N454 Test 2 UPDATED ACTUAL Exam
Questions and CORRECT Answers
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular
insufficiency for the patient with infective endocarditis (IE) based on which assessment
finding(s)?
a. Fever, chills, and diaphoresis
b. Urine output less than 30 mL/hr
c. Petechiae on the inside of the mouth and conjunctiva
d. Increase in heart rate of 15 beats/minute with walking - CORRECT ANSWER - ANS: B
Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine
output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by
decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE),
which intervention is a priority for the nurse to include?
a. Monitor labs for streptococcal antibodies.
b. Arrange for placement of a long-term IV catheter.
c. Teach the importance of completing all oral antibiotics.
d. Encourage the patient to begin regular aerobic exercise. - CORRECT ANSWER - ANS:
B
Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria,
which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC)
line. Rest periods and limiting physical activity to a moderate level are recommended during the
treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause
IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic
therapy
A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to
teach the patient about the purpose of
,a. echocardiography.
b. daily blood cultures.
c. cardiac catheterization.
d. 24-hour Holter monitor. - CORRECT ANSWER - ANS: A
Echocardiograms are useful in detecting the presence of the pericardial effusions associated with
pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac
catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis
The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the
presence of pulsus paradoxus, the nurse should
a. note when Korotkoff sounds are auscultated during both inspiration and expiration.
b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.
d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.
- CORRECT ANSWER - ANS: A
Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff
sounds can be heard during only expiration and when they can be heard throughout the
respiratory cycle. The other methods described would not be useful in determining the presence
of pulsus paradoxus
The nurse is admitting a patient with possible rheumatic fever. Which question on the admission
health history will be most pertinent to ask?
a. "Do you use any illegal IV drugs?"
b. "Have you had a recent sore throat?"
c. "Have you injured your chest in the last few weeks?"
d. "Do you have a family history of congenital heart disease?" - CORRECT ANSWER -
ANS: B
,Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection.
Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk
factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family
history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest
pain rather than rheumatic fever.
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and
polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate?
a. Pain related to permanent joint fixation
b. Activity intolerance related to arthralgia
c. Risk for infection related to open skin lesions
d. Risk for impaired skin integrity related to pruritus - CORRECT ANSWER - ANS: B
The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic
fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint
inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with
permanent joint changes
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of
knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering
from rheumatic fever without carditis says which of the following?
a. "I will need prophylactic antibiotic therapy for 5 years."
b. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain."
c. "I will call the doctor if I develop excessive fatigue or difficulty breathing."
d. "I will be immune to further episodes of rheumatic fever after this infection." - CORRECT
ANSWER - ANS: D
Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with
rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5 years.
The other patient statements are correct and would not support the nursing diagnosis of
ineffective health maintenance
, When developing a community health program to decrease the incidence of rheumatic fever,
which action would be most important for the community health nurse to include?
a. Vaccinate high-risk groups in the community with streptococcal vaccine.
b. Teach community members to seek treatment for streptococcal pharyngitis.
c. Teach about the importance of monitoring temperature when sore throats occur.
d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever. -
CORRECT ANSWER - ANS: B
The incidence of rheumatic fever is decreased by treatment of streptococcal infections with
antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that
is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring
temperature will not decrease the incidence of rheumatic fever.
While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular
regurgitation, the nurse determines that discharge teaching has been effective when the patient
states that it will be necessary to
a. take antibiotics before any dental appointments.
b. limit physical activity to avoid stressing the heart.
c. take an aspirin a day to prevent clots from forming on the valve.
d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs. - CORRECT
ANSWER - ANS: D
Use of stimulant medications should be avoided by patients with MVP because these may
exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients
with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but
will not be necessary for this patient
During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a
mechanical valve, the nurse instructs the patient on the
a. use of daily aspirin for anticoagulation.
b. correct method for taking the radial pulse.
Questions and CORRECT Answers
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular
insufficiency for the patient with infective endocarditis (IE) based on which assessment
finding(s)?
a. Fever, chills, and diaphoresis
b. Urine output less than 30 mL/hr
c. Petechiae on the inside of the mouth and conjunctiva
d. Increase in heart rate of 15 beats/minute with walking - CORRECT ANSWER - ANS: B
Decreased renal perfusion caused by inadequate cardiac output will lead to decreased urine
output. Petechiae, fever, chills, and diaphoresis are symptoms of IE, but are not caused by
decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise
When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE),
which intervention is a priority for the nurse to include?
a. Monitor labs for streptococcal antibodies.
b. Arrange for placement of a long-term IV catheter.
c. Teach the importance of completing all oral antibiotics.
d. Encourage the patient to begin regular aerobic exercise. - CORRECT ANSWER - ANS:
B
Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria,
which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC)
line. Rest periods and limiting physical activity to a moderate level are recommended during the
treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause
IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic
therapy
A patient is admitted to the hospital with possible acute pericarditis. The nurse should plan to
teach the patient about the purpose of
,a. echocardiography.
b. daily blood cultures.
c. cardiac catheterization.
d. 24-hour Holter monitor. - CORRECT ANSWER - ANS: A
Echocardiograms are useful in detecting the presence of the pericardial effusions associated with
pericarditis. Blood cultures are not indicated unless the patient has evidence of sepsis. Cardiac
catheterization and 24-hour Holter monitor is not a diagnostic procedure for pericarditis
The nurse suspects cardiac tamponade in a patient who has acute pericarditis. To assess for the
presence of pulsus paradoxus, the nurse should
a. note when Korotkoff sounds are auscultated during both inspiration and expiration.
b. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
c. check the electrocardiogram (ECG) for variations in rate during the respiratory cycle.
d. listen for a pericardial friction rub that persists when the patient is instructed to stop breathing.
- CORRECT ANSWER - ANS: A
Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff
sounds can be heard during only expiration and when they can be heard throughout the
respiratory cycle. The other methods described would not be useful in determining the presence
of pulsus paradoxus
The nurse is admitting a patient with possible rheumatic fever. Which question on the admission
health history will be most pertinent to ask?
a. "Do you use any illegal IV drugs?"
b. "Have you had a recent sore throat?"
c. "Have you injured your chest in the last few weeks?"
d. "Do you have a family history of congenital heart disease?" - CORRECT ANSWER -
ANS: B
,Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection.
Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk
factor for rheumatic fever, and would not be as pertinent when admitting the patient. Family
history is not a risk factor for rheumatic fever. Chest injury would cause musculoskeletal chest
pain rather than rheumatic fever.
A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and
polyarthritis. Based on these findings, which nursing diagnosis would be most appropriate?
a. Pain related to permanent joint fixation
b. Activity intolerance related to arthralgia
c. Risk for infection related to open skin lesions
d. Risk for impaired skin integrity related to pruritus - CORRECT ANSWER - ANS: B
The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic
fever are not open or pruritic. Although acute joint pain will be a problem for this patient, joint
inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with
permanent joint changes
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of
knowledge regarding long-term management of rheumatic fever when a 30-year-old recovering
from rheumatic fever without carditis says which of the following?
a. "I will need prophylactic antibiotic therapy for 5 years."
b. "I will need to take aspirin or ibuprofen (Motrin) to relieve my joint pain."
c. "I will call the doctor if I develop excessive fatigue or difficulty breathing."
d. "I will be immune to further episodes of rheumatic fever after this infection." - CORRECT
ANSWER - ANS: D
Patients with a history of rheumatic fever are more susceptible to a second episode. Patients with
rheumatic fever without carditis require prophylaxis until age 20 and for a minimum of 5 years.
The other patient statements are correct and would not support the nursing diagnosis of
ineffective health maintenance
, When developing a community health program to decrease the incidence of rheumatic fever,
which action would be most important for the community health nurse to include?
a. Vaccinate high-risk groups in the community with streptococcal vaccine.
b. Teach community members to seek treatment for streptococcal pharyngitis.
c. Teach about the importance of monitoring temperature when sore throats occur.
d. Teach about prophylactic antibiotics to those with a family history of rheumatic fever. -
CORRECT ANSWER - ANS: B
The incidence of rheumatic fever is decreased by treatment of streptococcal infections with
antibiotics. Family history is not a risk factor for rheumatic fever. There is no immunization that
is effective in decreasing the incidence of rheumatic fever. Teaching about monitoring
temperature will not decrease the incidence of rheumatic fever.
While caring for a 23-year-old patient with mitral valve prolapse (MVP) without valvular
regurgitation, the nurse determines that discharge teaching has been effective when the patient
states that it will be necessary to
a. take antibiotics before any dental appointments.
b. limit physical activity to avoid stressing the heart.
c. take an aspirin a day to prevent clots from forming on the valve.
d. avoid use of over-the-counter (OTC) medications that contain stimulant drugs. - CORRECT
ANSWER - ANS: D
Use of stimulant medications should be avoided by patients with MVP because these may
exacerbate symptoms. Daily aspirin and restricted physical activity are not needed by patients
with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but
will not be necessary for this patient
During discharge teaching with a 68-year-old patient who had a mitral valve replacement with a
mechanical valve, the nurse instructs the patient on the
a. use of daily aspirin for anticoagulation.
b. correct method for taking the radial pulse.
