NURSING PROGRAM

Assig 2 - Cardiovascular System – PART 2 ANSWER KEY

1. A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks
for a cup of coffee. What is the nurse’s best response?
1. “Hot drinks such as coffee are not good for your heart.”
2. “Coffee is not permitted on the diet that was ordered for you.”
3. “You cannot have coffee. I can bring you a cup of tea if you like.”
4. “Coffee has caffeine that can affect your heart. It should be avoided.”
4. Caffeine is a stimulant that causes vasoconstriction and is contraindicated for a client with a
dysrhythmia
2. A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram.
Which explanation should the nurse include when teaching the client about this procedure?
1. “This is a noninvasive test to check your heart’s response to physical activity.”
2. “This test is the definitive method to identify the actual cause of your chest pain.”
3. “The findings of this test will be of minimal assistance in the treatment of angina.”
4. “The findings from this minimally invasive test will show how your body reacts to exercise.”
1. This test evaluates the heart’s ability to meet the need for additional oxygen in response to the
stress of exercising. Changes in the ECG identify dysrhythmias and ST changes indicative of myocardial
ischemia.

3. What must the nurse do to determine a client’s pulse pressure?

1. Multiply the heart rate by the stroke volume.
2. Subtract the diastolic from the systolic reading.
3. Determine the mean blood pressure by averaging the two.
4. Calculate the difference between the apical and radial rate.
2. Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood
pressure has been recorded.

4. A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What
physiologic changes should the nurse conclude is the result of this disease process? Select all that
apply.

1. Stasis ulcer
2. Necrotic tissue
3. Ecchymotic areas
4. Diminished pulses
5. Brown discoloration
1. Stasis ulcers result from edema or minor injury to the limb; they frequently form over the medial
malleolus (inner ankle).
5. The release of iron from hemoglobin as erythrocytes disintegrate in tissue results in ferrous sulfide
formation, causing darkening of the tissues.

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5. A nurse is caring for a client with chronic occlusive arterial disease. What precipitating cause is the
nurse most likely to identify for the development of ulceration and gangrenous lesions?
1. Emotional stress, which is short-lived
2. Poor hygiene and limited protein intake
3. Stimulants such as coffee, tea, or cola drinks
4. Trauma from mechanical, chemical, or thermal sources
4. Diminished sensation decreases awareness of injury. Injured tissue cannot heal properly because of
cellular deprivation of oxygen and nutrients; ulceration and gangrene may result.

6. A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to
prevent by teaching this client to avoid pressure on the popliteal space?
1. Cerebral embolism
2. Pulmonary embolism
3. Dry gangrene of a limb
4. Coronary vessel occlusion
2. The pulmonary capillary beds are the first small vessels that the embolus encounters once it is
released from the calf veins.
SOB, TC, cough, chest pain

7. After abdominal surgery, a client suddenly reports numbness in the right leg and a “funny feeling” in
the toes. What should the nurse do first?
1. Elevate the legs and tell the client to drink more fluids.
2. Instruct the client to remain in bed and notify the health care provider.
3. Rub the client’s legs to stimulate circulation and cover the client with a blanket.
4. Tell the client about the dangers of prolonged bed rest and encourage ambulation.
2. Localized sensory changes may indicate nerve damage, impaired circulation, or thrombophlebitis.
Activity should be limited and the health care provider notified.

8. A health care provider orders thigh-high anti-embolism stockings for a client with varicose veins. The
client’s thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing
discomfort and indentations on the upper thighs. What should the nurse do?
1. Replace the thigh-high stockings with knee-high stockings.
2. Leave the anti-embolism stockings off to prevent tissue damage.
3. Roll the top of the stockings to below the knees to limit popliteal pressure.
4. Ask the health care provider if an elastic bandage can be used in place of the stockings.
4. An elastic bandage can be adjusted to the varying proportions of the client’s legs.

9. What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic
hypotension?
1. Wear support hose continuously.
2. Lie down for 30 minutes after taking medication.
3. Avoid tasks that require high-energy expenditure.
4. Sit on the edge of the bed for 5 minutes before standing.
4. Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of
gravity on circulation in the upright position.

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10. What precisely should the nurse monitor when a client is receiving a platelet aggregation inhibitor
such as Clopidogrel (Plavix)?
1. Nausea
2. Epistaxis
3. Chest pain
4. Elevated temperature
2. The high vascularity of the nose, combined with its susceptibility to trauma (e.g., sneezing, nose
blowing), makes it a frequent site of hemorrhage.

11. A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the
daily dose of this anticoagulant is therapeutic?
1. INR
2. APTT
3. Bleeding time
4. Sedimentation rate
1. Warfarin (Coumadin) initially is prescribed day by day, based on international normalized ratio
(INR) blood test results. This test provides a standard system to interpret prothrombin times.

12. What should the nurse teach a client to expect when preparing for discharge after surgery for a
coronary artery bypass graft?
1. Mild fever and extreme fatigue for several weeks after surgery
2. Cessation of drainage from the incisions after hospitalization
3. Mild incisional pain and tenderness up to three weeks after surgery
4. Some edema in the leg used for the donor graft is expected with activity
4. The client is up more at home, so dependent edema usually increases.

13. What is the essential information the nurse and the rapid response team must keep in mind when
caring for a client who had a cardiac arrest?
1. Age of the client
2. How long the client was anoxic
3. The heart rate of the client before the arrest
4. Emergency medications available for the client
2 Irreversible brain damage will occur if a client is anoxic for more than 4 minutes.

14. A client is found unconscious and unresponsive. What should the nurse do first?
1. Initiate a code.
2. Check for a radial pulse.
3. Compress the lower sternum.
4. Give four full lung inflations.
1 Additional help and a cardiac defibrillator must be obtained immediately.

15. A nurse is performing cardiac compression on an adult client. How far must the nurse depress the
lower sternum to maintain circulation until a defibrillator is available?
1. 3/4 to 1 inch
2. 1.2 to 3.4 inch
3. 1 to 1.12 inches
4. 2 to 2.12 inches
4 The sternum must be depressed at least 2 inches to compress the heart adequately between the
sternum and vertebrae and to simulate cardiac pumping action.

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16. A nurse is performing external cardiac compression. How should the nurse exert downward vertical
pressure?
1. Extending the fingers over the sternum and chest with the heels of each hand side by side
2. Placing the fingers of one hand on the sternum and the fingers of the other hand on top of them
3. Interlocking the fingers with the heel of one hand on the sternum and the heel of the other on top
of it
4. Clenching the hand into a fist and placing the fleshy part of a clenched fist on the lower sternum
3 This provides the best leverage for depressing the sternum. Thus, the heart is adequately
compressed, and blood is forced into the arteries. Grasping the fingers keeps them off the chest
and concentrates the energy expended in the heel of the hand while minimizing the possibility of
fracturing ribs.

17. A client has edema in the lower extremities during the day, which disappears at night. With which
medical problem does the nurse conclude this clinical finding is consistent?
1. Pulmonary edema
2. Myocardial infarction
3. Right ventricular heart failure
4. Chronic obstructive lung disease
3 Right ventricular heart failure causes increased pressure in the systemic venous system, which leads
to a fluid shift into the interstitial spaces. Because of gravity, the lower extremities are first affected in
an ambulatory client.

18. A client admitted to the hospital has edematous ankles. What should the nurse do to reduce edema
of the lower extremities best?
1. Restrict fluids.
2. Elevate the legs.
3. Apply elastic bandages.
4. Do range-of-motion exercises.
2 Elevation of extremities promotes venous and lymphatic drainage by gravity.

19. What clinical indicators is the nurse most likely to identify when taking the admission history of a
client with right ventricular failure? Select all that apply.
1. Edema
2. Vertigo
3. Polyuria
4. Dyspnea
5. Palpitations
Answer: 1, 4.

20. Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select
all that apply.
1. Tachycardia
2. Hypertension
3. Increased CVP
4. Increased urine output
5. Jugular vein distention
Answer: 1, 3, 5.

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21. A client with upper gastrointestinal (GI) bleeding develops mild anemia. What should the nurse
expect to be prescribed for this client?
1. Epogen
2. Dextran
3. Iron salts
4. Vitamin B12
3 Iron is needed in the formation of hemoglobin.

22. An emergency department nurse is admitting a client after an automobile collision. The health care
provider estimates that the client has lost about 15% to 20% of blood volume. Which assessment
finding should the nurse expect this client to exhibit?
1. Urine output of 50 mL/hr
2. Blood pressure of 150/90 mm Hg
3. The apical heart rate of 142 beats/min
4. Respiratory rate of 16 breaths/min
3 In hypovolemic shock, tachycardia is a compensatory mechanism in an attempt to increase blood
flow to body organs.

23. A pale client is diagnosed with esophageal varices and is admitted to the hospital. The health care
provider orders a blood transfusion. What nursing actions should be taken?
1. Take the vital signs, verify the blood product with another nurse against the client’s ID bracelet,
and monitor the vital signs according to agency policy.
2. Since the vital signs were recorded during admission, hang the blood and monitor the client’s vital
signs every 15 minutes until the transfusion is absorbed.
3. Record the vital signs following facility policy and check the blood product against the client’s ID
bracelet in the presence of the nursing supervisor.
4. Take the vital signs after hanging the blood because the client is pale and moaning and is in critical
condition; return in 15 minutes to monitor the vital signs.
1 Baseline vital signs should be obtained immediately before administering the blood product for
future comparison purposes. Two licensed nurses should confirm the verifying data between the
client and the blood product. The nurse should remain with and monitor the client’s vital signs during
the first 15 minutes of administration of the blood product and then follow the institution’s protocol
to monitor for a transfusion reaction or fluid overload.

24. A health care provider orders 1 unit of whole blood for a client after gastrointestinal surgery. What
is an important nursing responsibility when administering blood?
1. Maintain patency of the IV catheter with a dextrose solution.
2. Warm the blood to body temperature to prevent chilling the client.
3. Draw a blood sample from the client before each unit is transfused.
4. Run the blood at a slower rate during the first few minutes of the transfusion.
4 A slow rate provides time to recognize a transfusion reaction that is developing before too much
blood has been administered.

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25. During a blood transfusion, a client develops chills and a headache. What is the priority nursing
action?
1. Cover the client.
2. Stop the transfusion at once.
3. Decrease the rate of blood infusion.
4. Notify the health care provider immediately.
2. Chills, headache, nausea, and vomiting are all signs of a transfusion reaction.