating for the first time 3. a pt receiving antibiotics for bacterial endocarditis who is reporting anxiety & chest pain 4. a pt who is recovering from coronary artery bypass grafting (CABG) surgery w/ a temperature of 101° F. - ANS Answer: 3 Rationale 1: Dyspnea is a chronic symptom w/ hypertrophic cardiomyopathy, which requires assessment. However, the pt w/ a possible PE is the most emergent. Rationale 2: The pt ambulating for the first time will be assessed by a nurse. However, the pt w/ a possible PE is the most emergent. Rationale 3: The pt w/ bacterial endocarditis is at risk for thrombus formation. This pt requires immediate attention as chest pain & anxiety are signs of pulmonary embolism (PE), which is life-threatening. Rationale 4: A temperature of 101° F requires further assessment; will be assessed by a nurse. However, the pt w/ a possible PE is the most emergent. A pt w/ endocarditis develops sudden leg pain w/ pallor, tingling, & a loss of peripheral pulses. The initial nursing intervention should be to do which of the following? 1. Notify the physician about these findings. 2. Elevate the leg above the level of the heart. 3. Wrap the extremity in a loose, warm blanket. Apply a foot cradle. 4. Perform passive range of motion (PROM) exercises to stimulate circulation. - ANS Answer: 3 Rationale 1: The physician should be notified after the nurse wraps the leg in a loose, warm blanket to maintain temperature & protect it from injury. Rationale 2: The leg should not be elevated above the heart because this can worsen the ischemia. Rationale 3: The pt is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. W/out immediate intervention, tissue ischemia & necrosis will ensue & ultimately loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain temperature & protect from injury, then notify the physician. Rationale 4: Passive ROM exercises will increase tissue demand for oxygen & increase ischemia. A pt, newly diagnosed w/ heart failure, is prescribed 40 mg of furosemide (Lasix) to be given IV push. Knowing that the pt is also prescribed digoxin (Lanoxin), the nurse should review which laboratory result? 1. sodium level 2. digoxin level 3. creatinine level 4. potassium level - ANS Answer: 4 Rationale 1: Furosemide can cause hyponatremia but the risk of hypokalemia has more severe consequences in this situation. Rationale 2: Heightened digoxin effect can occur in the pt w/ hypokalemia. Rationale 3: No data indicates renal insufficiency; therefore creatinine level is not relevant. Rationale 4: Serum potassium level is measured in the pt receiving digoxin & furosemide. Heightened digoxin effect can occur in the pt w/ hypokalemia. Hypokalemia also predisposes the pt to ventricular dysrhythmias. A pt is admitted w/ acute pericarditis. When auscultating heart sounds, the nurse should ask the pt to do which of the following? 1. Sit, lean forward, & auscultate at the left lower sternal border. 2. Lay supine & breathe quietly while auscultating for expiratory wheezes. 3. Sit upright & auscultate the outer aspects of the upper lobes for vesicular breath sounds. 4. Sit, lean forward, & auscultate at the second right intercostal space, near the sternal border. - ANS Answer: 1 Rationale 1: Pericardial friction rub is the characteristic sign of pericarditis & can be heard best at the left lower sternal border when the pt is sitting & leans forward. The rub is usually heart on expiration & may be constant or intermittent. Rationale 2: Pericardial friction rub is the characteristic sign of pericarditis & can be heard best at the left lower sternal border when the pt is sitting & leans forward. Rationale 3,4: Auscultating lung sounds for expiratory wheezes & vesicular breath sounds is done, but does not focus on the pericardial friction rub. A pt is being discharged from the healthcare facility following surgical replacement of a mitral valve w/ a mechanical valve. The pt asks the nurse how much longer he will need to take warfarin (Coumadin). What is the nurse's best response? 1. "You will be on it for the rest of your life because you have a mechanical valve." 2. "That will depend upon your surgeon. Ask him when you go to your office visit." 3. "You will be on it for the rest of your life because you have a biologic tissue valve." 4. "You will be told when to stop, which means your mechanical prosthetic valve is probably healed & there is minimal risk of clots." - ANS Answer: 1 Rationale 1: Long-term anticoagulation is necessary w/ a mechanical prosthetic valve, due to the risk of development of clots on the valve. Rationale 2: Option 2 gives false reassurance to the pt & does not answer the pt's question. Rationale 3: Biologic tissue valves have a low risk of thrombus formation & long-term anticoagulation is rarely necessary. Rationale 4: Long-term anticoagulation is necessary w/ a mechanical prosthetic valve, due to the risk of development of clots on the valve The nurse measures a pt's blood pressure as 144/88 mmHg. Which of the following interventions would be most appropriate for this pt? 1. Provide stress-reduction techniques. 2. Inform the physician so antihypertensive meds can be prescribed. 3. Offer the pt a glass of water. 4. Remeasure the blood pressure in a few minutes. - ANS Answer: 4 Rationale 1: The pt may not feel stressed. Rationale 2: There is no evidence that this pt has had previously high blood pressure readings. The pt may not need meds. Rationale 3: Offering a glass of water would have no effect on the blood pressure. Rationale 4: There is no evidence that this pt has had previously high BP readings. The nurse should remeasure the BP in a few minutes in the event the reading was because of physical activity or anxiety. HTN is defined as systolic BP of 140 mmHg or higher, or diastolic pressure of 90 mmHg or higher, based on the average of 3 or more readings taken on separate occasions. A pt w/ diabetes is beginning treatment for hypertension. The nurse shares w/ the pt that a desirable blood pressure would be which of the following? 1. 140/90 mmHg 2. 135/85 mmHg 3. 130/80 mmHg 4. 120/80 mmHg - ANS Answer: 3 Rationale 1: Hypertension management focuses on reducing the BP to less than 140 mmHg systolic & 90 mmHg diastolic. Rationale 2: The treatment goal is a BP less than 130/80. Rationale 3: Hypertension management focuses on reducing the BP to less than 140 mmHg systolic & 90 mmHg diastolic. The ultimate goal of HTN management is to reduce cardiovascular & renal morbidity & mortality. The risk of cardiovascular complications decreases when the average BP is less than 140/90; when the pt also has diabetes or renal disease, the treatment goal is a BP less than 130/80. Rationale 4: The treatment goal is a BP less than 130/80. The nurse is instructing a pt w/ hypertension about lifestyle modifications. Which of the following would be appropriate to include in the teaching for this pt? Select all that apply. 1. Review the DASH diet. 2. Begin a walking program, & progress to 30 minutes 5 to 6 days each week. 3. Plan a weight lifting regimen. 4. Eliminate dairy products from the diet. 5. Restrict fluid intake. - ANS Correct Answer: 1,2 Rationale 1: Lifestyle modifications are recommended for all pts whose BP falls w/in the prehypertension range & everyone w/ intermittent or sustained hypertension. These modifications include weight loss, dietary changes, restricted alcohol use & cigarette smoking, increased physical activity, & stress reduction. Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium & calcium intakes, & reducing total & saturated fat intake. The DASH diet has proven beneficial effects in lowering BP. Rationale 2: Previously sedentary pts are encouraged to engage in aerobic exercise for 30 to 45 minutes per day most days of the week. Rationale 3: Isometric exercise, such as weight training, may not be appropriate, as it can raise the systolic blood pressure. Rationale 4: Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium & calcium intakes, & reducing total & saturated fat intake. Rationale 5: Fluid restriction is not indicated. A pt is being started on enalapril (Vasotec). The most common complaint from pts who routinely take this meds is which of the following? 1. increased thirst 2. reduced urine output 3. persistent cough 4. sore throat - ANS Answer: 3 Rationale: Primary adverse affects for both ACE I & ARBs include persistent cough, first dose hypotension, & hyperkalemia, not thirst. A pt's BP continues to be elevated despite being prescribed an ACE inhibitor for several weeks. Which of the following would be most appropriate for the nurse to do at this time? 1. Ask if the pt is taking the prescribed meds. 2. Suggest to the physician that another meds be added. 3. Schedule the pt to have the blood pressure checked again in a week. 4. Realize the pt is anxious because of the diagnosis. - ANS Answer: 1 Rationale 1: Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for any pt w/ a chronic disease. Prescribed medss may have undesirable effects; whereas hypertension itself often has no symptoms or noticeable effects. The nurse should inquire about reasons for noncompliance w/ the recommended treatment plan by assessing for factors that can contribute to noncompliance, such as adverse drug effects. Rationale 2,3,4: If it is determined that the pt is not taking the prescribed meds, this intervention would not be indicated at this time. During the abdominal assessment of an elderly pt, the nurse palpates a mass in the mid-abdomen. Which of the following should the nurse do next? 1. Percuss the mass. 2. Ask the pt to cough. 3. Notify the physician. 4. Auscultate the mass. - ANS Answer: 4 Rationale 1, 2: If an aneurysm is suspected, asking the pt to cough & percussing the mass would be inappropriate responses that could increase the pressure on the weakened site. Rationale 3: Further assessment is needed before the physician would be contacted, typically first by phone. Rationale 4: Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- & upper abdomen & a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam. The nurse suspects a pt who is recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. Which of the following are indications of this event? Select all that apply. 1. urine output 45 mL/hr 2. complaint of groin pain 3. abdominal dressing dry & intact 4. respiratory rate 16 & regular 5. complaint of back discomfort - ANS Answer: 2,5 Rationale 1: This is considered w/in normal limits. Rationale 2: The nurse should monitor for & report any of the following manifestations of graft leakage: ecchymoses of the scrotum, perineum, or penis; a new or expanding hematoma; increased abdominal girth; weak or absent peripheral pulses; tachycardia; hypotension; decreased motor function or sensation in the extremities; decreased hemoglobin & hematocrit; increased abdominal, pelvic, back, or groin pain; decreased urinary output (less than 30 mL/ hour); decreased CVP, pulmonary artery pressure, or pulmonary artery wedge pressure. These manifestations may signal graft leakage & possible hemorrhage. Pain may be due to pressure from an expanding hematoma or bowel ischemia. Rationale 3,4: This is considered w/in normal limits. Rationale 5: The nurse should monitor for & report any of the following manifestations of graft leakage: ecchymoses of the scrotum, perineum, or penis; a new or expanding hematoma; increased abdominal girth; weak or absent peripheral pulses; tachycardia; hypotension; decreased motor function or sensation in the extremities; decreased hemoglobin & hematocrit; increased abdominal, pelvic, back, or groin pain; decreased urinary output (less than 30 mL/ hour); decreased CVP, pulmonary artery pressure, or pulmonary artery wedge pressure. These manifestations may signal graft leakage & possible hemorrhage. Pain may be due to pressure from an expanding hematoma or bowel ischemia. The nurse suspects that a pt is experiencing the effects of peripheral atherosclerosis. Which of the following did the nurse most likely assess in this pt? 1. rubor w/ extremity elevation 2. normal hair distribution bilaterally over lower extremities 3. peripheral pulses present bilaterally 4. complaints of leg pain upon rest - ANS Answer: 4 Rationale 1: Manifestations of peripheral atherosclerosis include rubor w/ extremities in dependent position. Rationale 2: Manifestations of peripheral atherosclerosis include thin, shiny, hairless skin. Rationale 3: Manifestations of peripheral atherosclerosis include diminished or absent peripheral pulses. Rationale 4: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest; paresthesias; diminished or absent peripheral pulses; pallor w/ extremity elevation; rubor w/ extremities in dependent position; thin, shiny, hairless skin; thickened toenails; & areas of skin discoloration or skin breakdown. A pt is having segmental pressure measurements conducted to help diagnose peripheral vascular disease. Which of the following would indicate the presence of this disorder? 1. thigh pressure higher than the arm 2. calf pressure higher than the arm 3. calf pressure lower than the arm 4. no difference between the arm or leg - ANS Answer: 3 Rationale 1,2: In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms. Rationale 3: Noninvasive studies often are sufficient to diagnose peripheral vascular disease. Segmental pressure measurements use sphygmomanometer cuffs & a Doppler device to compare blood pressures between the upper & lower extremities & w/in different segments of the affected extremity. Rationale 4: In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms. A pt is demonstrating signs of ineffective peripheral tissue perfusion. Which of the following interventions would be appropriate for this pt? 1. Encourage pt to reduce level of exercise. 2. Discuss smoking cessation techniques. 3. Keep extremities cool. 4. Assist w/ pillow placement under knees. - ANS Answer: 2 Rationale 1: Interventions for a pt who is experiencing ineffective peripheral tissue perfusion discussing the benefits of regular exercise. Rationale 2: Interventions for a pt who is experiencing ineffective peripheral tissue perfusion include assessing peripheral pulses, pain, color, temperature, & capillary refill every 4 hours & prn; positioning w/ extremities dependent; instructing to avoid smoking; discussing the benefits of regular exercise; using a foot cradle & lightweight blankets, socks, & slippers to keep extremities warm; avoiding electric heating pads or hot water bottles; encouraging frequent position changes; & instructing to avoid crossing legs or using a pillow under the knees. Rationale 3: Interventions for a pt who is experiencing ineffective peripheral tissue perfusion include using a foot cradle & lightweight blankets, socks, & slippers to keep extremities warm & avoiding electric heating pads or hot water bottles. Rationale 4: Interventions for a pt who is experiencing ineffective peripheral tissue perfusion include instructing to avoid crossing legs or using a pillow under the knees. A pt is diagnosed w/ thromboangiitis obliterans. Appropriate teaching for this pt includes which of the following? 1. Medss are the only cure. 2. Surgical procedures can be performed to cure this disorder. 3. Management depends upon the pt's willingness to stop smoking. 4. Management strategies have no effect on disorder. - ANS Answer: 3 Rationale 1: No cure is available. Rationale 2: No cure is available. Rationale 3 & 4: The prognosis for thromboangiitis obliterans depends significantly on the pt's ability & willingness to stop smoking. W/ smoking cessation & good foot care, the prognosis for saving the extremities is good, even though no cure is available. A pt is being discharged on long-term oral anticoagulant therapy for arterial thrombus formation in the lower extremity. Which of the following should be included in this pt's discharge instructions? 1. Slight bleeding from the nose is expected. 2. Contact the physician's office for follow-up laboratory studies. 3. Pain in the limb is a sign of healing. 4. Take two doses of the prescribed anticoagulant if a dose is missed one day. - ANS Answer: 2 Rationale 1: Nasal bleeding is not expected. Rationale 2: When preparing the pt & family for home or community-based care related to an acute arterial occlusion, discuss the following topics as necessary: incision care; manifestations of complications to be reported, including symptoms of infection or occlusion of the graft or artery; long-term anticoagulant therapy, including the reason, prescribed dose, follow-up laboratory testing & appointments, interactions w/ other drugs, & manifestations of excessive bleeding; any activity restrictions or dietary modifications; lifestyle modifications to slow atherosclerosis & control hypertension; & measures to promote peripheral circulation & maintain tissue integrity. Rationale 3: Pain in the limb could indicate another clot has formed. Rationale 4: Anticoagulant meds should never be "doubled" even in the case of a missed dose. The pt would be encouraged to notify the physician if a dose is missed. A pt is demonstrating signs of thrombophlebitis. W/ this disorder, the nurse realizes that which three mechanisms occur to cause this condition? Select all that apply. 1. pooling of blood in the vessel 2. blood hypercoagulation 3. sluggish blood flow 4. elevated systemic blood pressure 5. vessel damage - ANS Answer: 2,3,5 Rationale 1: Blood does not pool in the vessel, it is restricted. Rationale 2: Three pathologic factors, called Virchow's triad, are associated w/ thrombophlebitis: stasis of blood, vessel damage, & increased blood coagulability. Rationale 3: Three pathologic factors, called Virchow's triad, are associated w/ thrombophlebitis: stasis of blood, vessel damage, & increased blood coagulability. Rationale 4: Systemic blood pressure elevation is not a mechanism of this problem. Rationale 5: Three pathologic factors, called Virchow's triad, are associated w/ thrombophlebitis: stasis of blood, vessel damage, & increased blood coagulability. A pt is seen for increasing edema in his left lower extremity, erythema, & pain in the limb w/ ambulation. Which of the following disorders do these symptoms suggest? 1. arterial occlusion 2. deep vein thrombosis 3. superficial vein thrombosis (SVT) 4. varicose veins - ANS Answer: 2 Rationale 1: A DVT is not an arterial or a primary superficial vein problem. Rationale 2: The manifestations of deep vein thrombosis (DVT) are primarily due to the inflammatory process that accompanies the thrombus. Calf pain is the most common symptom, & it may be described as tightness or a dull, aching pain in the affected extremity, particularly upon walking. Tenderness, swelling, warmth, & erythema may be noted along the course of involved veins. The affected extremity may be cyanotic & often is edematous. Rarely, a cord may be palpated over the affected vein. A positive Homan's sign is an unreliable indicator of DVT. Rationale 3: A DVT is not an arterial or a primary superficial vein problem. Rationale 4: Varicose veins are tortuous veins w/ valve insufficiency. A pt w/ a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. The nurse anticipates that oral warfarin sodium should be prescribed 1. the same day the heparin is discontinued. 2. the day before the heparin is discontinued. 3. four to five days before the heparin is discontinued. 4. the day the pt is discharged. - ANS Answer: 3 Rationale 1 & 2: Anticoagulation w/ warfarin may be initiated concurrently w/ heparin therapy. Rationale 3: Oral anticoagulation w/ warfarin may be initiated concurrently w/ heparin therapy. Overlapping heparin & warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, & it may actually promote clotting during the first few days of therapy. Rationale 4: Overlapping heparin & warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, & it may actually promote clotting during the first few days of therapy. The nurse is planning care for a pt who was diagnosed w/ deep vein thrombosis (DVT). Which of the following should be included in the pt's plan of care? 1. activity as tolerated 2. measure & apply graduated compression stockings 3. encourage pt to sit out of bed several hours every day 4. assist pt w/ putting on tight-fitting pants - ANS Answer: 2 Rationale 1: The plan of care for a pt w/ deep vein thrombosis (DVT) includes possible bed rest, the duration of which is determined by the extent of leg edema. Rationale 2: The plan of care for a pt w/ deep vein thrombosis (DVT) includes possible bed rest, the duration of which is determined by the extent of leg edema; elevate legs 15 to 20 degrees, w/ the knees slightly flexed, above the level of the heart to promote venous return & discourage venous pooling; elastic antiembolism/compression stockings or pneumatic compression devices are also frequently ordered to stimulate the muscle-pumping mechanism that promotes the return of blood to the heart; when permitted, walking is encouraged; avoid prolonged standing or sitting; avoid leg crossing & tight-fitting garments or stockings that bind. Rationale 3: Walking is encouraged but the pt should avoid prolonged standing or sitting & avoid leg crossing. Rationale 4: The pt should avoid tight-fitting garments or stockings that bind. A pt who is being treated for a deep vein thrombosis (DVT) complains of chest pain & shortness of breath. Which of the following should the nurse do first? 1. Elevate the head of the bed & begin oxygen therapy. 2. Obtain a 12-lead EKG & notify the physician. 3. Measure the pt's blood pressure. 4. Assess the extremity w/ the thrombosis & heart sounds. 5. Assess the pulses on the extremity w/ the thrombosis & check the PT/INR level . - ANS Answer: 1 Rationale 1: Immediately report pt complaints of chest pain & shortness of breath, anxiety, or a sense of impending doom. The manifestations of pulmonary embolism are similar to those of myocardial infarction. Prompt intervention to restore pulmonary blood flow can reduce the risk of significant adverse effects. Initiate oxygen therapy, elevate the head of the bed, & reassure the pt who is experiencing manifestations of pulmonary embolism. Oxygen therapy & elevating the head of the bed promote ventilation & gas exchange in those alveoli that are well-perfused, & help to maintain tissue oxygenation. Rationale 2,3,4,5: This intervention is not the priority & would delay the initiation of required interventions in this situation. A 75-year-old pt is diagnosed w/ chronic venous insufficiency. Which of the following instructions are appropriate for this pt? 1. Keep legs in a dependent position as much as possible. 2. Avoid the use of knee-high hose or girdles. 3. Limit ambulation. 4. Dangle legs over the side of the bed several times per day. - ANS Answer: 2 An elderly pt is prescribed elastic graduated compression stockings. The nurse should instruct this pt to do which of the following? 1. Wear the stockings continuously, except when showering. 2. Expect areas of skin breakdown under the stockings. 3. Wear the stockings primarily while sleeping. 4. Remove the stockings once per day & while sleeping. - ANS Answer: 4 Rationale 1: The pt who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, & remove them once during the daytime & while sleeping. Rationale 2: Skin breakdown is not anticipated w/ wearing the stockings & would need to be reported to the physician. Rationale 3: The pt who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, & remove them once during the daytime & while sleeping. Rationale 4: The pt who is prescribed elastic graduated compression stockings should be instructed to wear the elastic stockings during the majority of waking hours, & remove them once during the daytime & while sleeping. The nurse is preparing to assess a pt's hematologic, peripheral vascular, & lymphatic systems. Which of the following assessment techniques is not typically utilized for this assessment? 1. inspection. 2. palpation 3. percussion 4. auscultation - ANS Answer: 3 Rationale 1,2,4 : The techniques used to assess these systems include inspection of the skin for such changes as edema, ulcerations, or alterations in color & temperature; auscultation of BP; & palpation of the major pulse points of the body & lymph nodes. Rationale 3: Percussion is not typically used to assess the hematologic, peripheral vascular, & lymphatic systems. During the assessment, a pt's pedal pulses are increased. The nurse should document this finding as which of the following? 1. +1 2. +2 3. +3 4. +4 - ANS Correct Answer: 3 Rationale: The correct documentation for this finding is +3. Pulses should be described as increased, normal, diminished, or absent. Scales that range from 0 to 4+ are sometimes used as follows: 0 = absent; 1+ = diminished; 2+ = normal; 3+ = increased; & 4+ = bounding. estions And Answers (Graded A+!!!!