NUR 325 Exam 3 New Latest Version Updated 2024-2025 Best Studying Material, Exams of Nursing

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NUR 325 Exam 3 New Latest Version Updated 2024- 2025

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When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? ----------- Correct Answer ---------- Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older patients have significantly higher blood pressure readings when taken by health care providers (white coat syndrome). Older patients experience orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients experience a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability. A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise? ----------- Correct Answer ---------- "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you." Exercise is not contraindicated for this client, but modifications are necessary to prevent further injury. Swimming or water aerobics provides support for the joints and muscles while increasing the uptake of glucose and promoting cardiovascular health. Jogging, vigorous exercise, or no exercise would increase the pathologies of this patient. A nures is caring for an older adult clients who has COPD with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis ----------- Correct Answer ------------ B (Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.) A nurse is providing instructions about pursed-lip breathing for a client who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following? a. Increases oxygen intake b. Promotes CO2 elimination c. Uses intercostal muscles d. Strengthens the diaphragm ----------- Correct Answer ------------ B (The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. This is one of the simplest ways to control dyspnea. It slows the client's pace of breathing, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves CO2 out of the lungs more efficiently.) A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. which of the following findings should the nurse recognize as an indication of pulmonary embolism? a. Sudden onset of dyspnea

b. Tracheal deviation c. Bradycardia d. Difficulty swallowing ----------- Correct Answer ------------ A (Dyspnea occurs due to reduced blood flow to the lungs. Tachycardia is a clinical manifestation of pulmonary embolism.) A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? a. Eat high calorie foods first. b. Increase intake of water at meal times c. Perform ative ROM exercises before meals d. Keep saltine crackers nearby for snacking ----------- Correct Answer ------------ A (A client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first. The client should limit intake of water at mealtimes to reduce the felling of early satiety. The client should rest before meals to decrease dyspnea while eating. The client should keep foods on hand for snacking, but should avoid dry and salty foods, which can place the client at risk for aspiration and make the client's mouth dry.) The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? ----------- Correct Answer ---------- Allow the insulin to warm to room temperature before injecting it. Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections. The nurse admits a 73-y/o male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? ----------- Correct Answer ---------- Bumetanide (Bumex) Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities. The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? ----------- Correct Answer ---------- Bronchospasm Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2- receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD. The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration? ----------- Correct Answer ---------- Pulse 48 beats/min Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits. When teaching a patient about dietary management of stage 1 hypertension, which instruction is most

appropriate? ----------- Correct Answer ---------- Restrict sodium intake. The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure. The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply.)? ----------- Correct Answer ---------- Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual. A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? ----------- Correct Answer ---------- Does the patient have a headache or confusion? The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency. A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After one hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? ----------- Correct Answer ---------- Stop the nitroprusside infusion and assess the patient for potential complications. Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be approximately 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding? ----------- Correct Answer ---------- "If I develop a dry cough while taking this medication, I should notify my doctor." Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet. The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? ----------- Correct Answer -------- -- Take BP and HR with patient standing.

The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine positon. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes. Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? ----------- Correct Answer ---------- Assess his adherence to therapy. A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy. The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? ----------- Correct Answer ---------- Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues. The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? ----------- Correct Answer ---------- BP 128/86 mm Hg Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure. The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? ----------- Correct Answer ---------- "I can lower my blood pressure by switching to smokeless tobacco." Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? ----------- Correct Answer ---------

• Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? ----------- Correct Answer ---------- Inhibits conversion of angiotensin I to angiotensin II Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. β blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure. When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? ----------- Correct Answer ---------- Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet. The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr- old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? ----------- Correct Answer ---------- Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient. The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? ----------

• Correct Answer ---------- Venous thromboembolism The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and postthrombotic syndrome are the sequelae of venous thromboembolism. The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? ----------- Correct Answer ---------- Prothrombin time (PT) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the PT or the international normalized ratio demonstrate the need for this medication. Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? ----------- Correct Answer ---------- Remove the patient's IV catheter. The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often

therapeutic. A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? ----------- Correct Answer ---------- Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore, tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD. A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on postoperative day 1? ----------- Correct Answer ---------- Assist patient to walk several times. To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines. The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? ----------- Correct Answer ---------- Leave the air bubble in the prefilled syringe. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue. The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? ----------- Correct Answer ---------- Hold the medication and record in the electronic medical record. Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record. What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? ----------- Correct Answer ---------- Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position. A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation.

Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? ----------- Correct Answer ---------- The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred. Which assessment finding would alert the nurse that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox)? ----------- Correct Answer ---------- Pain and swelling in a lower extremity Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in a lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy. A 67-yr-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? ----------- Correct Answer ---------- Patient says muscle leg pain occurs with continued exercise. Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted? ----------- Correct Answer ---------- The Glasgow Coma Scale is unchanged from 3 hours ago. Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement. Ketone bodies, blood osmolarity, and serum potassium levels are consistent with improvement. Which clinical manifestation of decreased renal function in the diabetic clinic should the nurse anticipate as a potential problem? ----------- Correct Answer ---------- Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration. The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to inability to swallow oral form? ----------- Correct Answer ---------- Position the client face down or in a side-lying position. Intramuscular injection of glucagon often causes vomiting, increasing the patient's risk for aspiration. Elevating the head of the bed, instituting the use of a padded tongue blade, or applying pressure at or massaging injection site is not a safe nursing practice. The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation? ----------- Correct Answer ---------- Requirements for intensive therapy with small, frequent insulin doses The pen injector allows greater accuracy with small doses of less than 5 units. It is not recommended for those with cognitive or visual impairments or those who suffer frequent hypoglycemic episodes.

It is most important for the nurse to include which risk factors in a teaching plan associated with the development of type 2 diabetes mellitus? ----------- Correct Answer ---------- Delivery of a 4.99-kg baby. Body mass index greater than 25 kg/m. Hypertension. Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL. Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis? ----------- Correct Answer ---------- Administration of intravenous insulin The Kussmaul's respirations pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1 to 6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells. A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? ----------- Correct Answer ---------- Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters. Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time? ----------- Correct Answer ---------- Ketone bodies in the urine Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake. Assessing for ketones in the urine may indicate insulin deficiency. When planning care for a diabetic patient with microalbuminuria, it is important to include which goal to reduce the progression to renal failure? ----------- Correct Answer ---------- Decrease the total percentage of calories from proteins Restriction of dietary protein to 0.8 g/kg body weight per day is recommended for clients with microalbuminuria to reduce the progression to renal failure. All other choices can increase blood glucose and total body weight but are not specific for progression to renal failure. A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? ------ ----- Correct Answer ---------- Perfusion assists the cell by delivering oxygen and removing waste products. Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness. A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? ----------- Correct Answer ---------- "Your father may be having mini-strokes; I will notify his physician." Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the

confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified. The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is: ----------- Correct Answer ---------- use pillows to prop yourself up while sleeping. Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat. The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? ------ ----- Correct Answer ---------- Myocardial infarction Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort. Exercise and activity are included in a cardiac rehabilitation program for which purposes? ----------- Correct Answer ---------- A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure. A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? ----------- Correct Answer ---------- Status of acid-base balance in arterial blood The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? ----------- Correct Answer ---------- Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas What is the most significant modifiable risk factor for the development of impaired gas exchange? -------- --- Correct Answer ---------- Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use. The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? ----------- Correct Answer ---------- A patient experiencing a problem with a pneumothorax When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A

thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy. The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? ----------- Correct Answer ---------- No observable respiratory difficulty or shortness of breath over the last 24 hours Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode. The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? ----------- Correct Answer ---------- Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor. What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply.)? ----------- Correct Answer ------- --- Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent cardiovascular disease events in PAD patients. Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? --------- -- Correct Answer ---------- A 70-yr-old man with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol. When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? ----------- Correct Answer ---------- The duplex

ultrasound is the most widely used test to diagnose VTE. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound Which assessment findings of the left lower extremity will the nurse identify as consistent with arterial occlusion (select all that apply.)? ----------- Correct Answer ---------- Arterial occlusion may result in loss of limb if not timely revascularized. When an artery is occluded, perfusion to the extremity is impaired or absent. On assessment, the nurse would note a cold, mottled extremity with impaired sensation or numbness. The pulse would not be identified, even with a Doppler. In contrast, the nurse would find edema, erythema, and increased warmth in the presence of a venous occlusion (deep vein thrombosis). Capillary refill would be greater than 3 seconds in an arterial occlusion and less than 3 seconds with a venous occlusion. A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the effectiveness of the medication, which assessment will the nurse perform? ----------- Correct Answer ------ ---- Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved, and vasospastic attacks are reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status. The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients 'always' have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? ------ ----- Correct Answer ---------- Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered. The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? ----------- Correct Answer ---------- Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. When the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium. The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? ----------- Correct Answer ---------- Administer the daily dose of warfarin. The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. To maintain therapeutic values, the nurse will administer the medication as ordered. Holding the medication would lower the INR, which would increase the risk of clot formation. Conversely, the higher the INR is, the more prolonged the clotting time. Calling the health care provider is not indicated. Although teaching is important, administering the medication is a higher priority at this time.

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? ----------- Correct Answer ---------- Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles. A 73-yr-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching on which type of diet for this patient and his caregiver? ----------- Correct Answer ---------- High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered. A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be most appropriate? ----------- Correct Answer ---------- "While you're still lying in bed in the morning, put on your stockings." The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously and should not be removed several times daily. Dangling at the bedside before application is likely to decrease their effectiveness. A patient was admitted for possible ruptured aortic aneurysm. No back pain was reported. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings? ----------- Correct Answer ---------- Bleeding into the abdomen is likely. The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space, where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There are no assessment data indicating decreased perfusion to the legs. A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? ----------- Correct Answer ---------- Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin. The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? ----------- Correct Answer ---------- Pinch the skin between the thumb and forefinger before inserting the needle. The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before

inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection. The nurse is admitting a 68-yr-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? ----------- Correct Answer ---------- Coumadin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin). The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? ----------- Correct Answer ---------- Use IV fluids to maintain adequate BP. The priority is to maintain an adequate blood pressure (BP) (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it. The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? a. Ischemia b. Pneumonia c. Myocardial infarction d. Peptic ulcer disease ----------- Correct Answer ------------ C (Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort.) A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? a. Perfusion assists the body by preventing clots and increasing stamina. b. Perfusion assists the cell by delivering oxygen and removing waste products. c. Perfusion assists the heart by increasing the cardiac output. d. Perfusion assists the brain by increasing mental alertness. ----------- Correct Answer ------------ B (Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.) A 72-year-old man presents to the emergency room. The patient appears diaphoretic and anxious, and has noted peripheral edema. The patient's vital signs are blood pressure of 100/40, heart rate of 130 and irregular, and respiratory rate of 26. How does the nurse interpret these findings? a. The patient is having a myocardial infarction. b. The patient has impaired central perfusion. c. The patient has a virus. d. Pain medication should be administered to this patient. ----------- Correct Answer ------------ B (This patient has the classic symptoms of impaired central perfusion. Central perfusion occurs when cardiac output is optimal and blood is pumped to all of the organs and tissues from the arteries, through the capillaries, and then back to the heart through the veins. The nurse needs to administer oxygen. Chest pain is often present with myocardial infarction, along with elevated blood pressure readings and electrocardiogram changes. Viral illness commonly presents with other symptoms such as body ache or

gastrointestinal issues, and typically has little or no effect on the heart rate. Pain management is not indicated for patients who do not present with pain. Also, the question is asking what assessment the nurse has made, and is not asking about interventions.) The nurse knows that including teaching on modifiable risk factors for impaired perfusion in the patient's plan of care includes which of the following: a. Impaired perfusion increases with age. b. Genetics play a role in impaired perfusion. c. Exercise should be kept at a minimum to prevent a myocardial infarction. d. A smoking cessation plan should be in place. ----------- Correct Answer ------------ D (The importance of distinguishing between modifiable versus nonmodifiable risk factors is imperative when determining what sort of lifestyle changes can be discussed when formulating the patient's plan of care. Impaired perfusion can affect all people and age groups regardless of gender, race, or economic status. Smoking cessation is an example of a modifiable risk factor for impaired perfusion that can be included in the patient's plan of care. Modifiable risk factors can be changed by the patient through teaching from the nurse. Although impaired perfusion can increase with age, this is an example of an unmodifiable risk factor (something that the patient cannot change). Genetics is an example of an unmodifiable risk factor for impaired perfusion. A sedentary lifestyle can lead to obesity, which would then become a modifiable risk factor for impaired perfusion.) The nurse knows that primary prevention strategies to prevent impaired perfusion in the patient include which of the following recommendations by the American Heart Association (AHA): a. Routine blood pressure monitoring b. Administering furosemide (Lasix) to a patient with active congestive heart failure (CHF) symptoms c. Eating a healthy diet and exercising most days of the week d. Monitoring routine serum lipids ----------- Correct Answer ------------ C (Primary prevention strategies include measures that promote health and prevent disease from developing. The American Heart Association recommends eating a heart-healthy diet, exercising most days of the week, taking a low-dose aspirin, and not smoking. Routine blood pressure monitoring is considered secondary prevention, which also includes screening and early diagnosis of health issues.Although administering a diuretic such as furosemide to a patient who presents with active CHF symptoms is considered an optimal treatment of symptoms, this is not considered a primary prevention strategy. Testing for routine serum lipids is considered secondary prevention.) The nurse observes that during morning care the patient is complaining of leg pain when ambulating to the bathroom. The nurse assists the patient back into bed and notices that the patient's leg pain is relieved. Further assessment reveals bilateral pedal edema. The nurse knows that the cause of the patient's leg pain is most likely which of the following: a. The pain indicates an inadequate amount of blood to transport oxygen to meet the demands of leg muscles. b. The pain indicates a muscle spasm. c. The patient is having a myocardial infarction. d. The pain is due to over-exertion during morning care. ----------- Correct Answer ------------ A (Impaired perfusion often results in leg pain as related to peripheral arterial disease (PAD). PAD leg pain is often relieved with rest and worsens with walking. Leg pain that is relieved with rest is called intermittent claudication and means that there is an inadequate supply of blood being transported to the muscles. Edema also develops from the obstruction of venous blood flow.Although pain is common during a muscle spasm, it is usually not relieved with rest. During a myocardial infarction, pain is often felt in the

chest and not in the lower extremities.Although pain may occur from exercise, acute leg pain with the presence of edema indicates a perfusion problem and warrants further investigation.) A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem? a. "Have you ever had this pain before?" b. "Can you describe the pain to me?" c. "Does the pain get worse when you breathe in?" d. "Can you rate the pain on a scale of 1-10, with 10 being the worst?" ----------- Correct Answer ---------- -- C (Chest pain is assessed by using the standard pain assessment parameters. Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.) You read in Mr. Smith's medical record that he was diagnosed with stage 1 hypertension and started on a diuretic. Which statement defines stage 1 hypertension? a. A systolic reading of less than 120 mm Hg, and a diastolic reading of less than 80 mm Hg b. A systolic reading of 120-139 mm Hg, or a diastolic reading of 80-89 mm Hg c. A systolic reading of 140-159 mm Hg, or a diastolic reading of 90-99 mm Hg d. A systolic reading of 160 mm Hg or greater, or a diastolic reading of 100 mm Hg or greater ----------- Correct Answer ------------ C A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? a. Review the intake and output records for the last 2 days b. Change the time of diuretic administration from morning to evening c. Request a sodium restriction of 1 g/day from the physician d. Order daily weights starting the following morning ----------- Correct Answer ------------ A (Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.) For all persons without a normal blood pressure, treatment recommendations vary by blood pressure classification. Blood pressure classification should be based on: a. an average of two or more blood pressure readings taken at one healthcare visit b. an average of two or more blood pressure readings taken at each of two healthcare visits c. the highest pressure over a week d. the lowest pressure over a week ----------- Correct Answer ------------ B (Blood pressure classification should be made on the basis of average blood pressure readings (two or more) obtained at each of two separate healthcare visits.) A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to: a. Check the client status and lead placement b. Press the recorder button on the electrocardiogram console c. Call the physician

d. Call a code blue ----------- Correct Answer ------------ A (Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention.) Which assessment is indicated to evaluate a patients' leg circulation? a. Carotid arteries for bruits b. Pedal and tibial pulses for presence and quality c. Orthostatic blood pressure readings ----------- Correct Answer ------------ B A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect? a. Thin, pliable toe nails b. Leg pain at rest c. Hairy legs d. Flushed/ warm legs ----------- Correct Answer ------------ B (In the initial stages of PAD, clients might experience intermittent claudication. As the disease progresses, the client will experience pain even at rest due to ischemia of the distal extremities. The client might describe this pain as a persistent burning or aching pain that often awakens the client at night. A client who has PAD will have thickened toenails. They will also have shiny, dry skin on the legs with sparse hair growth, and they will have skin that is cool or cold to the touch.) A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? a. Dilated pupils b. Dysrhythmias c. Diarrhea d. Gastric ulcer ----------- Correct Answer ------------ B (Dysrhythmias can result from straining while defecating. When the client contracts the abdominal muscles and holds their breath while bearing down then the client exhales, there is a sudden release of intraabdominal pressure against the closed airway, which can result in cardiac dysrhythmias and elevated blood pressure.) A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? a. Decrease in RR from 20 to 16/min. b. Decrease in urinary output from 50 mL to 30mL per hour. c. Increase in the temp from 99.5 fahrenheit to 101.5 fahrenheit. d. Increase in the HR from 88 to 110/min. ----------- Correct Answer ------------ D (Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the HR increases steadily. In the first stage of shock, the HR is >100/min. As shock progresses, the HR continues to accelerate to more than 150/min. Hyperthermia is seen in septic shock, one of the classic signs of shock is cool, moist skin. A client experiencing shock would have an increased RR.) While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

a. Impaired tissue perfusion b. Alteration in body image c. Alteration in activity tolerance d. Impaired skin integrity ----------- Correct Answer ------------ A (When using the airway, breathing, and circulation priority framework, the nurse should identify impaired perfusion of tissues as the priority finding.) A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.) a. Genetic predisposition b. Hypercholesterolemia c. Hypertension d. Obesity e. Smoking ----------- Correct Answer ------------ B C D E A nurse is caring for a client who has heart failure and a potassium level of 2.4 mEq/L. The nurse should identify which of the following medications as the case of the client's low potassium level? a. Furosemide b. Nitroglycerin c. Metoprolol d. Spironolactone ----------- Correct Answer ------------ A (Furosemide is a loop diuretic that inhibits the reabsorption of sodium and chloride and results in diuresis, which decreases potassium levels through excretion in the distal nephrons. Hypokalemia is an adverse effect of furosemide. Spironolactone is a potassium-sparing diuretic medication, therefore, hyperkalemia is an adverse effect of this medication.)(reg potassium=3.5-5.0) A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions? a. Atrial gallop b. Ventricular gallop c. Closure of mitral valve d. Closure of the pulmonic valve ----------- Correct Answer ------------ B (S3 indicates a ventricular gallop caused by a rush of blood into a ventricle that is stiff or dilates. This can be a finding of heart failure and hypertension.) An S4 sound represents an Atrial Gallop. Closure of the mitral valve is represented by the S1 sound, and closure of the pulmonic valve is represented by the S2 sound. A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? a. Obtain a pair of slipper-socks for the client b. Rub the client's feet briskly for several minutes c. Increase the client's oral fluid intake d. Place a moist heating pad under the client's feet ----------- Correct Answer ------------ A (In cold weather or when the client's feet are cold, he should wear extra socks or slipper socks to help provide warmth and increase his level of comfort. Massaging the legs or feet can cause a clot to break loose in the bloodstream. Impairment of arterial or venous circulating to a lower extremity is a contraindication for massage and heating pads. If there is co-existing sensory involvement, the client might not be able to feel

a burn and be prone to serious injury) While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? a. A systolic murmur b. A third heart sound (S3) c. An expected heart sound d. A fourth heart sound (S4) ----------- Correct Answer ------------ A (Cardiac murmurs are relatively loud, turbulent sounds the nurse can hear between the usual, expected heart sounds. They create a whooshing or a swishing sounds. Those between S1 and S2 are systolic murmurs. Those between S2 and the next S1 are diastolic murmurs.) While auscultating a client's heart sounds, the nurse hears turbulence between S2 and the next S1 heart sound. The nurse should document this finding as which of the following? a. A systolic murmur b. A third heart sound (S3) c. A diastolic murmur d. A fourth heart sound (S4) ----------- Correct Answer ------------ C A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? a. Seating the client with arm bared, supported, and at heart level. b. Measuring the blood pressure after the client has been seated quietly for 5 minutes. c. Using a cuff with a rubber bladder that encircles at least 80% of the limb. d. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. ----------- Correct Answer ------------ D (BP should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy.) A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin: A. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this to exert an anticoagulant effect. B. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect. C. Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for this to begin. D. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic. ----------- Correct Answer ------------ B (Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited) A 60-year-old male client comes into the emergency department with complaints of crushing chest pain

that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest x-ray, an ECG, and 2 mg of morphine given intravenously. The nurse should first: a. Administer the morphine b. Obtain a 12-lead ECG c. Obtain the lab work d. Order the chest x-ray ----------- Correct Answer ------------ A (Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse's priority action would be to relieve the crushing chest pain.) When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to: a. Help keep him well hydrated b. Dissolve clots he may have c. Prevent kidney failure d. Treat potential cardiac arrhythmias ----------- Correct Answer ------------ B (Thrombolytic drugs are administered within the first 6 hours after onset of a MI to lyse clots and reduce the extent of myocardial damage.) A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse's next action would be to: a. Call for the doctor b. Start an intravenous line c. Obtain a portable chest radiograph d. Draw blood for laboratory studies ----------- Correct Answer ------------ B (Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood are important but secondary to starting the intravenous line.) The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following? a. Cancer b. Hypertension c. Liver disease d. Myocardial infarction ----------- Correct Answer ------------ D (Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within 4 to 6 hours after infarction (Note: less than 90 mg/L is normal).) When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride: a. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction. b. Increases norepinephrine secretion and thus decreases blood pressure and heart rate. c. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood

pressure. d. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II ----------- Correct Answer ------------ A (Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction.) The most important long-term goal for a client with hypertension would be to: a. Learn how to avoid stress b. Explore a job change or early retirement c. Make a commitment to long-term therapy d. Control high blood pressure ----------- Correct Answer ------------ C (Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance.) Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of: a. Cerebrovascular accident b. Liver disease c. Myocardial infarction d. Pulmonary disease ----------- Correct Answer ------------ A (Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVA's can be related to long-term hypertension. Liver or pulmonary disease is generally not associated with hypertension. Myocardial infarction is generally related to coronary artery disease.) The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to: a. Open and dilate the blocked coronary arteries b. Assess the extent of arterial blockage c. Bypass obstructed vessels d. Assess the functional adequacy of the valves and heart muscle ----------- Correct Answer ------------ B (Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results.) As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principal effects are produced by: a. Antispasmodic effect on the pericardium b. Causing an increased myocardial oxygen demand c. Vasodilation of peripheral vasculature d. Improved conductivity in the myocardium ----------- Correct Answer ------------ C (Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium.)

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including: a. Headache b. High blood pressure c. Shortness of breath d. Stomach cramps ----------- Correct Answer ------------ A (Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or sit down to avoid fainting. Nitro does not cause shortness of breath or stomach cramps.) Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs? a. Take one tablet every 2 to 5 minutes until the pain stops. b. Take one tablet and rest for 10 minutes. Call the physician if pain persists after 10 minutes. c. Take one tablet, then an additional tablet every 5 minutes for a total of 3 tablets. Call the physician if pain persists after three tablets. d. Take one tablet. If pain persists after 5 minutes, take two tablets. If pain still persists 5 minutes later, call the physician. ----------- Correct Answer ------------ C A murmur is heard at the second left intercostal space along the left sternal border. Which valve is this? a. Aortic b. Mitral c. Pulmonic d. Tricuspid ----------- Correct Answer ------------ C (Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricupsid valve abnormalities are heard at the 3rd and 4th intercostal spaces along the sternal border.) Which of the following blood tests is most indicative of cardiac damage? a. Lactate dehydrogenase b. Complete blood count (CBC) c. Troponin I d. Creatine kinase (CK) ----------- Correct Answer ------------ C (Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren't detectable in people without cardiac injury.) Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage? a. Cardiac catheterization b. Cardiac enzymes c. Echocardiogram d. Electrocardiogram (ECG) ----------- Correct Answer ------------ D (The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. Cardiac enzymes are used to diagnose MI but can't determine the location. An echocardiogram is used most widely to view myocardial wall function after an MI has been diagnosed. Cardiac catheterization is an invasive study for determining coronary artery disease and may also indicate the location of myocardial damage, but the

study may not be performed immediately.) Which of the following types of pain is most characteristic of angina? a. Knifelike b. Sharp c. Shooting d. Tightness ----------- Correct Answer ------------ D (The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms.) Which of the following parameters is the major determinant of diastolic blood pressure? a. Baroreceptors b. Cardiac output c. Renal function d. Vascular resistance ----------- Correct Answer ------------ D (Vascular resistance is the impedance of blood flow by the arterioles that most predominantly affects the diastolic pressure. Cardiac output determines systolic blood pressure.) Which of the following factors can cause blood pressure to drop to normal levels? a. Kidneys' excretion of sodium only b. Kidneys' retention of sodium and water c. Kidneys' excretion of sodium and water d. Kidneys' retention of sodium and excretion of water ----------- Correct Answer ------------ C (The kidneys respond to a rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic pressure by regulating blood volume.) Baroreceptors in the carotid artery walls and aorta respond to which of the following conditions? a. Changes in blood pressure b. Changes in arterial oxygen tension c. Changes in arterial carbon dioxide tension d. Changes in heart rate ----------- Correct Answer ------------ A (Baroreceptors located in the carotid arteries and aorta sense pulsatile pressure. Decreases in pulsatile pressure cause a reflex increase in heart rate. Chemoreceptors in the medulla are primarily stimulated by carbon dioxide. Peripheral chemoreceptors in the aorta and carotid arteries are primarily stimulated by oxygen.) Which of the following terms describes the force against which the ventricle must expel blood? a. Afterload b. Cardiac output c. Overload d. Preload ----------- Correct Answer ------------ A (Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. Cardiac output is the amount of blood expelled from the heart per minute. Overload refers to an abundance of circulating volume. Preload is the volume of blood in the ventricle at the end of diastole.) A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension.

Before administered propranolol, which of the following actions should the nurse take first? a. Monitor the apical pulse rate b. Instruct the client to take medication with food c. Question the physician about the order d. Caution the client to rise slowly when standing ----------- Correct Answer ------------ C (Propranolol and other beta-adrenergic blockers are contraindicated in a client with asthma, so the nurse should question the physician before giving the dose. The other responses are appropriate actions for a client receiving propranolol, but questioning the physician takes priority. The client's apical pulse should always be checked before giving propranolol; if the pulse rate is extremely low, the nurse should withhold the drug and notify the physician.) One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect? a. Hypocalcemia b. Hypermagnesemia c. Hypokalemia d. Hypernatremia ----------- Correct Answer ------------ C (Furosemide is a potassium-depleting diuretic than can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia.) A client is receiving spironolactone to treat hypertension. Which of the following instructions should the nurse provide? a. "Eat foods high in potassium." b. "Take daily potassium supplements." c. "Discontinue sodium restrictions." d. "Avoid salt substitutes." ----------- Correct Answer ------------ D (Because spironolactone is a potassium-sparing diuretic, the client should avoid salt substitutes because of their high potassium content. The client should also avoid potassium-rich foods and potassium supplements. To reduce fluid- volume overload, sodium restrictions should continue.) To evaluate a client's condition following cardiac catheterization, the nurse will palpate the pulse: a. In all extremities b. At the insertion site c. Distal to the catheter insertion d. Above the catheter insertion ----------- Correct Answer ------------ C (Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong.) A client enters the ER complaining of severe chest pain. A myocardial infarction is suspected. A 12 lead ECG appears normal, but the doctor admits the client for further testing until cardiac enzyme studies are returned. All of the following will be included in the nursing care plan. Which activity has the highest priority? a. Monitoring vital signs b. Completing a physical assessment c. Maintaining cardiac monitoring

d. Maintaining at least one IV access site ----------- Correct Answer ------------ C (Even though initial tests seem to be within normal range, it takes at least 3 hours for the cardiac enzyme studies to register. In the meantime, the client needs to be watched for bradycardia, heart block, ventricular irritability, and other arrhythmias. Other activities can be accomplished around the MI monitoring.) A client enters the ER complaining of chest pressure and severe epigastric distress. His VS are 158/90, 94, 24, and 99*F. The doctor orders cardiac enzymes. If the client were diagnosed with an MI, the nurse would expect which cardiac enzyme to rise within the next 3 to 8 hours? a. Creatine kinase (CK or CPK) b. Lactic dehydrogenase (LDH) c. LDH- 1 d. LDH- 2 ----------- Correct Answer ------------ A (Creatine kinase (CK, formally known as CPK) rises in 3 - 8 hours if an MI is present. When the myocardium is damaged, CPK leaks out of the cell membranes and into the bloodstream. Lactic dehydrogenase rises in 24-48 hours, and LDH-1 and LDH-2 rises in 8- 24 hours.) A 45-year-old male client with leg ulcers and arterial insufficiency is admitted to the hospital. The nurse understands that leg ulcers of this nature are usually caused by: a. Decreased arterial blood flow secondary to vasoconstriction b. Decreased arterial blood flow leading to hyperemia c. Atherosclerotic obstruction of the arteries d. Trauma to the lower extremities ----------- Correct Answer ------------ A (Decreased arterial flow is a result of vasospasm. The etiology is unknown. It is more problematic in colder climates or when the person is under stress. Hyperemia occurs when the vasospasm is relieved.) Direct-acting vasodilators have which of the following effects on the heart rate? a. Heart rate decreases b. Heart rate remains significantly unchanged c. Heart rate increases d. Heart rate becomes irregular ----------- Correct Answer ------------ C (Heart rate increases in response to decreased blood pressure caused by vasodilation.) With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compresses d. Placing the limb in a plane horizontal to the body ----------- Correct Answer ------------ B When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: a. At least 12 hours b. The first 24 hours c. 2-3 days d. 1 week ----------- Correct Answer ------------ C Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that

which of the following medications is available on the nursing unit? a. Vitamin K b. Aminocaproic acid c. Potassium chloride d. Protamine sulfate ----------- Correct Answer ------------ D (The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur) A nurse has an order to begin administering warfarin sodium (coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin? a. Vitamin K b. Aminocaproic acid c. Potassium chloride d. Protamine sulfate ----------- Correct Answer ------------ A (The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if excessive bleeding or hemorrhage should occur.) A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: a. Normal because of the increased blood flow through the leg b. Slightly deteriorating and should be monitored for another hour c. Moderately impaired, and the surgeon should be called. d. Adequate from the arterial approach, but venous complications are arising. ----------- Correct Answer -- ---------- A In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: a. Walking several times each day as an exercise program. b. Keeping the heat up so that the environment is warm c. Wearing TED hose during the day d. Using hydrotherapy for increasing oxygenation ----------- Correct Answer ------------ B (The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.) A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? a. An acute obstruction in the vessels of the legs b. Peripheral vascular problems in both legs c. Diabetes d. Calcium deficiency ----------- Correct Answer ------------ B (Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.)