MED SURGE EXAM –CM QUESTIONS WITH ANSWERS 2023 A+ SUCCESS GUARANTEED, Exams of Nursing

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 When caring for a patient in shock, one of the major nursing goals is to reduce the risk that

the patient will develop complications of shock. How can the nurse best achieve this goal?

A) Provide a detailed diagnosis and plan of care in order to promote the patients and familys coping. B) Keep the physician updated with the most accurate information because in cases of shock the nurse often cannot provide relevant interventions. C) Monitor for significant changes and evaluate patient outcomes on a scheduled basis focusing on blood pressure and skin temperature. D) Understand the underlying mechanisms of shock, recognize the subtle and more obvious signs, and then provide rapid assessment. Ans: D  A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply. A) Hypovolemia B) Difficulty breathing C) Cardiovascular overload D) Pulmonary edema E) Hypoglycemia Ans: B, C, D  The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment? A) To prevent the formation of infarcts of emboli B) To limit stroke volume and cardiac output C) To prevent pulmonary and peripheral edema D) To maintain adequate mean arterial pressure Ans: D  An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patients infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patients risk of septic shock? A) Apply an antibiotic ointment to the patients mucous membranes, as ordered. B) Perform passive range-of-motion exercises unless contraindicated

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C) Initiate total parenteral nutrition (TPN) D) Remove invasive devices as soon as they are no longer needed Ans: D  A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome Ans: C  A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? Confusion – Answer Unconsciousness Petechia Coma/lethargy  A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis? A) Increase calcium and vitamin intake. B) Perform meticulous foot care. C) Exercise 3 to 4 times weekly for at least 30 minutes. D) Take corticosteroids as ordered. Ans: B  An elderly female with osteoporosis has been hospitalized. Prior to discharge, when teaching the patient, the nurse should include information about which major complication of osteoporosis? A) Bone fracture B) Loss of estrogen C) Negative calcium balance D) Dowager's hump

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Ans: A  A nurse is caring for a client who is postoperative following a below-the-knee-amputation and will soon undergo fitting for a leg prosthesis. which of the following is an appropriate intervention for this client at this time? a) wrap the stump with an elastic bandage in a figure-eight configuration b) remove the elastic bandage and re-wrap the stump once a day c) wrap the stump with an elastic bandage in a proximal-to-distal direction d) secure the elastic bandage to the lowest joint Ans: A  A nurse is caring for a client who is sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? a. The client complains of pain b. The client develops a life-threatening situation c. The client needs to have an x-ray of the femur preformed d. The client must be repositioned in bed Ans: B  A client returns to the surgical unit from the post anesthesia care unit in skeletal traction. The nurse should take action to correct which of the following problems with the traction setup? A. The ropes are in the center of the wheel grooves B. The weights rest against the foot of the bed C. The weights are equal on each side D. The ropes attach securely attached to the pin. Ans: B  A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? A. Cryoprecipitates B. Albumin C. Platelets D. Packed Red blood cells Ans: D

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 A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? A- DIC is controllable with lifelong heparin usage B- DIC is caused by abnormal coagulation involving fibrinogen C- DIC is a genetic involving a vitamin K deficiency D- DIC is characterized by an elevated platelet count Ans: B  The nurse knows that a patient with crush injuries to the lower extremities is a high risk for what complication? A. Bradycardia B. Hypotension C. Acute kidney injury D. Spinal nerve injury Ans: C  A middle-aged patient has a tight cast on the left lower leg. Which assessment finding would prompt the nurse to assess further for compartment syndrome? A. Diminished pulses B. Discoloration of some of the toes C. Tingling sensation of the upper leg D. Pain more intense than expected based on initial injury Ans: D  The nurse is taking a patient for testing to determine the extent of injury sustained to the patient's knee when a fall occurred at work. The nurse explains that which diagnostic test best demonstrates musculoskeletal and soft tissue damage A. Standard x-rays B. Electromyography C. CT D. MRI Ans: D  A nurse is caring for an adolescent who has a newly applied fiberglass cast for a fractured tibia. Immediately following application of a fiberglass cast, the nurse should recognize that the nursing priority is to Perform neurovascular assessment

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 A 29-year-old male is admitted to the orthopedic unit with a fractured femur after running his motorcycle into a bridge abutment. The patient has been placed in traction until his femur can be rodded in surgery. What early complications would the nurse have to monitor this patient for? (Mark all that apply.) (question was similar to this one) A) Alteration in elimination B) Alteration in personality C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism Ans: C, D, E  Assessment findings for hypovolemic shock? (not sure on this) -declining lactate and potassium  Fluid overload: (also not sure. check me) -increased hr -increased bp -increased respirations  Which assessment finding does the nurse interpret as demonstrating a client’s fluid resuscitation adequacy? A. Decreased skin turgor B. Decreased pulse pressure C. Decreased core body temperature D. Decreased urine specific gravity Ans: D  Which nursing interventions decreases the risk for cross-contamination in the client with a severe burn injury? Select all that apply. A. Place a client in isolation B. Encourage multiple visitors to support clients C. Ensure that no plants or flowers are in the client’s room D. Teach family members not to bring fresh fruit and vegetables E. Change gloves after cleaning and dressing of one wound are before cleaning and dressing another Ans: A, C, D  Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective?

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A. Oxygen saturation remains unchanged B. Core body temperature has increased to 99 F (37.2 C) C. The client correctly states month and year D. Serum lactate and serum potassium levels are declining Ans: D  With which client should the nurse remain alert for the possibility of sepsis and septic shock? A. 41-year-old man who sustained closed depression fractures of the face when hit with a baseball B. 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago D. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate cancer Ans: C  A client who has a plaster leg splint reports a painful pressure sensation under the elastic wrap that is holding the splint in place. What is the nurse’s best initial action? A. Remove the splint to reduce skin pressure B. Perform a neurovascular assessment C. Report the client’s concern to the primary health care provider D. Inspect the skin under the elastic bandage Ans: B  A client who had an elective below-the-knee amputation (BKA) reports pain in the foot that was that was amputated last week. What is the nurse’s most appropriate response to the client’s pain? A. “The pain will go away after the swelling increases.” B. “That’s phantom limb pain, and every amputee has that.” C. “Your foot has been amputated, so it’s in your head.” D. “On a scale of 0 to 10, how would you rate your pain?” Ans: D  What is the nurse’s priority when doing an admission for a client who has returned directly from the operating suite after a carpal tunnel repair? A. Monitor vital signs, including pulse oximetry B. Check the surgical dressing to ensure that it is intact C. Assess neurovascular assessment in the affected arm D. Monitor intake and output

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Ans: A CM 4 Exam 4 Note: 2 questions had EKG strips so they’re omitted & some have correct answer only  During a shift assessment, the nurse is identifying the clients point of maximum impulse (PMI). Where will the nurse best palpate the PMI? A) Left midclavicular line of the chest at the level of the nipple B) Lef t midclavicular line of the chest at the fifth intercostal space C) Midline between the xiphoid process and the left nipple D) Two to three centimeters to the left of the sternum Ans: B  The physical therapist notifies the nurse that a patient with coronary artery disease (CAD) experiences a much greater-than-average increase in heart rate during physical therapy. The nurse recognizes that an increase in heart rate in a patient with CAD may result in what? A) Development of an atrial-septal defect B) Myocardial ischemia C) Formation of a pulmonary embolism D) Release of potassium ions from cardiac cells Ans: B  The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization. This pathologic change would be most evident in what component of the ECG? A) P wave B) T wave C) QRS complex D) U wave Ans: C  The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate goal for the patient? A) Maintain a resting heart rate below 70 bpm. B) Maintain adequate control of chest pain.

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C) Maintain adequate cardiac output. D) Maintain normal cardiac structure. Ans: C  A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose of this device. What would be the nurse’s best response? A) To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia B) To detect and treat bradycardia, which is an excessively slow heart rate C) To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently D) To shock your heart if you have a heart attack at home Ans: A  A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166 bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the main goal of treatment is what? A) Decrease SA node conduction B) Control ventricular heart rate C) Improve oxygenation D) Maintain anticoagulation Ans: B  A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects? A) Nervousness or paresthesia B) Throbbing headache or dizziness C) Drowsiness or blurred vision D) Tinnitus or diplopia Ans: B  The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following?

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A) Drug therapy and smoking cessation

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B) Diet and drug therapy C) Diet therapy only D) Diet therapy and smoking cessation Ans: D  The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient? A) Oxycodone B) Warfarin C) Morphine D) Acetaminophen Ans: C  The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patients care plan? A) Facilitate daily arterial blood gas (ABG) sampling. B) Administer supplementary oxygen, as needed. C) Have patient maintain supine positioning when in bed. D) Perform chest physiotherapy, as indicated. Ans: B  The nurse is caring for an 84-year-old man who has just returned from the OR after inguinal hernia repair. The OR report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that the patient is at risk for left-sided heart failure. What signs and symptoms would indicate left-sided heart failure? A) Jugular vein distention B) Right upper quadrant pain C) Bibasilar fine crackles D) Dependent edema Ans: C  The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient to be at greatest risk for the development of cardiogenic shock? A) The patient admitted with acute renal failure B) The patient admitted following an MI

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C) The patient admitted with malignant hypertension D) The patient admitted following a stroke Ans: B  The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a. Administer the prescribed tetanus toxoid vaccine. b. Assess the clients wounds for signs of infection. c. Encourage the client to breathe deeply every hour. d. Wash your hands on entering the clients room. ANS: D  The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a. I get my chimney swept every other year. b. My hot water heater is set at 120 degrees. c. Sometimes I wake up at night and smoke. d. I use a space heater when it gets below zero. ANS: C  A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a. I will allow my spouse to change my dressings. b. I want to have surgical reconstruction. c. I will bathe and dress before breakfast. d. I have secured the pressure dressings as ordered. ANS: C  The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a. It is normal to feel some depression. b. I will go back to work immediately. c. I will not feel anger about my situation. d. Once I get home, things will be normal. ANS: A

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 A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?

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a. Assess the level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and bronchi. d. Measure abdominal girth and auscultate bowel sounds. ANS: C  A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a. Arterial pH: 7. b. Hematocrit: 52% c. Serum potassium: 6.5 mEq/L d. Serum sodium: 131 mEq/L ANS: C  A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this clients discharge teaching? a. You should change the batteries in your smoke detector once a year. b. Join a program that assists burn clients to reintegration into the community. c. I will demonstrate how to change your wound dressing for you and your family. d. Let me tell you about the many options available to you for reconstructive surgery. ANS: C  A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)? a. It causes vasoconstriction and increased MAP. b. Lower blood volume lowers MAP. c. There is no direct correlation to MAP. d. It raises cardiac output and MAP. ANS: B  A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the clients tissue perfusion further. c. Document the findings in the clients chart. d. Increase the rate of the clients IV infusion.

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ANS: B

 The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours ANS: A  A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed. ANS: B  A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority? a. Apply direct pressure to the bleeding. b. Ensure the client has a patent airway. c. Obtain consent for emergency surgery. d. Start two large-bore IV catheters. ANS: B  A nurse assesses a client with a fracture who is being treated with skeletal traction. Which assessment should alert the nurse to urgently contact the health provider? a. Blood pressure increases to 130/86 mm Hg b. Traction weights are resting on the floor c. Oozing of clear fluid is noted at the pin site d. Capillary refill is less than 3 seconds ANS: B  A trauma nurse cares for several clients with fractures. Which client should the nurse identify as at highest risk for developing deep vein thrombosis?

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a. An 18-year-old male athlete with a fractured clavicle b. A 36-year old female with type 2 diabetes and fractured ribs c. A 55-year-old woman prescribed aspirin for rheumatoid arthritis d. A 74-year-old man who smokes and has a fractured pelvis ANS: D  A nurse delegates care of a client in traction to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating hygiene care for this client? a. Remove the traction when re-positioning the client. b. Inspect the clients skin when performing a bed bath. c. Provide pin care by using alcohol wipes to clean the sites. d. Ensure that the weights remain freely hanging at all times. ANS: D  (not exact question but very similar) A nurse is caring for a client who is recovering from an above- the-knee amputation. The client reports pain in the limb that was removed. How should the nurse respond? a. The pain you are feeling does not actually exist. b. This type of pain is common and will eventually go away. c. Would you like to learn how to use imagery to minimize your pain? d. How would you describe the pain that you are feeling? ANS: D  A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority? a. Document the findings in the clients chart. b. Give the client warmed blankets for comfort. c. Notify the health care provider immediately. d. Prepare to administer insulin per sliding scale. ANS: C  A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? A. Document the findings and reassess in 1 hour. B. Loosen any constrictive dressings on the chest. C. Raise the head of the bed to a semi-Fowlers position. D. Gather appropriate equipment and prepare for an emergency airway.

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ANS: D

 A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications. ANS: A  A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patients health problem? A) Blood is shunted from vital organs to peripheral areas of the body. B) Cells lack an adequate blood supply and are deprived of oxygen and nutrients. C) Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient. D) Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion. Ans: B  In an acute care setting, the nurse is assessing an unstable patient. When prioritizing the patients care, the nurse should recognize that the patient is at risk for hypovolemic shock in which of the following circumstances? A) Fluid volume circulating in the blood vessels decreases. B) There is an uncontrolled increase in cardiac output. C) Blood pressure regulation becomes irregular. D) The patient experiences tachycardia and a bounding pulse. Ans: A  The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation? A) Increased urine output B) Decreased heart rate C) Hyperactive bowel sounds D) Cool, clammy skin

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Ans: D  The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse perform on this patient? Select all that apply. A) Platelet level B) Fluid status C) Cardiac rhythm D) Action of medications E) Sputum volume Ans: B, C, D  The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip. How should the nurse best respond? A) Recognize that the view of the electrical current changes in relation to the lead placement. B) Recognize that the electrophysiological conduction of the heart differs with lead placement. C) Inform the technician that the ECG equipment has malfunctioned. D) Inform the physician that the patient is experiencing a new onset of dysrhythmia. Ans: A  The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action should the nurse perform? A) Place gel pads over the apex and posterior chest for better conduction. B) Ensure no one is touching the patient at the time shock is delivered. C) Continue to ventilate the patient via endotracheal tube during the procedure. D) Allow at least 3 minutes between shocks. Ans: B  When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize? A) Core body temperature B) Heart rate and rhythm C) Blood pressure D) Oxygen saturation level Ans: B

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 A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? Ans: C a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.  A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? Ans: B a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking  A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L Ans: B  A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? Ans: C a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours  The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurse's most recent assessment reveals that the patient's left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurse's best response? A) Document this expected assessment finding during the initial postoperative period. B) Reposition the patient with his left leg in a dependent position. C) Inform the patient's physician of this assessment finding. D) Administer an ordered dose of subcutaneous heparin.

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Ans: C  A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patient's daily medication administration record, the nurse should anticipate administering what drug? A) Ibuprofen B) Clopidogrel C) Dipyridamole D) Acetaminophen Ans: B  A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk? Ans: C A) Administration of bronchodilators by nebulizer B) Administration of inhaled corticosteroids by metered dose inhaler (MDI) C) Patient's consistent performance of deep breathing and coughing exercises D) Patient's active participation in the cardiac rehabilitation program  A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? Ans: B A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg. D) Massage the patient's lower leg to temporarily restore venous return.  The critical care nurse is caring for a client who has been experiencing bradycardia after cardiovascular surgery. The nurse knows that the heart rate is determined by myocardial cells with the fastest inherent firing rate. Under normal circumstances where are these cells located? Ans: A a. SA node b. AV node c. Bundle of His d. Purkinje cells  The nurse is conducting client teaching about cholesterol levels. When discussing the client's elevated LDL and lowered HDL levels, the client shows an understanding of the significance of these levels by stating what? a. "Increased LDL and decreased HDL increase my risk of coronary artery disease." b. "Increased LDL has the potential to decrease my risk of heart disease." c. "The decreased HDL level will increase the amount of cholesterol moved away from the artery

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Ans: A walls." d. "The increased LDL will decrease the amount of cholesterol deposited on the artery walls."  The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence? Ans: D a. SA node to bundle of His to AV node to Purkinje fibers b. SA node to AV node to Purkinje fibers to bundle of His c. SA node to bundle of His to Purkinje fibers to AV node d. SA node to AV node to bundle of His to Purkinje fibers  The nurse is caring for a client admitted with angina who is scheduled for cardiac catheterization. The client is anxious and asks the reason for this test. What is the best response? Ans: A a. "Cardiac catheterization is usually done to assess how blocked or open a client's coronary arteries are." b. "Cardiac catheterization is most commonly done to detect how efficiently a client's heart muscle contracts." c. "Cardiac catheterization is usually done to evaluate cardiovascular response to stress." d. "Cardiac catheterization is most commonly done to evaluate cardiac electrical activity."  The nurse is performing an intake assessment on a client with a new diagnosis of coronary artery disease. What would be the most important determination to make during this intake assessment? Ans: C a. Whether the client and involved family members understand the role of genetics in the etiology of the disease b. Whether the client and involved family members understand dietary changes and the role of nutrition c. Whether the client and involved family members are able to recognize symptoms of an acute cardiac problem and respond appropriately d. Whether the client and involved family members understand the importance of social support and community agencies  A resident of a long-term care facility has reported chest pain to the nurse. What aspect of the resident's pain would be most suggestive of angina as the cause? Ans: B a. The pain is worse when the resident inhales deeply. b. The pain occurs immediately following physical exertion. c. The pain is worse when the resident coughs. d. The pain is most severe when the resident moves his upper body.

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 The nurse is caring for a client with coronary artery disease. What assessment finding does the nurse expect if the client's mean arterial blood pressure decreases below 60 mm Hg? a. Increased cardiac output b. Hypertension c. Chest pain d. Decreased heart rate Ans: C  The nurse is participating in the care conference for a patient with ACS. What goal should guide the care team's selection of assessments, interventions, and treatments? A) Maximizing cardiac output while minimizing heart rate B) Decreasing energy expenditure of the myocardium C) Balancing myocardial oxygen supply with demand D) Increasing the size of the myocardial muscle Ans: C  A patient had an inferior wall myocardial infarction (MI). The nurse notes the patient's cardiac rhythm as shown below: What action by the nurse is most important? Select one: a. Assess the patient's blood pressure and level of consciousness. b. Call the healthcare provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication. Ans: B  A patient with pericarditis has just been admitted to the CCU. The nurse planning the patients care should prioritize what nursing diagnosis? A) Anxiety related to pericarditis B) Acute pain related to pericarditis C) Ineffective tissue perfusion related to pericarditis D) Ineffective breathing pattern related to pericarditis Ans: B  A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same

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time

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ANS: D

 A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? Ans: "It is hypertension with no specific cause"  The nurse is taking a health history of a new client who reports pain in his left lower leg and foot when walking. The pain is relieved with rest and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should MOST likely address what health problem? Ans: Intermittent claudication  The nurse is caring for four hypertensive patients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? A.) Furosemide (Lasix)/potassium: 2.9 mEq/L B.) Spironolactone (Aldactone)/potassium: 5.1 mEq/L C.) Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L D.) Torsemide (Demadex)/sodium: 142 mEq/L Ans: A  A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of heart failure and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent what complication? Ans: Deep vein thrombosis  A patient who is at high risk for developing intracardiac thrombi has been placed on long- term anticoagulation. What aspect of the patient’s health history creates a heightened risk of intracardiac thrombi? A) Atrial fibrillation B) Infective endocarditis C) Recurrent pneumonia D) Recent surgery Ans: A  A client presents to the clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the client the angina is most often attributed to what cause? Ans: Coronary arteriosclerosis

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 A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient? A) Hyperlipidemia B) Bleeding at insertion site C) Left ventricular hypertrophy D) Congestive heart failure Ans: B  A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? Ans: C A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.  A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? Ans: "Continue to educate the client on possible healthy changes."  The nurse administers a beta blocker to a client after a myocardial infarction. What assessment finding does the nurse expect? a. Blood pressure increase of 10% b. Increasing respiratory rate c. Increased cardiac output d. Pulse decrease from 100 to 80 beats/min Ans: D  The nurse is caring for a patient admitted with unstable angina. The laboratory result for the initial troponin I is elevated in this patient. The nurse should recognize what implication of this assessment finding? Ans: This is an accurate indicator of myocardial injury.  The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac

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rhythm on the monitor. The nurse’s rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how will the nurse describe this initial absence of cardiac rhythm? A) Pulseless electrical activity (PEA) B) Ventricular fibrillation C) Ventricular tachycardia D) Asystole Ans: D