NUR257 Exam 2 Questions with Answers, Exams of Nursing

Download NUR257 Exam 2 Questions with Answers and more Exams Nursing in PDF only on Docsity! 1 / 34 NUR257 Exam 2 Questions with Answers 1. A client with a confirmed DVT is being discharged from the ED. Which client statement indicates that the client has received proper nursing instruction and understands how to manage this condition? "I should try not to drink too much during the daytime." "I should lie on my side with my knees bent when sleeping." "I need to ice my leg every 2 hours for about 20 minutes." "I need to do my leg exercises five times or more every hour.": "I need to do my leg exercises five times or more every hour." 2. A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect the surgical insertion site closely for which complica- tion(s)? Bleeding and infection Bleeding and wound dehiscence Thrombosis and infection Evisceration: Bleeding and infection 3. A client who recently had a myocardial infarction develops pericarditis and complains of chest pain rated 6 (on a scale of 0-10) with deep breathing. Which ordered pro re nata medications is most appropriate for the nurse to administer? Morphine sulfate 6 mg IVP every 2-4 hours Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours Acetaminophen 650 mg PO every 4 hours Ibuprofen 800 mg PO every 8 hours: Ibuprofen 800 mg PO every 8 hours 4. The nurse instructs a client recovering from mechanical valve replacement surgery. Which client statement indicates that teaching has been effective? "I can play soccer in a week or two." "I will not drive until informed by my health care provider." "I have a low risk of developing an infection in my heart." 2 / 34 "I will not need to take anticoagulant medication every day.": "I will not drive until informed by my health care provider." 5. A nurse is caring for a client receiving warfarin therapy following a mechan- ical valve replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's first priority ? Assess the client for bleeding and notify the health care provider of the results. Notify the next nurse on afternoon shift to hold the evening dose of warfarin. Notify the health care provider to request an increase in the warfarin dose. Be prepared to administer an I.M. vitamin K injection and notify the healthcare provider of the results.: Assess the client for bleeding and notify the health care provider of the results. 6. The nurse suspects a client has developed pericarditis after a week of cold-like symptoms. Which of the client's signs and symptoms indicate peri- carditis? low urine output secondary to left ventricular dysfunction fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR) pitting edema, chest discomfort, and nonspecific ST-segment elevation lethargy, anorexia, and heart failure: fever, chest discomfort, and elevated ery- throcyte sedimentation rate (ESR) 7. A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate the development of left ventricular failure? Orthopnea, nausea, pedal edema Distended jugular veins, pedal edema, nausea Dyspnea, orthopnea, pulmonary edema Dyspnea, distended jugular veins, orthopnea: Dyspnea, orthopnea, pulmonary edema 8. Which would the nurse stress as a periodic lifelong necessity for a client managing infective endocarditis? 5 / 34 best response is which of the following? "The layers of the heart become loose from each other and rub together with 6 / 34 each heart beat." "The lung surfaces lose their lubrication and rub against the myocardium with each heart beat." "The great vessels rub against the pericardium with each heart beat." "The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other.": "The pericardial surfaces lose their lubricating fluid because of inflammation and rub against each other." 17. The nurse determines that a patient has a characteristic symptom of pericarditis. What symptom does the nurse recognize as significant for this diagnosis? Dyspnea Fatigue lasting more than 1 month Uncontrolled restlessness Constant chest pain: Constant chest pain 18.A patient is being seen in a clinic to rule out mitral valve stenosis. Which assessment data would be most significant? The patient's has an enlarged liver and edematous abdomen. The patient reports chest pain after eating a large meal. The patient has jugular vein distention and 3+ pedal edema. The patient reports shortness of breath when walking.: The patient reports shortness of breath when walking. 19.A nurse is teaching a client about valve replacement surgery. Which state- ment by the client indicates an understanding of the benefit of an autograft replacement valve? "The valve is mechanical, and it will not deteriorate or need replacing." "The valve is made from a pig tissue, and I will not need to take any blood-thin- ning drugs when I am discharged." "The valve is from a tissue donor, and I will not need to take any blood-thinning drugs when I am discharged." 7 / 34 "The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged.": "The valve is made from my own heart valve, and I will not need to take any blood-thinning drugs when I am discharged." 20. The nurse is providing discharge teaching for a client with rheumatic endocarditis but no valvular dysfunction. On which nursing diagnosis should the nurse focus her teaching? Chronic pain Impaired gas exchange Risk for infection Impaired memory: Risk for infection 21.A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider? 2.6 3.4 3.0 3.8: 3.8 22.A client with aortic stenosis is reluctant to have valve replacement surgery. A nurse is present when the health care provider talks to the client about a treatment that is less invasive than surgery which will likely relieve some of the client's symptoms. What treatment option has been discussed? Balloon percutaneous valvuloplasty Placement of an autograft valve Antibiotic therapy Placement of a xenograft valve: Balloon percutaneous valvuloplasty 23.A client with a recent history of atrial fibrillation has been prescribed 10 / endocarditis understands discharge teaching upon which client state- ment? 11 / "Can I take the antibiotics as a pill now?" "I have to call my doctor so I can get antibiotics before seeing the dentist." "I need a referral to a dietician to understand a low-sodium diet." "If I quit smoking, it will help the endocarditis.": "I have to call my doctor so I can get antibiotics before seeing the dentist." 31.A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD? It is specifically designed for long-term use. It is designed for extremely active patients. An LVAD only supports a failing left ventricle. It never needs batteries.: An LVAD only supports a failing left ventricle. 32.A client comes into the emergency department reporting about chest pain that gets worse when taking deep breaths and lying down. After ruling out a myocardial infarction, a nurse would assess for which diagnosis? Cardiomyopathy Mitral valve stenosis Pericarditis Rheumatic fever: Pericarditis 33. The school nurse is providing care to a child with a sore throat. With any sign of throat infection, the nurse stresses which of the following? Administering antiseptic lozenges Warm, salt water gargling Fluid increase to 2500cc Obtaining a throat culture: Obtaining a throat culture 34.A nurse is admitting a client with hypertrophic cardiomyopathy (HCM). What medication order will the nurse question? spironolactone 12 / metoprolol isosorbide dinitrate enalapril: isosorbide dinitrate 35. The instructor is talking with a nursing student who is caring for a client with pericarditis. The instructor asks the student to name the main character- istic of pericarditis. What should be the student's answer? Respiratory symptoms Dyspnea Fever Precordial pain: Precordial pain 36. The nurse is caring for a patient diagnosed with pericarditis. What serious complication should this patient be monitored for? Hypertension Left ventricular hypertrophy Cardiac tamponade Decreased venous pressure: Cardiac tamponade 37. The nurse is preparing to administer warfarin to a client with a mechanical valve replacement. The client's international normalized ratio is 2.7. What action will the nurse take? Prepare to administer vitamin K. Administer the medication as ordered. Hold the medication and notify the HCP. Asses the client for abnormal bleeding.: Administer the medication as ordered. 38.A nurse is caring for a client with acute mitral regurgitation related to an acute myocardial infarction. The nurse knows to monitor the client carefully for symptoms of which initial complication or result? Cerebral vascular accident (CVA) 15 / Serum cardiac antigens Complete blood count Positive blood culture Immunosuppressant assay: Positive blood culture 47.A young parent brings a 4-year-old child to the pediatric clinic with a mild fever and a red, spotty rash that is beginning to fade. The child's heart rate is rapid, and the rhythm is abnormal. The parent states the child has been healthy until about 3 weeks ago, when the child had a sore throat. The nurse suspects rheumatic carditis. What organism causes rheumatic carditis? Group A beta-hemolytic strep Staphylococcus aureus Epstein- Barr virus Streptococcus viridians: Group A beta-hemolytic strep 48.Which of the following clinical manifestations would the nurse expect to find in the client diagnosed with aortic regurgitation? Systolic pressure is lower in the lower extremities Decrescendo systolic murmur Visible neck vein pulsations Pulse pressure shortens: Visible neck vein pulsations 49.A nurse is assigned to the medical intensive care unit. The nurse auscul- tates a water-hammer pulse. What will the sound resemble? low-pitched diastolic murmur at the apex quick, sharp strokes that suddenly collapse mitral click high-pitched blowing sound at the apex: quick, sharp strokes that suddenly collapse 50.What is the most common cause of mitral stenosis? Congestive heart failure 16 / Degenerative stenosis Rheumatic endocarditis Myocardial infarction: Rheumatic endocarditis 51. The nurse is caring for a five-client assignment on a cardiac unit. In caring for which client would the nurse be most correct to assess for an effusion? A client with chest pain A client with chest trauma A client with aortic stenosis A client with mitral valve prolapse: A client with chest trauma 52.A patient has had a successful heart transplant for end-stage heart dis- ease. What immunosuppressant will be necessary for this patient to take to prevent rejection? Nifedipine Vancomycin Cyclosporine Verapamil: Cyclosporine 53.Which mitral valve condition generally produces no symptoms? Regurgitation Stenosis Prolapse Infection: Prolapse 54. The nursing instructor is teaching a class on thrombophlebitis. What should the nurse tell the students about the inflammatory response in throm- bophlebitis? The inflammatory response is caused by accumulated waste products in the blocked vessel. The inflammatory response is caused by an excess for fibrin in the blocked vessel. The inflammatory response is caused by the irritation of the clot. The inflammatory response is caused by the irritation of blood trying to flow through 17 / the vessel.: The inflammatory response is caused by accumulated waste products in the blocked vessel. 55.A client with infective endocarditis is assessed by the nurse for the pres- ence of Janeway lesions. On inspection, the nurse recognizes these lesions by identifying which characteristic sign? Splinter hemorrhages seen under the fingernails Patterns of petechiae on the chest Erythematosus modules on the pads of the fingers Red or purple macules found on the palms of the hands: Red or purple macules found on the palms of the hands 56.A client comes into the emergency department reporting about chest pain that gets worse when taking deep breaths and lying down. After ruling out a myocardial infarction, a nurse would assess for which diagnosis? Rheumatic fever Mitral valve stenosis Pericarditis Cardiomyopathy: Pericarditis 57.A client reports headaches and "just not feeling right," which the client blames on ongoing sleep disturbances. Inspection reveals Janeway lesions on the bottoms of the client's feet. These symptoms may indicate: infective endocarditis. myocarditis. rheumatic fever. dilated cardiomyopathy.: infective endocarditis. 58.When teaching a client with rheumatic carditis and a history of recurrent rheumatic fever, which statement by the client indicates that teaching has been successful? "I may have to take prophylactic antibiotics for up to 10 years." "I will avoid any kind of activity." 20 / 63.A client needs to have a cardiac valve replacement. The nurse offers client education about the procedures involved—including the benefits and risks. Which client statement indicates the need for more education? "I might lose some blood, but not likely a large quantity of it." "Since the procedure is minimally invasive, there is less surgical trauma." "Since the procedure is minimally invasive, there is less postoperative pain than with other techniques." "I'm anxious because I'll need to have cardiopulmonary bypass.": "I'm anxious because I'll need to have cardiopulmonary bypass." 64.Which action will a public health nurse include when planning ways to decrease the incidence of rheumatic fever in the community? Provide prophylactic antibiotics to individuals with a family history of rheumatic fever. Educate individuals in the community about the importance of monitoring temperature when infections occur. Encourage susceptible groups in the community to receive immunizations with streptococcal vaccine. Teach individuals in the community to seek medical treatment for streptococ- cal pharyngitis.: Teach individuals in the community to seek medical treatment for streptococcal pharyngitis. 65.Which type of cardiomyopathy are characterized by diastolic dysfunction caused by rigid ventricular walls that impair diastolic filling and ventricular stretch. Dilated cardiomyopathy (DCM) Arrhythmogenic right ventricular cardiomyopathy (ARVC) Hypertrophic cardiomyopathy (HCM) Restrictive cardiomyopathy (RCM): Restrictive cardiomyopathy (RCM) 66.Which intervention should the nurse include in the plan of care for a client with 21 / valvular heart disease who is experiencing pulmonary congestion? Report a weight gain of 3 pounds in 1 week Drink at least 2 L of fluid daily and monitor urine output Take nitroglycerin if shortness of breath develops Rest and sleep in a chair or sit in bed with head elevated: Rest and sleep in a chair or sit in bed with head elevated 67.A client with aortic valve endocarditis develops dyspnea, crackles in the lungs, and restlessness. The novice nurse discusses this development with the nurse manager. What statement indicates the novice nurse is applying the assessment findings? "I placed the patient in a semi-Fowler's position and started an NPO diet." "I told the patient that this is a normal complication and to take deep breaths." "I anticipated this complication and I will call the health care provider right now." "I instructed the patient to do coughing and deep breathing and I will reassess in 30 minutes.": "I anticipated this complication and I will call the health care provider right now." 68.A nurse is caring for four clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? A client with hypertrophic cardiomyopathy A client with a history of repaired ventricular septal defect A client 1 day post coronary stent placement A client 4 days postoperative after mitral valve replacement: A client 4 days postoperative after mitral valve replacement 69. The nurse is caring for a client with manifestations of dilated cardiomyopa- thy. When planning care, which consideration would the nurse make? Assess abdominal girth daily. Assist client to bathroom every 2 hours. 22 / Instruct client to avoid strenuous activity. Place bed in a high or semi-high Fowler's position as needed.: Place bed in a high or semi-high Fowler's position as needed. 70. The nurse is admitting a client with infective endocarditis (IE). What ques- tions will the nurse ask to explore known risk factors associated with IE? Select all that apply. Did you have a recent eye examination? Do you have any tattoos? Do you smoke marijuana? Did you have a pacemaker insertion? Are you injecting any drugs?: Did you have a pacemaker insertion? Do you have any tattoos? Are you injecting any drugs? 71. The nurse is auscultating the heart sounds of a patient with mitral stenosis. The pulse rhythm is weak and irregular. What rhythm does the nurse expect to see on the electrocardiogram (ECG)? Ventricular tachycardia Sinus dysrhythmia First-degree atrioventricular block Atrial fibrillation: Atrial fibrillation 72. The nurse is teaching a client with an atrial septal defect (ASD) about atrial fibrillation. What risk factor will the nurse include with the teaching? stroke cardiomegaly splenomegaly heart failure: stroke 73. The nurse is caring for a client with cardiogenic shock in an critical care unit and the family is asking about the intra-aortic balloon pump (IABP). What will the nurse 25 / greater incidence of a history of repaired congenital heart defects higher rate of tuberculosis increased use of prosthetic valve replacements increase in IV drug use: increased use of prosthetic valve replacements 79. The nurse is assessing a client admitted with acute left-sided infective endocarditis. What is the best diagnostic test to confirm the diagnosis? complete blood count blood cultures transesophageal echocardiogram urinalysis: blood cultures 80.A client is diagnosed with cardiomyopathy. Which symptoms that are specific to cardiomyopathy will the nurse instruct the client to report to the health care provider? Select all that apply. Weight gain of 5 lbs. (2.3 kg) in one week Swollen lymph nodes Petechiae on the roof of the mouth Persistent cough Shortness of breath at rest: Persistent cough Shortness of breath at rest Weight gain of 5 lbs. (2.3 kg) in one week 81.A client with a recent myocardial infarction was admitted to the hospital with a new diagnosis of mitral valve regurgitation. Which assessment data obtained by the nurse should be immediately communicated to the health care provider? A palpable thrill felt over the left anterior chest A loud systolic murmur all across the precordium Crackles audible throughout the lungs 4+ peripheral edema in both legs: Crackles audible throughout the lungs 26 / 82.A nurse working at a pediatric clinic is teaching a group of parents. A parent asks the nurse if it is okay to let the young child recover from a sore throat naturally, rather than bringing the child to the clinic for diagnosis and treatment. What is the nurse's best response? "Health care providers tend to overtreat children with antibiotics so the child recovers quickly." "It is fine to let the child recover naturally; it will save you time and money." "It is not a good idea to give antibiotics for every sore throat that your child has because of the overuse of antibiotics." "It may be streptococcal sore throat. Rheumatic heart disease can be prevent- ed with early treatment.": "It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment." 83. The nurse is caring for a client diagnosed with infective endocarditis and awaiting blood culture results. The client asks, "Where did I pick up these bacteria?" The nurse is most safe to speculate which of the following? From droplets from a cough From a break in the skin From the fecal-oral route From ingestion of a food: From a break in the skin 84.A client with mitral stenosis comes to the physician's office for a routine checkup. When listening to the client's heart, the nurse expects to hear which type of murmur? Systolic, harsh, crescendo-decrescendo Pansystolic, blowing, high-pitched Diastolic, blowing, decrescendo Diastolic, rumbling, low-pitched: Diastolic, rumbling, low-pitched 85.A client with mitral stenosis is admitted to the hospital. What assessment findings would indicate right ventricular failure? 27 / Dyspnea, distended jugular veins, orthopnea Distended jugular veins, pedal edema, nausea Dyspnea, orthopnea, pulmonary edema Orthopnea, nausea, pedal edema: Distended jugular veins, pedal edema, nausea 86.While auscultating the heart of a pediatric client who is recovering from acute rheumatic fever, the nurse hears a murmur. This sound may indicate: cardiac tamponade. pericarditis. atrial gallop. valve damage.: valve damage. 87. The nurse has created a care plan for a client admitted with acute pericardi- tis and a nursing diagnosis of acute pain related to pericardial inflammation. What is an appropriate nursing intervention for this client? Administering around-the-clock opioids as prescribed Placing the patient in the high-Fowler's position with an over-the-bed table for the patient to lean on Positioning the patient on the right side with the head of the bed elevated 15 degrees Promoting progressive relaxation techniques with the use of slow, deep breathing: Placing the patient in the high-Fowler's position with an over-the-bed table for the patient to lean on 88.A client with infective endocarditis of a prosthetic mitral valve returns to the emergency department with a second episode of left-sided weakness and visual changes. What collaborative management will the nurse expect for this client? higher than usual antibiotic dosages administration of anticoagulants surgical valve replacement embolectomy: surgical valve replacement 30 / records that the client is demonstrating paroxysmal nocturnal dyspnea. hyperpnea. orthopnea. dyspnea upon exertion.: orthopnea 98. The nurse monitors a client for side effects associated with furosemide, which is newly prescribed for the treatment of heart failure. Complete the following sentence by choosing from the lists of options. Due to the client's high risk for developing (hypokalemia, hyponatremia, hyperuricemia) as a result of the prescribed medication, the nurse focuses on monitoring the client for (ventricular arrhythmia, joint swelling, nausea) .: hypokalemia, ventricular arrhythmia 99. The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately? Ability to sleep through the night Persistent cough Weight loss Increased appetite: Persistent cough 100. The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure? Decreased urinary output Dyspnea on exertion Tachycardia Hypotension: Dyspnea on exertion 101. A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema? The client says his rings have become tight and are difficult to remove. The 31 / client says that he has been urinating less frequently at night. The client says he is short of breath when ambulating. The client says he has been hungry in the evening.: The client says his rings have become tight and are difficult to remove. 102. A client is exhibiting digitalis toxicity. Which of the following medications would the nurse expect to be ordered for this client? Ibuprofen Warfarin Amlodipine Digoxin immune FAB: Digoxin immune FAB 103. The nurse is preparing to administer furosemide to a client with severe heart failure. What lab study should be of most concern for this client while taking furosemide? BNP of 100 Potassium level of 3.1 Sodium level of 135 Hemoglobin of 12: Potassium level of 3.1 104. A client is in the early stage of heart failure. During this time, which compensatory mechanism occurs? Decreased renal blood flow causes the renin-angiotensin-aldosterone system to decrease secretion of aldosterone and antidiuretic hormone. Low blood pressure triggers the baroreceptors to increase sympathetic ner- vous system stimulation. Low blood pressure triggers the baroreceptors to decrease sympathetic ner- vous system stimulation. Increased renal blood flow causes the renin-angiotensin-aldosterone system to increase aldosterone secretion.: Low blood pressure triggers the barorecep- tors to 32 / increase sympathetic nervous system stimulation. 105. Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)? Ethacrynic acid Chlorothiazide Spironolactone Bumetanide: Spironolactone 106. A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure? Complete blood count (CBC) Blood urea nitrogen (BUN) B-type natriuretic peptide (BNP) Serum electrolytes: B-type natriuretic peptide (BNP) 107. A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect? Heart failure Pulmonary embolism Cardiac tamponade Tension pneumothorax: Heart failure 108. The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart? pulmonary arterial pressure MRI echocardiogram nuclear angiography: echocardiogram 109. The nurse identifies which symptom as a characteristic of right-sided heart failure? 35 / 117. A client has been experiencing increasing shortness of breath and fa- tigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered? A chest x-ray An echocardiogram An electrocardiogram A ventriculogram: An echocardiogram 118. A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence? The pericardial space is eliminated with scar tissue and thickened pericardi- um. Fibrin accumulation on the visceral pericardium infiltrates into the myocardi- um, creating generalized myocardial dysfunction. The parietal and visceral pericardial membranes adhere to each other, pre- venting normal myocardial contraction. Excess pericardial fluid compresses the heart and prevents adequate dias- tolic filling.: Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. 119. A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber? atrial fibrillation rhythm urine output of 300 mL in eight hours heart rate of 55 beats per minute blood pressure of 125/80: heart rate of 55 beats per minute 120. A client has been prescribed furosemide 80 mg twice daily. The asympto- matic client begins to have rare premature ventricular contractions followed by runs of 36 / bigeminy with stable signs. What action will the nurse perform next? Notify the health care provider. Administer potassium. Check the client's potassium level. Calculate the client's intake and output.: Check the client's potassium level. 121. The nurse is receiving a client from the emergency in cardiogenic shock. What mechanical device does the nurse anticipate will be inserted into the client? defibrillator cardiac pacemaker intra-aortic balloon pump hypothermia-hyperthermia machine: intra-aortic balloon pump 122. The clinical manifestations of cardiogenic shock reflect the pathophysi- ology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following? Right atrial function Left ventricular function Left atrial function Right ventricular function: Left ventricular function 123. A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis? orthopnea bibasilar rales cleared with coughing resting bradycardia increased appetite: orthopnea 124. A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea? Observe for mist in the endotracheal tube. Call 37 / for a chest x-ray. Attach a pulse oximeter probe and obtain values. Listen for breath sounds over the epigastrium.: Call for a chest x-ray. 125. A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured? echocardiogram 40 / high urine output: pulmonary crackles 133. A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid: dried peas. angel food cake. canned peas. ready-to-eat cereals.: canned peas. 134. A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client? Hourly administration of a fluid bolus Intubation of the airway Insertion of a central venous catheter BP and pulse measurements every 15 to 30 minutes: BP and pulse measure- ments every 15 to 30 minutes 135. The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure? pitting edema oliguria decreased O2 saturation levels S4 ventricular gallop sign: pitting edema 136. A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician? JVD is noted 2 cm above the sternal angle. JVD is noted 4 cm above the sternal angle. No JVD is present. JVD is noted at the level of the sternal angle.: JVD is noted 4 cm above the sternal 41 / angle. 137. A client in the emergency room is in cardiac arrest and exhibiting pulse- less electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action? Administer epinephrine. Stop all emergency measures. Analyze the arterial blood gas. Change oxygen delivery to a mask.: Administer epinephrine. 138. Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest? I II III IV: IV 139. Which diagnostic study is usually performed to confirm the diagnosis of heart failure? Electrocardiogram (ECG) Blood urea nitrogen (BUN) Serum electrolytes Echocardiogram: Echocardiogram 140. A client has been diagnosed with congestive heart failure. Which is a cause of crackles heard in the bases of the lungs? Aortic valve stenosis Pulmonary hypertension Mitral valve stenosis Pulmonary congestion: Pulmonary congestion 141. The nurse is admitting a client with heart failure. What client statement indicates that fluid overload was occurring at home? "I eat six small meals a day when I am hungry." "My best time of the day is the morning." 42 / "I've stopped eating foods with salt, though I miss the taste." "I'm having trouble going up the steps during the day.": "I'm having trouble going up the steps during the day." 142. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? Assessing for peripheral edema Assessing the client's vital signs every 4 hours Weighing the client daily at the same time each day Checking the client's lungs for crackles during every shift: Weighing the client daily at the same time each day 143. The nurse is assessing a client with crackling breath sounds or pul- monary congestion. What is the cause of the congestion? ascites nocturia inadequate cardiac output hepatomegaly: inadequate cardiac output 144. A patient is undergoing a pericardiocentesis. Following withdrawal of pericardial fluid, which assessment by the nurse indicates that cardiac tam- ponade has been relieved? Increase in CVP Absence of cough Decrease in blood pressure Decrease in central venous pressure (CVP): Decrease in central venous pres- sure (CVP) 145. A client who was admitted to the hospital with a diagnosis of throm- bophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and 45 / nurse closely monitor when caring for the client? Flexion contractures Vasculitis nausea and vomiting Enlargement of joints: nausea and vomiting 154. A nurse is caring for a client with left-sided heart failure. During the nurse's assessment, the client is wheezing, restless, tachycardic, and has severe apprehension. The clients reports that these symptoms came on sud- denly. The nurse knows that these are symptoms of what condition? Acute pulmonary edema Progressive heart failure Cardiogenic shock Pulmonary hypertension: Acute pulmonary edema 155. A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)? Myocardial ischemia Ineffective right ventricular contraction Cystic fibrosis Pulmonary embolus: Myocardial ischemia 156. Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone? Encourage the client to ambulate in room Titrate milrinone rate slowly before discontinuing Monitor blood pressure frequently Teach the client about safe home use of the medication: Monitor blood pressure frequently 157. A client is receiving captopril for heart failure. During the nurse's assess- ment, what sign indicates that the medication therapy is ineffective? bradycardia 46 / skin rash postural hypotension peripheral edema: peripheral edema 158. The nurse is administering furosemide to a client with heart failure. What best describes the therapeutic action of the medication? The medication promotes potassium secretion into the distal tubule and 47 / constrict renal vessels. Furosemide blocks reabsorption of potassium on the collecting tubule. The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. Furosemide promotes sodium secretion into the distal tubule.: The medication blocks sodium reabsorption in the ascending loop and dilate renal vessels. 159. The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer? Metolazone (Zaroxolyn) Carvedilol (Coreg) Digoxin (Lanoxin) Valsartan (Diovan): Valsartan (Diovan) 160. The nurse is discussing basic cardiac hemodynamics and explains pre- load to the client. What nursing intervention will decrease preload? administration of a vasodilating drug (as ordered by a health care provider) increasing activity sustained elevation of the client's legs application of antiembolic stockings: administration of a vasodilating drug (as ordered by a health care provider) 161. Which assessment parameter is important for the client diagnosed with congestive heart failure? Photosensitivity Crepitus Excess tears Distended veins: Distended veins 162. The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determi- nant of the patient's ventilation and oxygenation status? 50 / A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling: Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours 171. Following a left anterior myocardial infarction, a client undergoes inser- tion of a pulmonary artery catheter. Which finding most strongly suggests left-sided heart failure? Increased pulmonary artery diastolic pressure Decreased mean pulmonary artery pressure Increase in the cardiac index Decreased central venous pressure: Increased pulmonary artery diastolic pres- sure 172. A patient in cardiogenic shock after a myocardial infarction is placed on an intra-aortic balloon pump (IABP). What does the nurse understand is the mechanism of action of the balloon pump? The balloon will inflate at the beginning of systole and deflate before diastole to provide a long-term solution to a failing myocardium. The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. The balloon delivers an electrical impulse to correct dysrhythmias the patient experiences. The balloon keeps the vessels open so that blood will adequately deliver to the myocardium.: The balloon inflates at the beginning of diastole and deflates before systole to augment the pumping action of the heart. 173. The nurse is interviewing a client during an initial visit at a cardiologist's 51 / office. What symptom will the nurse expect to find as an early symptom of chronic heart failure? nocturia fatigue irregular pulse pedal edema: fatigue 174. What is the main difference between Class I and Class II heart failure as defined by the New York Heart Association (NYHA)? Duration of symptoms There is a marked limitation of physical activity. The client is unable to carry out any physical activity. The level of physical activity each allows: The level of physical activity each allows