NUR 257 EXAM 1,2 AND 3 BUNDLE NEWEST ACTUAL EXAM
COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS
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."
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 healthcare
provider of the results. - ANSWER: Assess the client for bleeding and notify the
health care provider of the results.
The nurse suspects a client has developed pericarditis after a week of cold-like
symptoms. Which of the client's signs and symptoms indicate pericarditis?
low urine output secondary to left ventricular dysfunction
fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
pitting edema, chest discomfort, and nonspecific ST-segment elevation
lethargy, anorexia, and heart failure - ANSWER: fever, chest discomfort, and elevated
erythrocyte sedimentation rate (ESR)
A client is admitted to the hospital with aortic stenosis. What assessment findings
would indicate the development of left ventricular failure?
Orthopnea, nausea, pedal edema
Distended jugular veins, pedal edema, nausea
Dyspnea, orthopnea, pulmonary edema
Dyspnea, distended jugular veins, orthopnea - ANSWER: Dyspnea, orthopnea,
pulmonary edema
Which would the nurse stress as a periodic lifelong necessity for a client managing
infective endocarditis?
Exercise regimen
Antihypertensive medication
Potassium replacement
Antibiotic therapy - ANSWER: Antibiotic therapy
The nurse is caring for a client who has been diagnosed with aortic stenosis. The
client is prescribed digoxin. What is the rationale for the medication?
left ventricular dysfunction
angina
dyspnea
edema - ANSWER: left ventricular dysfunction
A client is admitted to the hospital with possible acute pericarditis and pericardial
effusion. The nurse knows to prepare the client for which diagnostic test to confirm
the client's diagnosis?
Computed tomography
Echocardiography
Chest x-ray
Cardiac catheterization - ANSWER: Echocardiography
A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed
with streptococcal pharyngitis. A nurse knows that early diagnosis and effective
treatment is essential to avoid which preventable disease?
Rheumatic fever
Cardiomyopathy
,Pericarditis
Mitral stenosis - ANSWER: Rheumatic fever
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 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.
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 blood-thinning
drugs when I am discharged."
"The valve is from a tissue donor, and I will not need to take any blood-thinning
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."
The nurse is providing discharge teaching for a client with rheumatic endocarditis
but no valvular dysfunction. On which nursing diagnosis should the nurse focus her
teaching?
Chronic pain
Impaired gas exchange
Risk for infection
Impaired memory - ANSWER: Risk for infection
A client who had a prosthetic valve replacement was taking warfarin to reduce the
risk of postoperative thrombosis. The client visited the nurse at a clinic once a week.
What INR level would alert the nurse to notify the health care provider?
2.6
3.4
3.0
3.8 - ANSWER: 3.8
COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS
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."
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 healthcare
provider of the results. - ANSWER: Assess the client for bleeding and notify the
health care provider of the results.
The nurse suspects a client has developed pericarditis after a week of cold-like
symptoms. Which of the client's signs and symptoms indicate pericarditis?
low urine output secondary to left ventricular dysfunction
fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
pitting edema, chest discomfort, and nonspecific ST-segment elevation
lethargy, anorexia, and heart failure - ANSWER: fever, chest discomfort, and elevated
erythrocyte sedimentation rate (ESR)
A client is admitted to the hospital with aortic stenosis. What assessment findings
would indicate the development of left ventricular failure?
Orthopnea, nausea, pedal edema
Distended jugular veins, pedal edema, nausea
Dyspnea, orthopnea, pulmonary edema
Dyspnea, distended jugular veins, orthopnea - ANSWER: Dyspnea, orthopnea,
pulmonary edema
Which would the nurse stress as a periodic lifelong necessity for a client managing
infective endocarditis?
Exercise regimen
Antihypertensive medication
Potassium replacement
Antibiotic therapy - ANSWER: Antibiotic therapy
The nurse is caring for a client who has been diagnosed with aortic stenosis. The
client is prescribed digoxin. What is the rationale for the medication?
left ventricular dysfunction
angina
dyspnea
edema - ANSWER: left ventricular dysfunction
A client is admitted to the hospital with possible acute pericarditis and pericardial
effusion. The nurse knows to prepare the client for which diagnostic test to confirm
the client's diagnosis?
Computed tomography
Echocardiography
Chest x-ray
Cardiac catheterization - ANSWER: Echocardiography
A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed
with streptococcal pharyngitis. A nurse knows that early diagnosis and effective
treatment is essential to avoid which preventable disease?
Rheumatic fever
Cardiomyopathy
,Pericarditis
Mitral stenosis - ANSWER: Rheumatic fever
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 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.
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 blood-thinning
drugs when I am discharged."
"The valve is from a tissue donor, and I will not need to take any blood-thinning
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."
The nurse is providing discharge teaching for a client with rheumatic endocarditis
but no valvular dysfunction. On which nursing diagnosis should the nurse focus her
teaching?
Chronic pain
Impaired gas exchange
Risk for infection
Impaired memory - ANSWER: Risk for infection
A client who had a prosthetic valve replacement was taking warfarin to reduce the
risk of postoperative thrombosis. The client visited the nurse at a clinic once a week.
What INR level would alert the nurse to notify the health care provider?
2.6
3.4
3.0
3.8 - ANSWER: 3.8
