Cardiovascular NCLEX Questions

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1. The client is admitted to the telemetry *1. The client with 2. The nurse is developing a nursing care 1. Ambulating in the
unit diagnosed with acute exacerbation CHF would exhibit plan for a client diagnosed with hall by day of
of tachycardia (apical congestive discharge
congestive heart failure (CHF). Which pulse rate of 110), heart failure. A nursing diagnosis of would be a more
signs/symptoms would the nurse dependent edema, "decreased cardiac output related to appropriate goal
expect to find fatigue, third heart inability of for an
when assessing this client? sounds, lung the heart to pump effectively" is activity-intolerance
1. Apical pulse rate of 110 and 4+ congestion, and written. Which short-term goal would nursing diagnosis.
pitting edema of feet. change in be best for the *2. Audible S1 and
2. Thick white sputum and crackles that mental status. client? The client will: S2 sounds are
clear with cough. 2. The client with 1. Be able to ambulate in the hall by normal for
3. The client sleeping with no pillow CHF usually has date of discharge. a heart with
and eupnea. pink 2. Have an audible S1 and S2 with no adequate output.
4. Radial pulse rate of 90 and capillary frothy sputum and S3 heard by end of shift. An audible
refill time <3 seconds. crackles that do not 3. Turn, cough, and deep breathe every S3 sound might
clear two (2) hours. indicate left
with coughing. 4. Have a pulse oximeter reading of ventricular
3. The client with 98% by day two (2) of care. failure which could
CHF would report be life threatening.
sleeping 3. This is a nursing
on at least two intervention, not a
pillows, if not short-term goal,
sleeping in an for this client.
upright position, 4. A pulse
and labored oximeter reading
breathing, not would be a goal
eupnea, which for impaired gas
means normal exchange, not for
breathing. cardiac
4. In a client output.
diagnosed with
heart failure, the
apical pulse, not
the radial pulse, is
the best
place to assess the
cardiac status.
3. The nurse is developing a
discharge-teaching plan for the
client diagnosed with
congestive heart failure. Which
interventions should be included
in the plan? Select all
that apply.
1. Notify health-care provider of
a weight gain of more than one
(1) pound in a week.
2. Teach client how to count the
radial pulse when taking digoxin,
a cardiac glycoside.
3. Instruct client to remove the
saltshaker from the dinner table.
4. Encourage client to monitor
urine output for change in color
to become dark.
5. Discuss the importance of
taking the loop diuretic
furosemide at bedtime.
4. The nurse enters the room of the
client diagnosed with congestive
heart failure. The
client is lying in bed gasping for
breath, is cool and clammy, and
has buccal cyanosis.
Which intervention would the
nurse implement first?
1. Sponge the client's forehead.
2. Obtain a pulse oximetry
reading.
3. Take the client's vital signs.
4. Assist the client to a sitting
position.
1. The client should notify 5. The nurse is assessing the client 1. Pitting edema
the HCP of weight diagnosed with congestive heart changing from 3+ to
gain of more than two (2) failure. Which 4+ indicates
or three signs/symptoms would indicate that a worsening of the
(3) pounds in one (1) day. the medical treatment has been CHF.
*2. The client should not effective? 2. The client's ability
take digoxin if the 1. The client's peripheral pitting to take the radial
radial pulse is less than edema has gone from 3+ to 4+. pulse
60. 2. The client is able to take the radial would evaluate
*3. The client should be pulse accurately. teaching, not medical
on a low-sodium 3. The client is able to perform ADLs treatment.
diet to prevent water without dyspnea. *3. Being able to
retention. 4. The client has minimal jugular vein perform activities of
4. The color of the urine distention. daily
should not change to living (ADLs) without
a dark color; if anything, shortness of
it might become breath (dyspnea)
lighter and the amount would indicate the
will increase with client's condition is
diuretics. improving. The
5. Instruct the client to client's heart is a
take the diuretic in the more effective pump
morning to prevent and can oxygenate
nocturia. the body better
without
1. Sponging the client's
increasing fluid in the
forehead would be
lungs.
appropriate,
4. Any jugular vein
but it is not the first
distention indicates
intervention.
that
2. Obtaining a pulse
the right side of the
oximeter reading would
heart is failing, which
be appropriate, but it is
would not indicate
not the first intervention.
effective medical
3. Taking the vital signs
treatment.
would be appropriate,
but it is not the first
intervention.
*4. The nurse must first
put the client in a
sitting position to
decrease the workload
of the heart by
decreasing venous return
and maximizing lung
expansion. Then,
the nurse could take vital
signs and check the pulse
oximeter and then
sponge the client's
forehead.
6. The nurse is assessing the client *1. BNP is a specific 7.
diagnosed with congestive heart diagnostic test.
failure. Which Levels
laboratory data would indicate that higher than normal
the client is in severe congestive indicate congestive
heart failure? heart failure, with the
1. An elevated B-type natriuretic higher the number,
peptide (BNP). the more severe the
2. An elevated creatine kinase (CK- CHF.
MB). 2. An elevated CK-
3. A positive D-dimer. MB would indicate a
4. A positive ventilation/perfusion myocardial infarction,
(V/Q) scan. not severe CHF.
CK-MB is an
isoenzyme.
3. A positive D-dimer
would indicate a
pulmonary
embolus.
4. A positive
ventilation/perfusion
(V/Q) scan
(ratio) would indicate
a pulmonary
embolus.
The health-care provider has ordered 1. If a cough
an angiotensin-converting enzyme develops, the client
(ACE) should notify
inhibitor for the client diagnosed with the health-care
congestive heart failure. Which provider because
discharge this is an
instructions should the nurse include? adverse reaction and
1. Instruct the client to take a cough the HCP will
suppressant if a cough develops. discontinue
2. Teach the client how to prevent the medication.
orthostatic hypotension. *2. Orthostatic
3. Encourage the client to eat hypotension may
bananas to increase potassium level. occur with
4. Explain the importance of taking ACE inhibitors as a
the medication with food. result of
vasodilation.
Therefore, the nurse
should instruct
the client to rise
slowly and sit on
the side of the bed
until equilibrium is
restored.
3. ACE inhibitors
may cause the client
to retain
potassium; therefore,
the client should
not increase
potassium intake.
4. An ACE inhibitor
should be taken one
(1) hour before meals
or two (2) hours
after a meal to
increase absorption
of the
medication.
8. The nurse on the telemetry unit has *1. An S3 heart 9. The nurse and an unlicensed assistive 1. Allowing the UAP
just received the a.m. shift report. sound indicates left personnel (UAP) are caring for four to take a client down
Which client ventricular clients on to
should the nurse assess first? failure, and the a telemetry unit. Which nursing task smoke is not cost
1. The client diagnosed with nurse must assess would be best for the nurse to effective and is not
myocardial infarction who has an this client first delegate to the supportive
audible S3 heart because it is an UAP? of the medical
sound. emergency situation. 1. Assist the client to go down to the treatment regimen
2. The client diagnosed with 2. The nurse would smoking area for a cigarette. that discourages
congestive heart failure who has 4+ expect a client with 2. Transport the client to the smoking.
sacral pitting CHF intensive care unit via a stretcher. 2. The client going
edema. to have sacral 3. Provide the client going home to the ICU would be
3. The client diagnosed with edema of 4+; the discharge-teaching instructions. unstable, and the
pneumonia who has a pulse oximeter client with 4. Help position the client who is nurse should not
reading of 94%. an S3 would be in a having a portable x-ray done. delegate
4. The client with chronic renal failure more life- to a UAP any nursing
who has an elevated creatinine level. threatening task that involves
situation. an unstable client.
3. A pulse oximeter 3. The nurse cannot
reading of greater delegate teaching.
than *4. The UAP can
93% is considered assist the x-ray
normal. technician
4. An elevated in positioning the
creatinine level is client for the
expected in a portable x-ray. This
client diagnosed does not require
with chronic renal judgment.
failure.
10. The charge nurse is making shift 1. This client is stable 11. The client diagnosed with congestive 1. The client with
assignments for the medical floor. because discharge is heart failure is complaining of leg peripheral edema
Which client scheduled for the cramps at will
should be assigned to the most following day. night. Which nursing interventions experience calf
experienced registered nurse? Therefore, should be implemented? tightness but would
1. The client diagnosed with this client does not 1. Check the client for peripheral not
congestive heart failure who is being need to be assigned edema and make sure the client takes have leg cramping,
discharged in the to the most a diuretic which is the result
morning. experienced early in the day. of
2. The client who is having frequent registered 2. Monitor the client's potassium level low potassium
incontinent liquid bowel movements nurse. and assess the client's intake of levels. The timing
and 2. This client is more bananas and of the
vomiting. in need of custodial orange juice. diuretic will not
3. The client with an apical pulse rate nursing care than 3. Determine if the client has gained change the side
of 116, a respiratory rate of 26, and a care from the most weight and instruct the client to keep effect
blood experienced the legs of leg cramping
pressure of 94/62. registered nurse. elevated. resulting from low
4. The client who is complaining of Therefore, the 4. Instruct the client to ambulate potassium levels.
chest pain with inspiration and a charge nurse could frequently and perform calf-muscle *2. The most
nonproductive assign a less stretching probable cause of
cough. experienced exercises daily. the leg
nurse to this client. cramping is
*3. This client is potassium
exhibiting excretion as a
signs/symptoms result of diuretic
of shock, which medication.
makes this client the Bananas
most unstable. An and orange juice
experienced nurse are foods that are
should care for this high in potassium.
client. 3. Weight gain is
4. These complaints monitored in clients
usually indicate with
muscular CHF, and elevating
or pleuritic chest the legs would
pain; cardiac chest decrease
pain does not peripheral edema
fluctuate with by increasing the
inspiration. rate of return to the
central circulation,
but these
interventions would
not help
with leg cramps.
4. Ambulating
frequently and
performing
leg-stretching
exercises will not
be effective
in alleviating the
leg cramps.
12. The nurse has written an outcome 1. Measuring the 14. Along with persistent, crushing chest 1. Midepigastric pain
goal "demonstrates tolerance for intake and output is pain, which signs/symptoms would would support a
increased an appropriate make the diagnosis
activity" for a client diagnosed with intervention to nurse suspect that the client is of peptic ulcer
congestive heart failure. Which implement for a experiencing a myocardial disease; pyrosis is
intervention client with CHF, but it infarction? belching.
should the nurse implement to assist does not address 1. Midepigastric pain and pyrosis. *2. Diaphoresis
the client to achieve this outcome? getting the client to 2. Diaphoresis and cool clammy skin. (sweating) is a
1. Measure intake and output. tolerate activity. 3. Intermittent claudication and systemic
2. Provide two (2)-g sodium diet. 2. Dietary sodium is pallor. reaction to the MI.
3. Weigh client daily. restricted in clients 4. Jugular vein distention and The body
4. Plan for frequent rest periods. with dependent edema. vasoconstricts
CHF, but this is an to shunt blood from
intervention for the periphery
decreasing to the trunk of the
fluid volume, not for body; this, in
increasing turn, leads to cold,
tolerance for activity. clammy skin.
3. Daily weighing 3. Intermittent
monitors fluid claudication is leg
volume status, pain secondary
not activity tolerance. to decreased oxygen
*4. Scheduling to the muscle,
activities and rest and pallor is
periods paleness of the skin
allows the client to as a result
participate in his or of decreased blood
her own care and supply. Neither is an
addresses the desired early sign of MI.
outcome. 4. Jugular vein
distension (JVD) and
13. Which cardiac enzyme would the 1. CPK-MB elevates in
dependent
nurse expect to elevate first in a 12 to 24 hours.
edema are
client diagnosed 2. LDH elevates in 24
signs/symptoms of
with a myocardial infarction? to 36 hours.
congestive
1. Creatine kinase (CK-MB). *3. Troponin is the
heart failure, not of
2. Lactate dehydrogenase (LDH). enzyme that elevates
MI.
3. Troponin. within 1 to 2 hours.
4. White blood cells (WBCs). 4. WBCs elevate as a
result of necrotic
tissue,
but this is not a
cardiac enzyme.
15. The client diagnosed with rule-out 1. The nurse must 16.
myocardial infarction is assume the chest
experiencing chest pain pain is
while walking to the bathroom. secondary to
Which action should the nurse decreased oxygen to
implement first? the
1. Administer sublingual myocardium and
nitroglycerin. administer a
2. Obtain a STAT electrocardiogram. sublingual
3. Have the client sit down nitroglycerin tablet,
immediately. which is a coronary
4. Assess the client's vital signs. vasodilator, but this
is not the first action.
2. An ECG should be
ordered, but it is not
the first intervention.
*3. Stopping all
activity will decrease
the
need of the
myocardium for
oxygen
and may help
decrease the chest
pain.
4. Assessment is
often the first nursing
intervention,
but when the client
has chest pain
and a possible MI,
the nurse must first
take care of the
client. Taking vital
signs
would not help
relieve chest pain.
The nurse is caring for a client 1. Morphine should
diagnosed with a myocardial be administered
infarction who is intravenously,
experiencing chest pain. Which not intramuscularly.
interventions should the nurse *2. Aspirin is an
implement? Select all antiplatelet
that apply. medication
1. Administer morphine and should be
intramuscularly. administered orally.
2. Administer an aspirin orally. *3. Oxygen will help
3. Apply oxygen via a nasal cannula. decrease myocardial
4. Place the client in a supine ischemia, thereby
position. decreasing pain.
5. Administer nitroglycerin 4. The supine
subcutaneously. position will increase
respiratory
effort, which will
increase myocardial
oxygen
consumption; the
client should be
in the semi-Fowler's
position.
5. Nitroglycerin, a
coronary
vasodilator, is
administered
sublingually, not
subcutaneously.
17. The client who has had a myocardial 1. The social worker 18. The client is one (1) day postoperative 1. The nurse should
infarction is admitted to the addresses financial coronary artery bypass surgery. The medicate the client
telemetry unit concerns client as
from intensive care. Which referral or referrals after complains of chest pain. Which needed, but it is not
would be most appropriate for the discharge, which intervention should the nurse the first
client? are not indicated for implement first? intervention.
1. Social worker. this client. 1. Medicate the client with intravenous *2. The nurse must
2. Physical therapy. 2. Physical therapy morphine. always assess the
3. Cardiac rehabilitation. addresses gait 2. Assess the client's chest dressing client to determine
4. Occupational therapy. problems, and vital signs. if the chest pain
lower extremity 3. Encourage the client to turn from that is occurring is
strength building, and side to side. expected
assisting with transfer, 4. Check the client's telemetry postoperatively
which are not monitor. or if it is a
required for this complication of the
client. surgery.
*3. Cardiac 3. Turning will help
rehabilitation is the decrease
most complications
appropriate referral. from immobility,
The client can such as pneumonia,
start rehabilitation in but
the hospital and it will not help
then attend an relieve the client's
outpatient cardiac pain.
rehabilitation 4. The nurse, not a
clinic, which includes machine, should
progressive always
exercise, diet take care of the
teaching, and client.
classes on modifying
risk factors.
4. Occupational
therapy assists the
client in
regaining activities of
daily living and
covers
mainly fine motor
activities.
19. The client diagnosed with a 1. After PTCA, the 20.
myocardial infarction is six (6) hours client must keep the
post-right femoral right leg straight for
percutaneous transluminal coronary at least six (6) to
angioplasty (PTCA), also known as eight (8) hours to
balloon prevent any arterial
surgery. Which assessment data bleeding from the
would require immediate insertion site in the
intervention by the nurse? right femoral artery.
1. The client is keeping the affected 2. A pressure
extremity straight. dressing is applied
2. The pressure dressing to the right to the insertion
femoral area is intact. site to help prevent
3. The client is complaining of arterial bleeding.
numbness in the right foot. *3. Any
4. The client's right pedal pulse is 3+ neurovascular
and bounding. assessment data that
are abnormal require
intervention by the
nurse; numbness
may indicate
decreased
blood supply to the
right foot.
4. A bounding pedal
pulse indicates that
adequate
circulation is getting
to the right
21.
foot; therefore, this
would not require
immediate
intervention.
The intensive care department nurse *1. An S3 indicates
is assessing the client who is 12 hours left ventricular
post-myocardial infarction. The nurse failure
assesses an S3 heart sound. Which and should be
intervention should the nurse reported to the
implement? healthcare
1. Notify the health-care provider provider. It is a
immediately. potential
2. Elevate the head of the client's bed. lifethreatening
3. Document this as a normal and complication of a
expected finding. myocardial
4. Administer morphine intravenously. infarction.
2. Elevating the
head of the bed
will not do
anything to help a
failing heart.
3. This is not a
normal finding; it
indicates
heart failure.
4. Morphine is
administered for
chest pain,
not for heart
failure, which is
suggested by
the S3 sound.
The nurse is administering a calcium 1. The apical pulse
channel blocker to the client is within normal
diagnosed with a limits—
myocardial infarction. Which 60 to 100 beats
assessment data would cause the per minute.
nurse to question 2. The serum
administering this medication? calcium level is
1. The client's apical pulse is 64. not monitored
2. The client's calcium level is when calcium
elevated. channel blockers
3. The client's telemetry shows are given.
occasional PVCs. 3. Occasional
4. The client's blood pressure is 90/62. PVCs would not
warrant
immediate
intervention prior
to
administering this
medication.
*4. The client's
blood pressure is
low, and
a calcium channel
blocker could
cause
the blood pressure
to bottom out.
22. The client diagnosed with a 1. Leg movement is 23.
myocardial infarction is on bedrest. an appropriate
The unlicensed action,
assistive personnel (UAP) is and the UAP
encouraging the client to move the should not be told
legs. Which action to stop
should the nurse implement? encouraging it.
1. Instruct the UAP to stop 2. This behavior is
encouraging the leg movements. not unsafe or
2. Report this behavior to the charge dangerous
nurse as soon as possible. and should not be
3. Praise the UAP for encouraging the reported to the
client to move legs. charge
4. Take no action concerning the nurse.
UAP's behavior. *3. The nurse
should praise and
encourage
UAPs to participate
in the client's care.
Clients on bedrest
are at risk for deep
vein thrombosis,
and moving the
legs
will help prevent
this from
occurring.
4. The nurse
should praise
subordinates for
appropriate
behavior,
especially when it
is
helping to prevent
life-threatening
complications.
The client diagnosed with a *1. The heart tissue
myocardial infarction asks the nurse, is dead, stress or
"Why do I have to activity
rest and take it easy? My chest may cause heart
doesn't hurt anymore." Which failure, and it
statement would be does take about six
the nurse's best response? (6) weeks for scar
1. "Your heart is damaged and needs tissue to form.
about four (4) to six (6) weeks to heal." 2. The nurse should
2. "There is necrotic myocardial tissue talk to the client in
that puts you at risk for dysrhythmias." layperson's terms,
3. "Your doctor has ordered bedrest. not medical terms.
Therefore, you must stay in the bed." Medical
4. "Just because your chest doesn't terminology is a
hurt anymore doesn't mean you are foreign language
out of to most clients.
danger." 3. This is not
answering the
client's question.
The nurse should
take any
opportunity to
teach the client.
4. This is a
condescending
response, and
telling the client
that he or she is
not out
of danger is not an
appropriate
response.
24. The client has just returned from a 1. These vital signs 25. The male client is diagnosed with 1. If the tablets are
cardiac catheterization. Which are within normal coronary artery disease (CAD) and is not kept in a dark
assessment data limits prescribed bottle,
would warrant immediate intervention and would not sublingual nitroglycerin. Which they will lose their
from the nurse? require any statement indicates the client needs potency.
1. The client's BP is 110/70 and pulse is immediate more teaching? 2. The tablets
90. intervention. 1. "I should keep the tablets in the should burn or
2. The client's groin dressing is dry 2. The groin dark-colored bottle they came in." sting when put
and intact. dressing should be 2. "If the tablets do not burn under my under the tongue.
3. The client refuses to keep the leg dry and tongue, they are not effective." 3. The client
straight. intact. 3. "I should keep the bottle with me in should keep the
4. The client denies any numbness *3. If the client my pocket at all times." tablets with
and tingling. bends the leg, it 4. "If my chest pain is not gone with him in case of
could one tablet, I will go to the ER." chest pain.
cause the insertion *4. The client
site to bleed. This should take one
is arterial blood tablet every
and the client five (5) minutes
could and, if no relief
bleed to death occurs
very quickly, so after the third
this tablet, have
requires immediate someone
intervention. drive him to the
4. The nurse must emergency
check the department
neurovascular or call 911.
assessment, and
paresthesia would
warrant
immediate
intervention, but no
numbness
and tingling is a
good sign.
26. The client with coronary artery *1. This is a correct 27. The client is scheduled for a right 1. The client's right
disease asks the nurse, "Why do I get statement femoral cardiac catheterization. leg should be kept
chest pain?" presented Which nursing straight to prevent
Which statement would be the most in layman's terms. intervention should the nurse arterial bleeding
appropriate response by the nurse? When the coronary implement after the procedure? from
1. "Chest pain is caused by decreased arteries cannot 1. Perform passive range-of-motion the femoral insertion
oxygen to the heart muscle." supply adequate exercises. site for the catheter
2. "There is ischemia to the oxygen 2. Assess the client's neurovascular used to perform the
myocardium as a result of to the heart status. catheterization.
hypoxemia." muscle, there is 3. Keep the client in high Fowler's *2. The nurse must
3. "The heart muscle is unable to chest pain. position. make sure that blood
pump effectively to perfuse the 2. This is the 4. Assess the gag reflex prior to is
body." explanation in feeding the client. circulating to the
4. "Chest pain occurs when the lungs medical terms right leg, so the
cannot adequately oxygenate the that should not be client
blood." used when should be assessed
explaining for pulses,
medical conditions paresthesia,
to a client. paralysis, coldness,
3. This explains and pallor.
congestive heart 3. The head of the
failure but bed should be
does not explain elevated no
why chest pain more than 10
occurs. degrees. The client
4. Respiratory should
compromise be kept on bedrest,
occurs when the flat with the affected
lungs cannot extremity straight, to
oxygenate the help decrease the
blood, such as chance of femoral
occurs with altered artery bleeding.
level of 4. The gag reflex is
consciousness, assessed if a scope is
cyanosis, and inserted
increased down the trachea
respiratory rate. (bronchoscopy) or
esophagus
(endoscopy) because
the throat
is numbed when
inserting the scope. A
catheter is inserted in
the femoral or
brachial artery when
performing a cardiac
catheterization.
28. The nurse is preparing to administer a 1. This blood 29.
beta blocker to the client diagnosed pressure is normal
with and the
coronary artery disease. Which nurse would
assessment data would cause the administer the
nurse to question medication.
administering the medication? *2. A beta blocker
1. The client has a BP of 110/70. decreases
2. The client has an apical pulse of 56. sympathetic
3. The client is complaining of a stimulation to the
headache. heart, thereby
4. The client's potassium level is 4.5 decreasing
mEq/L. the heart rate. An
apical rate
less than 60
indicates a lower-
thannormal
heart rate and
should make the
nurse question
administering this
medication
because it will
further decrease
the heart rate.
3. A headache will
not affect
administering
the medication to
the client.
4. The potassium
level is within
normal limits,
but it is usually not
monitored prior to
administering a
beta blocker.
Which intervention should the nurse 1. The nurse should
implement when administering a always assess the
loop diuretic apical
to a client diagnosed with coronary (not radial) pulse, but
artery disease? the pulse is not
1. Assess the client's radial pulse. affected by a loop
2. Assess the client's serum diuretic.
potassium level. *2. Loop diuretics
3. Assess the client's glucometer cause potassium to
reading. be
4. Assess the client's pulse oximeter lost in the urine
reading. output. Therefore,
the nurse should
assess the client's
potassium level, and
if the client is
hypokalemic, the
nurse should
question
administering this
medication.
3. The glucometer
provides a glucose
level,
which is not affected
by a loop diuretic.
4. The pulse
oximeter reading
evaluates peripheral
oxygenation and is
not affected by
a loop diuretic.
30. Which client teaching should the *1. A low-fat, low- 31.
nurse implement for the client cholesterol diet will
diagnosed with help decrease the
coronary artery disease? Select all buildup of
that apply. atherosclerosis
1. Encourage a low-fat, low- in the arteries.
cholesterol diet. *2. Walking will
2. Instruct client to walk 30 minutes a help increase
day. collateral
3. Decrease the salt intake to two (2) circulation.
g a day. 3. Salt should be
4. Refer to counselor for stress restricted in the diet
reduction techniques. of a
5. Teach the client to increase fiber in client with
the diet. hypertension, not
coronary
artery disease.
*4. Stress reduction
is encouraged for
clients with CAD
because this helps
prevent excess
stress on the heart
muscle.
*5. Increasing fiber
in the diet will help
remove cholesterol
via the
gastrointestinal
system.
The elderly client has coronary 1. Bowel movements
artery disease. Which question should are important, but
the nurse ask they are not
the client during the client teaching? pertinent to
1. "Do you have a daily bowel coronary artery
movement?" disease.
2. "Do you get yearly chest x-rays?" 2. Chest x-rays are
3. "Are you sexually active?" usually done for
4. "Have you had any weight respiratory
change?" problems, not for
coronary artery
disease.
*3. Sexual activity is
a risk factor for
angina resulting
from coronary
artery
disease. The client's
being elderly
should not affect
the nurse's
assessment
of the client's
concerns about
sexual activity.
4. Weight change is
not significant in a
client
with coronary artery
disease.
32. The nurse is discussing the 1. Isometric 33. The nurse is discussing angina with a 1. The client should
importance of exercise with the client exercises are weight client who is diagnosed with coronary take the coronary
diagnosed with lifting-type artery vasodilator
coronary artery disease. Which exercises. A client disease. Which action should the client nitroglycerin
intervention should the nurse with CAD should take first when experiencing angina? sublingually,
implement? perform 1. Put a nitroglycerin tablet under the but it is not the
1. Perform isometric exercises daily. isotonic exercises, tongue. first intervention.
2. Walk for 15 minutes three (3) times which increase 2. Stop the activity immediately and *2. Stopping the
a week. muscle tone, not rest. activity decreases
3. Do not walk outside if it is less than isometric exercises. 3. Document when and what activity the
40˚F. 2. The client should caused angina. heart's need for
4. Wear open-toed shoes when walk at least 30 4. Notify the health-care provider oxygen and may
ambulating. minutes immediately. help
a day to increase decrease the
collateral angina (chest
circulation. pain).
*3. When it is cold 3. The client
outside, should keep a
vasoconstriction diary of when
occurs, and this will angina occurs,
decrease what activity
oxygen to the heart causes it, and
muscle. Therefore, how many
the client should nitroglycerin
not exercise when it tablets are taken
is cold outside. before chest pain
4. The client should is relieved.
wear good 4. If the chest pain
supportive (angina) is not
tennis shoes when relieved
ambulating, not with three (3)
sandals nitroglycerin
or other open-toed tablets, the
shoes. client should call
911 or have
someone
take him to the
emergency
department.
Notifying the HCP
may take too long.
34. The client with coronary artery
disease is prescribed a Holter
monitor. Which
intervention should the nurse
implement?
1. Instruct client to keep a
diary of activity, especially
when having chest pain.
2. Discuss the need to remove
the Holter monitor during a.m.
care and showering.
3. Explain that all medications
should be withheld while
wearing a Holter monitor.
4. Teach the client the
importance of decreasing
activity while wearing the
monitor.
35. Which statement by the client
diagnosed with coronary
artery disease indicates that
the client understands the
discharge teaching concerning
diet?
1. "I will not eat more than six
(6) eggs a week."
2. "I should bake or grill any
meats I eat."
3. "I will drink eight (8) ounces
of whole milk a day."
4. "I should not eat any type
of pork products."
*1. The Holter monitor is a
24-hour
electrocardiogram, and the
client must
keep an accurate record of
activity
so that the health-care
provider can
compare the ECG
recordings with
different levels of activity.
2. The Holter monitor
should not be
removed for any reason.
3. All medications should
be taken as
prescribed.
4. The client should
perform all activity as
usual while wearing the
Holter monitor so
the HCP can get an
accurate account of
heart function during a 24-
hour period.
1. According to the
American Heart
Association,
the client should not eat
more than
three (3) eggs a week,
especially the egg
yolk.
*2. The American Heart
Association recommends
a low-fat, low-cholesterol
diet for a client with
coronary artery
disease. The client should
avoid any fried foods,
especially meats, and
bake,
broil, or grill any meat.
3. The client should drink
low-fat milk, not
whole milk.
4. Pork products (bacon,
sausage, ham) are
high in sodium, which is
prohibited in a
low-salt diet, not a low-
cholesterol, lowfat
diet.
36. The charge nurse is making
assignments for clients on
a cardiac unit. Which client
should the charge nurse
assign to a new graduate
nurse?
1. The 44-year-old client
diagnosed with a
myocardial infarction.
2. The 65-year-old client
admitted with unstable
angina.
3. The 75-year-old client
scheduled for a cardiac
catheterization.
4. The 50-year-old client
complaining of chest pain.
37. A client is being seen in
the clinic to R/O mitral
valve stenosis. Which
assessment
data would be most
significant?
1. The client complains of
shortness of breath when
walking.
2. The client has jugular
vein distention and 3+
pedal edema.
3. The client complains of
chest pain after eating a
large meal.
4. The client's liver is
enlarged and the abdomen
is edematous.
1. This client is at high risk for
complications
related to necrotic myocardial
tissue
and will need extensive
teaching, so this
client should not be assigned
to a new
graduate.
2. Unstable angina means this
client is at risk
for life-threatening
complications and
should not be assigned to a
new graduate.
*3. A new graduate should be
able to complete
a preprocedure checklist and
get
this client to the
catheterization
laboratory.
4. Chest pain means this client
could be having
a myocardial infarction and
should not
be assigned to a new
graduate.
*1. Dyspnea on exertion (DOE)
is typically
the earliest manifestation of
mitral
valve stenosis.
2. Jugular vein distention (JVD)
and 3+ pedal
edema are signs/symptoms of
right-sided
heart failure and indicate
worsening of the
mitral valve stenosis. These
signs would not be expected
in a client with early
manifestations
of mitral valve stenosis.
3. Chest pain rarely occurs
with mitral valve
stenosis.
4. An enlarged liver and
edematous abdomen
are late signs of right-sided
heart failure
that can occur with long-term
untreated
mitral valve stenosis.
38. Which assessment data would the 1. This would be 39. The client has just received a 1. Prophylactic
nurse expect to auscultate in the expected with mechanical valve replacement. Which antibiotics before
client diagnosed mitral valve behavior by the invasive
with mitral valve insufficiency? stenosis. client indicates the client needs more procedures prevent
1. A loud S1, S2 split, and a mitral *2. The murmur teaching? infectious
opening snap. associated with 1. The client takes prophylactic endocarditis.
2. A holosystolic murmur heard best at mitral antibiotics. 2. The client is
the cardiac apex. valve insufficiency 2. The client uses a soft-bristle undergoing
3. A midsystolic ejection click or is loud, toothbrush. anticoagulant
murmur heard at the base. highpitched, 3. The client takes an enteric-coated therapy and should
4. A high-pitched sound heard at the rumbling, and aspirin daily. use a soft-bristle
third left intercostal space. holosystolic 4. The client alternates rest with toothbrush to help
(occurring activity. prevent gum trauma
throughout and bleeding.
systole) and is *3. Aspirin and
heard best at the nonsteroidal
cardiac apex. antiinflammatory
3. This would be drugs (NSAIDs)
expected with interfere
mitral valve with clotting and
prolapse. may potentiate the
4. This would be effects of the
expected with anticoagulant
aortic therapy,
regurgitation. which the client
with a mechanical
valve will be
prescribed.
Therefore, the
client should not
take aspirin daily.
4. The client should
alternate rest with
activity
to prevent fatigue
to help decrease
the
workload of the
heart.
40. The nurse is teaching a class on 1. An advantage of 41.
valve replacements. Which having a biological
statement identifies a valve replacement is
disadvantage of having a biological that no
tissue valve replacement? anticoagulant
1. The client must take lifetime therapy is needed.
anticoagulant therapy. Anticoagulant
2. The client's infections are easier to therapy is needed
treat. with a mechanical
3. There is a low incidence of valve replacement.
thromboembolism. 2. This is an
4. The valve has to be replaced advantage of having
frequently. a biological
valve replacement;
infections are harder
to
treat in clients with
mechanical valve
replacement.
3. This is an
advantage of having
a biological
valve replacement;
there is a high
incidence
of
thromboembolism in
clients with
mechanical valve
replacement.
*4. Biological valves
deteriorate and need
to be replaced
frequently; this is a
disadvantage
of them. Mechanical
valves
do not deteriorate
and do not have to
be replaced often.
The nurse is preparing to administer *1. The therapeutic
warfarin (Coumadin), an oral range for most
anticoagulant, to clients'
a client with a mechanical valve INR is 2 to 3, but for
replacement. The client's a client with a
international normalized mechanical valve
ratio (INR) is 2.7. Which action should replacement it is 2
the nurse implement? to
1. Administer the medication as 3.5. The medication
ordered. should be given as
2. Prepare to administer vitamin K ordered and not
(AquaMephyton). withheld.
3. Hold the medication and notify the 2. Vitamin K is the
HCP. antidote for an
4. Assess the client for abnormal overdose
bleeding. of warfarin, but 2.7
is within therapeutic
range.
3. This laboratory
result is within the
therapeutic
range, INR 2 to 3,
and the medication
does not need to be
withheld.
4. There is no need
for the nurse to
assess
for bleeding
because 2.7 is within
therapeutic range.
42. Which signs/symptoms should the *1. Paroxysmal 43. The client is being evaluated for 1. An acute
nurse assess in any client who has a nocturnal dyspnea is valvular heart disease. Which myocardial
long-term a information would be infarction can
valvular heart disease? Select all sudden attack of most significant? damage
that apply. respiratory distress, 1. The client has a history of coronary heart valves,
1. Paroxysmal nocturnal dyspnea. usually occurring at artery disease. causing tearing,
2. Orthopnea. night because of 2. There is a family history of valvular ischemia,
3. Cough. the reclining heart disease. or damage to heart
4. Pericardial friction rub. position, and occurs 3. The client has a history of smoking muscles that
5. Pulsus paradoxus. in for 10 years. affects
valvular disorders. 4. The client has a history of valve leaflet
*2. This is an rheumatic heart disease. function, but
abnormal condition coronary heart
in which disease does not
a client must sit or cause valvular
stand to breathe heart
comfortably and disease.
occurs in valvular 2. Valvular heart
disorders. disease does not
*3. Coughing occurs show a
when the client with genetic etiology.
long-term valvular 3. Smoking can
disease has difficulty cause coronary
breathing when artery
walking or disease, but it does
performing not cause valvular
any type of activity. heart disease.
4. Pericardial friction *4. Rheumatic heart
rub is a sound disease is the most
auscultated common cause of
in clients with valvular heart
pericarditis, not disease.
valvular heart
disease.
5. Pulsus paradoxus
is a marked
decrease in
amplitude during
inspiration. It is a
sign
of cardiac
tamponade, not
valvular heart
disease.
44. The client who has just had a 1. Percutaneous 45.
percutaneous balloon valvuloplasty is balloon
in the recovery valvuloplasty is not
room. Which intervention should the an open-heart
recovery room nurse implement? surgery; therefore,
1. Assess the client's chest tube the chest
output. will not be open
2. Monitor the client's chest dressing. and the client will
3. Evaluate the client's endotracheal not
(ET) lip line. have a chest tube.
4. Keep the client's affected leg 2. This is not an
straight. open-heart surgery;
therefore,
the client will not
have a chest
dressing.
3. The endotracheal
(ET) tube is inserted
if
the client is on a
ventilator, and this
surgery
does not require
putting the client on
a ventilator.
*4. In this invasive
procedure,
performed
in a cardiac
catheterization
laboratory,
the client has a
catheter inserted
into
the femoral artery.
Therefore, the
client must keep the
leg straight to
prevent
hemorrhaging at
the insertion site.
The client with a mechanical valve *1. The client is at
replacement asks the nurse, "Why do risk for developing
I have to endocarditis and
take antibiotics before getting my should take
teeth cleaned?" Which response by prophylactic
the nurse is antibiotics before
most appropriate? any invasive
1. "You are at risk of developing an procedure.
infection in your heart." 2. Antibiotics have
2. "Your teeth will not bleed as much nothing to do with
if you have antibiotics." how
3. "This procedure may cause your much the teeth
valve to malfunction." bleed during a
4. "Antibiotics will prevent vegetative cleaning.
growth on your valves." 3. Teeth cleaning
will not cause the
valve to
malfunction.
4. Vegetation
develops on valves
secondary
to bacteria that
cause endocarditis,
but the
client may not
understand
"vegetative
growth on your
valves"; therefore,
this is
not the most
appropriate
answer.
46. The client had open-heart surgery to *1. Fluid intake may 47.
replace the mitral valve. Which be restricted to
intervention reduce the cardiac
should the intensive care unit nurse workload and
implement? pressures
1. Restrict the client's fluids as within the heart and
ordered. pulmonary
2. Keep the client in the supine circuit.
position. 2. The head of the
3. Maintain oxygen saturation at bed should be
90%. elevated to
4. Monitor the total parenteral help improve
nutrition. alveolar ventilation.
3. Oxygen saturation
should be no less
than
93%; 90% indicates
an arterial oxygen
saturation
of around 60
(normal is 80 to 100)
4. Total parenteral
nutrition would not
be
prescribed for a
client with mitral
valve
replacement. It is
ordered for clients
with
malnutrition,
gastrointestinal
disorders, or
conditions in which
increased calories
are
needed, such as
burns.
Which client would the nurse 1. Congestive heart
suspect of having a mitral valve failure does not
prolapse? predispose
1. A 60-year-old female with the female client to
congestive heart failure. having a mitral
2. A 23-year-old male with Marfan's valve prolapse.
syndrome. *2. Clients with
3. An 80-year-old male with atrial Marfan's syndrome
fibrillation. have
4. A 33-year-old female with Down life-threatening
syndrome. cardiovascular
problems,
including mitral valve
prolapse,
progressive dilation of
the aortic valve
ring, and weakness of
the arterial walls,
and they usually do
not live past the
age of 40 because of
dissection and
rupture of the aorta.
3. Atrial fibrillation
does not predispose a
client to mitral valve
prolapse.
4. A client with Down
syndrome may have
congenital heart
anomalies but not
mitral
valve prolapse.
48. The charge nurse is making shift 1. This client requires 49.
assignments. Which client would be teaching and an
most understanding of the
appropriate for the charge nurse to preprocedure
assign to a new graduate who just interventions
completed for diagnostic tests;
orientation to the medical floor? therefore, a
1. The client admitted for diagnostic more experienced
tests to rule out valvular heart nurse should be
disease. assigned to this
2. The client three (3) days post- client.
myocardial infarction being *2. Because this
discharged tomorrow. client is being
3. The client exhibiting discharged,
supraventricular tachycardia (SVT) it would be an
on telemetry. appropriate
4. The client diagnosed with atrial assignment
fibrillation who has an INR of five (5). for the new
graduate.
3. Supraventricular
tachycardia (SVT) is
not
life threatening, but
the client requires
intravenous
medication and
close monitoring
and therefore should
be assigned to a
more experienced
nurse.
4. A client with atrial
fibrillation is usually
taking the
anticoagulant
warfarin
(Coumadin), and the
therapeutic INR is
2 to 3. An INR of 5 is
high and the client
is at risk for
bleeding.
The telemetry nurse is unable to read 1. The telemetry
the telemetry monitor at the nurse's nurse should not
station. leave the
Which intervention should the monitors
telemetry nurse implement first? unattended at any
1. Go to the client's room to check the time.
client. 2. The telemetry
2. Instruct the primary nurse to assess nurse must have
the client. someone
3. Contact the client on the client call go assess the
system. client, but this is
4. Request the nursing assistant to not the first
take the crash cart to the client's intervention.
room. *3. If the client
answers the call
light and
is not experiencing
chest pain, then
there is probably a
monitor artifact,
which is not a life-
threatening
emergency.
After talking with
the client,
send a nurse to the
room to check the
monitor.
4. The crash cart
should be taken to
a room
when the client is
experiencing a
code.
50. The client shows ventricular 1. There are many 51. The client is experiencing multifocal *1. Lidocaine
fibrillation on the telemetry at the interventions that premature ventricular contractions. suppresses
nurse's station. should Which ventricular
Which action should the telemetry be implemented antidysrhythmic medication would ectopy and is the
nurse implement first? prior to the nurse expect the health-care drug of choice for
1. Administer epinephrine IVP. administering provider to order ventricular
2. Prepare to defibrillate the client. medication. for this client? dysrhythmias.
3. Call a STAT code. 2. The treatment of 1. Lidocaine. 2. Atropine
4. Start cardiopulmonary choice for 2. Atropine. decreases vagal
resuscitation. ventricular 3. Digoxin. stimulation and
fibrillation is 4. Adenosine. is the drug of
defibrillation, but it choice for asystole.
is not 3. Digoxin slows
the first action. heart rate and
*3. The nurse must increases cardiac
call a code that contractility and is
activates the drug of choice
the crash cart being for atrial fibrillation.
brought to 4. Adenosine is the
the room and a drug of choice for
team of health-care supraventricular
providers that will tachycardia.
care for the client
52. The client is exhibiting sinus 1. A thrombolytic
according to an
bradycardia, is complaining of medication is
established
syncope and weakness, administered
protocol.
and has a BP of 98/60. Which for a client
4. The first person
collaborative treatment should the experiencing a
at the bedside
nurse anticipate myocardial
should
being implemented? infarction.
start
1. Administer a thrombolytic 2. Assessment is an
cardiopulmonary
medication. independent nursing
resuscitation
2. Assess the client's cardiovascular action, not a
(CPR), but the
status. collaborative
telemetry nurse
3. Prepare for insertion of a treatment.
should call
pacemaker. *3. The client is
a code so that all
4. Obtain a permit for synchronized symptomatic and
necessary
cardioversion. will
equipment and
require a
personnel are at the
pacemaker.
bedside.
4. Synchronized
cardioversion is
used for
ventricular
tachycardia with a
pulse or
atrial fibrillation.
53. Which intervention should the nurse 1. The adult client 54. The client has chronic atrial *1. A client with
implement when defibrillating a client should be fibrillation. Which discharge teaching chronic atrial
who is defibrillated at should the nurse fibrillation
in ventricular fibrillation? 360 joules. discuss with the client? will be taking an
1. Defibrillate the client at 50, 100, and 2. The oxygen 1. Instruct the client to use a soft- anticoagulant to help
200 joules. source should be bristle toothbrush. prevent clot
2. Do not remove the oxygen source removed 2. Discuss the importance of getting formation. Therefore,
during defibrillation. to prevent any type a monthly partial thromboplastin the
3. Place petroleum jelly on the of spark during time (PTT). client is at risk for
defibrillator pads. defibrillation. 3. Teach the client about signs of bleeding and should
4. Shout "all clear" prior to 3. The nurse pacemaker malfunction. be instructed to use
defibrillating the client. should use 4. Explain to the client the a soft-bristle
defibrillator pads procedure for synchronized toothbrush.
or defibrillator gel cardioversion. 2. The client will
to prevent any type need a regularly
of skin burns while scheduled
defibrillating INR to determine the
the client. therapeutic level for
*4. If any member the anticoagulant
of the health-care warfarin (Coumadin);
team PTT levels are
is touching the monitored for
client or the bed heparin.
during 3. A client with
defibrillation, that symptomatic sinus
person could bradycardia,
possibly not a client with
be shocked. atrial fibrillation,
Therefore, the may need a
nurse pacemaker.
should shout "all 4. Synchronized
clear." cardioversion may
be prescribed
for new-onset atrial
fibrillation but
not for chronic atrial
fibrillation.
55. The client is exhibiting ventricular 1. Lidocaine is the 56. The client is in complete heart 1. A pacemaker will
tachycardia. Which intervention drug of choice for block. Which intervention should the have to be inserted,
should the nurse ventricular nurse but
implement first? tachycardia, but it implement first? it is not the first
1. Administer lidocaine, an is not the 1. Prepare to insert a pacemaker. intervention.
antidysrhythmic, IVP. first intervention. 2. Administer atropine, an *2. Atropine will
2. Prepare to defibrillate the client. 2. Defibrillation antidysrhythmic. decrease vagal
3. Assess the client's apical pulse and may be needed, 3. Obtain a STAT electrocardiogram stimulation
blood pressure. but it is not (ECG). and increase the
4. Start basic cardiopulmonary the first 4. Notify the health-care provider. heart rate.
resuscitation. intervention. Therefore, it is the
*3. The nurse must first intervention.
assess the apical 3. A STAT ECG may
pulse be done, but the
and blood pressure telemetry reading
to determine if the shows complete
client is in cardiac heart
arrest and then block, which is a life-
treat threatening
as ventricular dysrhythmia
fibrillation. If the and must be treated.
client's 4. The HCP will need
heart is beating, to be notified but not
the nurse would prior to
then administering a
administer medication. The
lidocaine. test taker must
4. CPR is only assume the nurse has
performed on a the
client who is order to administer
not breathing and medication. Many
does not have a telemetry
pulse. departments have
The nurse must standing
establish if this is protocols.
occurring
first, prior to taking
any other action.
57. The client is in ventricular fibrillation. *1. Ventricular 58.
Which interventions should the nurse fibrillation indicates
implement? Select all that apply. the
1. Start cardiopulmonary client does not have
resuscitation. a heartbeat.
2. Prepare to administer the Therefore, CPR
antidysrhythmic adenosine IVP. should be instituted.
3. Prepare to defibrillate the client. 2. Adenosine, an
4. Bring the crash cart to the antidysrhythmic, is
bedside. the drug
5. Prepare to administer the of choice for
antidysrhythmic amiodarone IVP. supraventricular
tachycardia,
not for ventricular
fibrillation.
*3. Defibrillation is
the treatment of
choice for
ventricular
fibrillation.
*4. The crash cart
has the defibrillator
and
is used when
performing
advanced
cardiopulmonary
resuscitation.
*5. Amiodarone is an
antidysrhythmic that
is used in ventricular
dysrhythmias.
The client who is one (1) day 1. The telemetry
postoperative coronary artery reading is accurate,
bypass surgery is and
exhibiting sinus tachycardia. Which there is no need for
intervention should the nurse the nurse to assess
implement? the
1. Assess the apical heart rate for client's heart rate.
one (1) full minute. 2. There is no reason
2. Notify the client's cardiac surgeon. to notify the
3. Prepare the client for surgeon
synchronized cardioversion. for a client
4. Determine if the client is having exhibiting sinus
pain. tachycardia.
3. Synchronized
cardioversion is
prescribed
for clients in acute
atrial fibrillation or
ventricular
fibrillation with a
pulse.
*4. Sinus tachycardia
means the sinoatrial
node is the
pacemaker, but the
rate is
greater than 100
because of pain,
anxiety, or fever.
The nurse must
determine the cause
and treat
appropriately.
There is no specific
medication
for sinus
tachycardia.
59. The client's telemetry reading shows *1. The P wave 60. Which client problem has priority for 1. Not every cardiac
a P wave before each QRS complex represents atrial the client with a cardiac dysrhythmia causes
and the rate contraction, dysrhythmia? alteration in
is 78. Which action should the nurse and the QRS 1. Alteration in comfort. comfort; angina is
implement? complex represents 2. Decreased cardiac output. caused by
1. Document this as normal sinus ventricular 3. Impaired gas exchange. decreased oxygen
rhythm. contraction—a 4. Activity intolerance. to the myocardium.
2. Request a 12-lead normal *2. Any abnormal
electrocardiogram. telemetry reading. electrical activity of
3. Prepare to administer the A rate between 60 the
cardiotonic digoxin PO. and 100 indicates heart causes
4. Assess the client's cardiac normal sinus decreased cardiac
enzymes. rhythm. output.
Therefore, the nurse 3. Impaired gas
should document exchange is the
this as normal sinus result of
rhythm and not pulmonary
take any action. complications, not
2. A 12-lead ECG cardiac
should be dysrhythmias.
requested for 4. Not all clients
chest pain or with cardiac
abnormal dysrhythmias
dysrhythmias. have activity
3. Digoxin is used intolerance.
to treat atrial
fibrillation.
4. Cardiac enzymes
are monitored to
determine
if the client has had
a myocardial
infarction.
Nothing in the stem
indicates the
client has had an
MI.
61. The client is diagnosed with 1. Pulsus paradoxus is 62. The client is diagnosed with acute *1. Acute pericardial
pericarditis. Which are the most the hallmark of pericarditis. Which sign/symptom effusion interferes
common cardiac warrants with normal cardiac
signs/symptoms the nurse would tamponade; a immediate attention by the nurse? filling and pumping,
expect to find when assessing the paradoxical pulse is 1. Muffled heart sounds. causing venous
client? markedly decreased 2. Nondistended jugular veins. congestion and
1. Pulsus paradoxus. in amplitude during 3. Bounding peripheral pulses. decreased cardiac
2. Complaints of fatigue and inspiration. 4. Pericardial friction rub. output. Muffled
arthralgias. 2. Fatigue and heart sounds,
3. Petechiae and splinter arthralgias are indicative of acute
hemorrhages. nonspecific pericarditis, must be
4. Increased chest pain with signs/symptoms that reported to the
inspiration. usually occur with health-care provider.
myocarditis. 2. Distended, not
3. Petechiae on the nondistended, jugular
trunk, conjunctiva, veins would warrant
and immediate
mucous membranes intervention.
and hemorrhagic 3. Decreasing quality
streaks under the of peripheral pulses,
fingernails or toenails not bounding
occur with peripheral pulses,
endocarditis. would
*4. Chest pain is the warrant immediate
most common intervention.
symptom 4. A pericardial
of pericarditis, friction rub is a
usually has an classic symptom
abrupt onset, and is of acute pericarditis,
aggravated by but it would not
respiratory warrant immediate
movements (deep intervention.
inspiration,
coughing), changes in
body position,
and swallowing.
63. The client is admitted to the medical 1. A sore throat in 64. The client with pericarditis is 1. Steroids, such as
unit to rule out carditis. Which the last month prescribed a nonsteroidal anti- prednisone, not
question should would not inflammatory drug NSAIDs,
the nurse ask the client during the support the (NSAID). Which teaching instruction must be tapered off
admission interview to support this diagnosis of should the nurse discuss with the to prevent adrenal
diagnosis? carditis. client? insufficiency.
1. "Have you had a sore throat in the *2. Rheumatic fever, 1. Explain the importance of tapering 2. NSAIDs will not
last month?" a systemic off the medication. make clients
2. "Did you have rheumatic fever as a inflammatory 2. Discuss that the medication will drowsy.
child?" disease caused by make the client drowsy. *3. NSAIDs must be
3. "Do you have a family history of an abnormal 3. Instruct the client to take the taken with food,
carditis?" immune medication with food. milk,
4. "What over-the-counter (OTC) response to 4. Tell the client to take the or antacids to help
medications do you take?" pharyngeal medication when the pain level is decrease gastric
infection around "8." distress.
by group A beta- NSAIDs reduce
hemolytic fever, inflammation,
streptococci, and pericardial pain.
causes carditis in 4. NSAIDs should
about 50% of be taken regularly
people who around
develop it. the clock to help
3. Carditis is not a decrease
genetic or inflammation,
congenital which, in turn, will
disease process. decrease pain.
4. This is an
appropriate
question to ask any
client, but OTC
medications do not
cause
carditis.
65. The client diagnosed with pericarditis 1. Oxygen may be 66.
is complaining of increased pain. needed, but it is not
Which the
intervention should the nurse first intervention.
implement first? 2. This would be
1. Administer oxygen via nasal appropriate to
cannula. determine if
2. Evaluate the client's urinary output. the urine output is at
3. Assess the client for cardiac least 30 mL/hr, but
complications. it is not the first
4. Encourage the client to use the intervention.
incentive spirometer. *3. The nurse must
assess the client to
determine if the pain
is expected
secondary to
pericarditis or if the
pain
is indicative of a
complication that
requires intervention
from the
health-care
provider.
4. Using the
incentive spirometer
will
increase the client's
alveolar ventilation
and help prevent
atelectasis, but it is
not
the first intervention.
The client diagnosed with *1. A
pericarditis is experiencing cardiac pericardiocentesis
tamponade. Which removes fluid
collaborative intervention should from the pericardial
the nurse anticipate for this client? sac and is the
1. Prepare for a pericardiocentesis. emergency treatment
2. Request STAT cardiac enzymes. for cardiac
3. Perform a 12-lead tamponade.
electrocardiogram. 2. Cardiac enzymes
4. Assess the client's heart and lung may be slightly
sounds. elevated
because of the
inflammatory
process,
but evaluation of
these would not be
ordered to treat or
evaluate cardiac
tamponade.
3. A 12-lead ECG
would not help treat
the
medical emergency
of cardiac
tamponade.
4. Assessment by the
nurse is not
collaborative;
it is an independent
nursing action.
67. The female client is diagnosed with 1. The full course 68. Which potential complication should 1. Pulmonary
rheumatic fever and prescribed of antibiotics must the nurse assess for in the client with embolus would
penicillin, an be infective occur with an
antibiotic. Which statement indicates taken to help endocarditis who has embolization of embolization of
the client needs more teaching ensure complete vegetative lesions from the mitral vegetative lesions
concerning the destruction valve? from
discharge teaching? of streptococcal 1. Pulmonary embolus. the tricuspid valve
1. "I must take all the prescribed infection. 2. Cerebrovascular accident. on the right side of
antibiotics." 2. Antibiotics kill 3. Hemoptysis. the
2. "I may get a vaginal yeast infection bacteria but also 4. Deep vein thrombosis. heart.
with penicillin." destroy *2. Bacteria enter
3. "I will have no problems as long as I normal body flora the bloodstream
take my medication." in the vagina, from
4. "My throat culture was positive for a bowel, invasive
streptococcal infection." and mouth, procedures, and
leading to a sterile
superinfection. platelet-fibrin
*3. Even with vegetation forms
antibiotic on
treatment for heart valves. The
rheumatic fever, mitral valve is on
the client may the
experience left side of the
bacterial heart and, if the
endocarditis in vegetation
later breaks off, it will go
years and should through the
know this may left ventricle into
occur. the systemic
4. A throat culture circulation
is taken to and may lodge in
diagnose the brain,
group A beta- kidneys, or
hemolytic peripheral tissues.
streptococcus and 3. Coughing up
is positive in 25% blood (hemoptysis)
to 40% of clients occurs
with when the
acute rheumatic vegetation breaks
fever. off the tricuspid
valve in the right
side of the heart
and
enters the
pulmonary artery.
4. Deep vein
thrombosis is a
complication of
immobility, not of a
vegetative embolus
from the left side of
the heart.
69. Which nursing diagnosis would be 1. Anxiety is a 70. The client diagnosed with pericarditis *1. Uninterrupted
priority for the client diagnosed psychosocial nursing is being discharged home. Which rest and sleep help
with diagnosis, which is not intervention decrease the
myocarditis? a priority over a should the nurse include in the workload of the
1. Anxiety related to possible long- physiological nursing discharge teaching? heart and
term complications. diagnosis. 1. Be sure to allow for uninterrupted help ensure the
2. High risk for injury related to 2. Antibiotic therapy rest and sleep. restoration of
antibiotic therapy. does not result in 2. Refer client to outpatient physical
3. Increased cardiac output related injury occupational therapy. and emotional
to valve regurgitation. to the client. 3. Maintain oxygen via nasal cannula health.
4. Activity intolerance related to 3. Myocarditis does at two (2) L/min. 2. Occupational
impaired cardiac muscle function. not result in valve 4. Discuss upcoming valve therapy addresses
damage replacement surgery. activities
(endocarditis does), of daily living. The
and there would client should be
be decreased, not referred to
increased, cardiac physical therapy to
output. develop a
*4. Activity intolerance realistic and
is priority for the progressive plan of
client with activity.
myocarditis, an 3. The client with
inflammation pericarditis is not
of the heart muscle. usually
Nursing care prescribed oxygen,
is aimed at decreasing and 2 L/min is a
myocardial work low
and maintaining dose of oxygen
cardiac output. that is prescribed
for a
client with chronic
obstructive
pulmonary
disease (COPD).
4. Endocarditis, not
pericarditis, may
lead to
surgery for valve
replacement.
71. The client has just had a *1. The nurse 72. The client with infective endocarditis 1. The nurse must
pericardiocentesis. Which should monitor the is admitted to the medical obtain blood
interventions should the nurse vital department. Which cultures
implement? Select all that apply. signs for any client health-care provider's order should prior to
1. Monitor vital signs every 15 minutes who has just be implemented first? administering
for the first hour. undergone surgery. 1. Administer intravenous antibiotic. antibiotics.
2. Assess the client's heart and lung *2. A 2. Obtain blood cultures times two *2. Blood cultures
sounds. pericardiocentesis (2). must be done
3. Record the amount of fluid involves entering 3. Schedule an echocardiogram. before
removed as output. the pericardial sac. 4. Encourage bedrest with bathroom administering
4. Evaluate the client's cardiac rhythm. Assessing heart privileges. antibiotics so that
5. Keep the client in the supine and an adequate
position. lung sounds allows number of
assessment for organisms can be
cardiac failure. obtained to culture
*3. The pericardial and identify.
fluid is 3. An
documented as echocardiogram
output. allows visualization
*4. Evaluating the of vegetations and
client's cardiac evaluation of valve
rhythm function. However,
allows the nurse to antibiotic therapy is
assess for cardiac priority before
failure, which is a diagnostic tests,
complication of and blood
pericardiocentesis. cultures must be
5. The client should obtained before
be in the semi- administering
Fowler's medication.
position, not in a 4. Bedrest should
flat position, which be implemented,
increases the but the
workload of the first intervention
heart. should be obtaining
blood cultures so
that antibiotic
therapy
can be started as
soon as possible.