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مكمل الفيرست 2
مكمل الفيرست 2
Which of the following actions is the first priority of care for a client
exhibiting signs and symptoms of coronary artery disease?
1. Decrease anxiety
2. Enhance myocardial oxygenation
3. Administer sublingual nitroglycerin
4. Educate the client about his symptoms
1. Cardiac catheterization
2. Coronary artery bypass surgery
3. Oral medication therapy
4. Percutaneous transluminal coronary angioplasty
1. Chest pain
2. Dyspnea
3. Edema
4. Palpitations
4. Which of the following symptoms is the most likely origin of pain the
client described as knifelike chest pain that increases in intensity with
inspiration?
1. Cardiac
2. Gastrointestinal
3. Musculoskeletal
4. Pulmonary
1. Lactate dehydrogenase
2. Complete blood count (CBC)
3. Troponin I
4. Creatine kinase (CK)
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3. To decrease the client’s anxiety
4. To decrease oxygen demand on the client’s heart
1. Aneurysm
2. Heart failure
3. Coronary artery thrombosis
4. Renal failure
1. Ventricular dilation
2. Systemic hypertension
3. Aortic valve malfunction
4. Increased atrial contractions
1. Administer morphine
2. Administer oxygen
3. Administer sublingual nitroglycerin
4. Obtain an ECG
1. Beta-adrenergic blockers
2. Calcium channel blockers
3. Narcotics
4. Nitrates
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1. Cardiogenic shock
2. Heart failure
3. arrhythmias
4. Pericarditis
13. With which of the following disorders is jugular vein distention most
prominent?
14. Toxicity from which of the following medications may cause a client to
see a green-yellow halo around lights?
1. Digoxin
2. Furosemide (Lasix)
3. Metoprolol (Lopressor)
4. Enalapril (Vasotec)
1. Crackles
2. Arrhythmias
3. Hepatic engorgement
4. Hypotension
16. In which of the following disorders would the nurse expect to assess
sacral edema in a bedridden client?
1. Diabetes
2. Pulmonary emboli
3. Renal failure
4. Right-sided heart failure
17. Which of the following symptoms might a client with right-sided heart
failure exhibit?
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18. Which of the following classes of medications maximizes cardiac
performance in clients with heart failure by increasing
ventricular contractility?
1. Beta-adrenergic blockers
2. Calcium channel blockers
3. Diuretics
4. Inotropic agents
1. Bradycardia
2. Tachycardia
3. Hypotension
4. Decreased myocardial contractility
1. Angina pectoris
2. Cardiomyopathy
3. Left-sided heart failure
4. Right-sided heart failure
1. Cardiomyopathy
2. Coronary artery disease
3. Myocardial infarction
4. Pericardial effusion
1. Dilated
2. Hypertrophic
3. Myocarditis
4. Restrictive
1. Congestive
2. Dilated
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3. Hypertrophic
4. Restrictive
1. Heart failure
2. Diabetes
3. MI
4. Pericardial effusion
25. Dyspnea, cough, expectoration, weakness, and edema are classic signs
and symptoms of which of the following conditions?
1. Pericarditis
2. Hypertension
3. MI
4. Heart failure
1. Dilated
2. Hypertrophic
3. Obliterative
4. Restrictive
27. Which of the following cardiac conditions does a fourth heart sound
(S4) indicate?
1. Dilated aorta
2. Normally functioning heart
3. Decreased myocardial contractility
4. Failure of the ventricle to eject all of the blood during systole
28. Which of the following classes of drugs is most widely used in the
treatment of cardiomyopathy?
1. Antihypertensives
2. Beta-adrenergic blockers
3. Calcium channel blockers
4. Nitrates
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1. Cardiac catheterization
2. Coronary artery bypass graft (CABG)
3. Heart transplantation
4. Intra-aortic balloon pump (IABP)
1. Anxiety
2. Stable angina
3. Unstable angina
4. Variant angina
31. Which of the following types of angina is most closely related with an
impending MI?
1. Angina decubitus
2. Chronic stable angina
3. Nocturnal angina
4. Unstable angina
1. Increased preload
2. Decreased afterload
3. Coronary artery spasm
4. Inadequate oxygen supply to the myocardium
33. Which of the following tests is used most often to diagnose angina?
1. Chest x-ray
2. Echocardiogram
3. Cardiac catheterization
4. 12-lead electrocardiogram (ECG)
34. Which of the following results is the primary treatment goal for angina?
1. Reversal of ischemia
2. Reversal of infarction
3. Reduction of stress and anxiety
4. Reduction of associated risk factors
35. Which of the following interventions should be the first priority when
treating a client experiencing chest pain while walking?
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1. Sit the client down
2. Get the client back to bed
3. Obtain an ECG
4. Administer sublingual nitroglycerin
37. Which of the following positions would best aid breathing for a client
with acute pulmonary edema?
1. Anoxia
2. Hypercapnia
3. Hyperoxygenation
4. Hypocapnia
1. Decreased BP
2. Alteration in LOC
3. Decreased BP and diuresis
4. Increased BP and fluid retention
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41. Which of the following terms describes the force against which the
ventricle must expel blood?
1. Afterload
2. Cardiac output
3. Overload
4. Preload
1. Left atrium
2. Right atrium
3. Left ventricle
4. Right ventricle
44. A client admitted with angina complains of severe chest pain and
suddenly becomes unresponsive. After establishing unresponsiveness,
which of the following actions should the nurse take first?
1. Anxiety
2. Ineffective tissue perfusion; cardiopulmonary
3. Acute pain
4. Ineffective therapeutic regimen management
46. A client comes into the E.R. with acute shortness of breath and a cough
that produces pink, frothy sputum. Admission assessment reveals crackles
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and wheezes, a BP of 85/46, a HR of 122 BPM, and a respiratory rate of 38
breaths/minute. The client’s medical history included DM, HTN, and heart
failure. Which of the following disorders should the nurse suspect?
1. Pulmonary edema
2. Pneumothorax
3. Cardiac tamponade
4. Pulmonary embolus
47. The nurse coming on duty receives the report from the nurse going off
duty. Which of the following clients should the on-duty nurse assess first?
1. The 58-year-old client who was admitted 2 days ago with heart failure, BP of
126/76, and a respiratory rate of 21 breaths a minute.
2. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50,
and a DNR order.
3. The 62-year-old client who was admitted one day ago
with thrombophlebitisand receiving IV heparin.
4. A 76-year-old client who was admitted 1 hour ago with new-onset atrial
fibrillation and is receiving IV diltiazem (Cardizem).
48. When developing a teaching plan for a client with endocarditis, which of
the following points is most essential for the nurse to include?
1. Recent URI
2. Nutritional anemia
3. Peptic ulcer disease
4. A-Fib
50. A nurse is preparing for the admission of a client with heart failure who
is being sent directly to the hospital from the physician’s office. The nurse
would plan on having which of the following medications readily available
for use?
1. Diltiazem (Cardizem)
2. Digoxin (Lanoxin)
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3. Propranolol (Inderal)
4. Metoprolol (Lopressor)
51. A nurse caring for a client in one room is told by another nurse that a
second client has developed severe pulmonary edema. On entering the
2nd client’s room, the nurse would expect the client to be:
1. Slightly anxious
2. Mildly anxious
3. Moderately anxious
4. Extremely anxious
52. A client with pulmonary edema has been on diuretic therapy. The client
has an order for additional furosemide (Lasix) in the amount of 40 mg IV
push. Knowing that the client also will be started on Digoxin (Lanoxin), a
nurse checks the client’s most recent:
1. Digoxin level
2. Sodium level
3. Potassium level
4. Creatinine level
53. A client who had cardiac surgery 24 hours ago has a urine output
averaging 19 ml/hr for 2 hours. The client received a single bolus of 500 ml
of IV fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory
results indicate the blood urea nitrogen is 45 mg/dL and the serum
creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:
1. Hypovolemia
2. UTI
3. Glomerulonephritis
4. Acute renal failure
54. A nurse is preparing to ambulate a client on the 3rd day after cardiac
surgery. The nurse would plan to do which of the following to enable the
client to best tolerate the ambulation?
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1. Normal sinus rhythm
2. Sinus bradycardia
3. Sinus tachycardia
4. Sinus dysrhythmia
57. A home care nurse is making a routine visit to a client receiving digoxin
(Lanoxin) in the treatment of heart failure. The nurse would particularly
assess the client for:
58. A client with angina complains that the angina pain is prolonged and
severe and occurs at the same time each day, most often in the morning,
On further assessment a nurse notes that the pain occurs in the absence of
precipitating factors. This type of anginal pain is best described as:
1. Stable angina
2. Unstable angina
3. Variant angina
4. Nonanginal pain
1. Antipyretic action
2. Antithrombotic action
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3. Antiplatelet action
4. Analgesic action
62. Which of the following reflects the principle on which a client’s diet will
most likely be based during the acute phase of MI?
1. Liquids as ordered
2. Small, easily digested meals
3. Three regular meals per day
4. NPO
65. Which of the following would be a priority nursing diagnosis for the
client with heart failure and pulmonary edema?
1. 5 to 10 minutes
2. 30 to 60 minutes
3. 2 to 4 hours
4. 6 to 8 hours
68. Which of the following foods should the nurse teach a client with heart
failure to avoid or limit when following a 2-gram sodium diet?
1. Apples
2. Tomato juice
3. Whole wheat bread
4. Beef tenderloin
69. The nurse finds the apical pulse below the 5th intercostal space. The
nurse suspects:
70. Which of the following arteries primarily feeds the anterior wall of the
heart?
1. Circumflex artery
2. Internal mammary artery
3. Left anterior descending artery
4. Right coronary artery
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Enhancing myocardial oxygenation is always the first priority when a client
exhibits signs or symptoms of cardiac compromise. Without adequate
oxygenation, the myocardium suffers damage.
4. Answer: 4. Pulmonary
5. Answer: 3. Troponin I
Troponin I levels rise rapidly and are detectable within 1 hour of myocardial
injury. Troponin I levels aren’t detectable in people without cardiac injury.
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● Option A: Lactate dehydrogenase (LDH) is present in almost all body
tissues and not specific to heart muscle. LDH isoenzymes are useful in
diagnosing a cardiac injury.
● Option B: CBC is obtained to review blood counts, and a complete
chemistry is obtained to review electrolytes.
● Option D: Because CK levels may rise with a skeletal muscle injury, CK
isoenzymes are required to detect cardiac injury.
The left ventricle is responsible for most of the cardiac output. An anterior wall MI
may result in a decrease in left ventricular function. When the left ventricle
doesn’t function properly, resulting in left-sided heart failure, fluid accumulates in
the interstitial and alveolar spaces in the lungs and causes crackles.
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Administering supplemental oxygen to the client is the first priority of care. The
myocardium is deprived of oxygen during an infarction, so additional oxygen is
administered to assist in oxygenation and prevent further damage.
● Options A and C: Morphine and nitro are also used to treat MI, but
they’re more commonly administered after the oxygen.
● Option D: An ECG is the most common diagnostic tool used to evaluate
MI.
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● Option C: An MI, if severe enough, can progress to heart failure,
however, in and of itself, an MI doesn’t cause JVD.
One of the most common signs of digoxin toxicity is the visual disturbance known
as the “green-yellow halo sign.” The other medications aren’t associated with
such an effect.
Crackles in the lungs are a classic sign of left-sided heart failure. These sounds
are caused by fluid backing up into the pulmonary system.
The most accurate area on the body to assess dependent edema in a bed-ridden
client is the sacral area. Sacral, or dependent, edema is secondary to right-sided
heart failure.
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Weight gain, nausea, and a decrease in urine output are secondary effects of
right-sided heart failure.
Although the cause isn’t entirely known, cardiac dilation and heart failure may
develop during the last month of pregnancy or the first few months after birth.
The condition may result from a preexisting cardiomyopathy not apparent prior to
pregnancy.
Because the structure and function of the heart muscle is affected, heart failure
most commonly occurs in clients with cardiomyopathy.
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● Option D: Pericardial effusion is most predominant in clients with
pericarditis.
27. Answer: 4. Failure of the ventricle to eject all of the blood during systole
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29. Answer: 3. Heart transplantation
The pain of stable angina is predictable in nature, builds gradually, and quickly
reaches maximum intensity.
The 12-lead ECG will indicate ischemia, showing T-wave inversion. In addition,
with variant angina, the ECG shows ST-segment elevation.
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● Option B: An infarction is permanent and can’t be reversed.
The initial priority is to decrease the oxygen consumption; this would be achieved
by sitting the client down.
The body compensates for a decrease in cardiac output with a rise in BP, due to
the stimulation of the sympathetic NS and an increase in blood volume as the
kidneys retain sodium and water.
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Production of pink, frothy sputum is a classic sign of acute pulmonary edema.
Because the client is at high risk for decompensation, the nurse should call for
help but not leave the room. The other three interventions would immediately
follow.
The left ventricle is responsible for the majority of force for the cardiac output. If
the left ventricle is damaged, the output decreases and fluid accumulates in the
interstitial and alveolar spaces, causing pulmonary edema.
● Option A: Damage to the left atrium would contribute to heart failure but
wouldn’t affect cardiac output or, therefore, the onset of pulmonary
edema.
● Options B and D: If the right atrium and right ventricle were damaged,
right-sided heart failure would result.
Diagnosis of rheumatic fever requires that the client have either two major Jones
criteria or one minor criterion plus evidence of a previous streptococcal infection.
Major criteria include carditis, polyarthritis, Sydenham’s chorea, subcutaneous
nodules, and erythema marginatum (transient, non pruritic macules on the trunk
or inner aspects of the upper arms or thighs). Minor criteria include fever,
arthralgia, elevated levels of acute phase reactants, and a prolonged PR-interval
on ECG.
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mask or pocket mask. Next, check for signs of circulation by palpating the carotid
pulse.
SOB, tachypnea, low BP, tachycardia, crackles, and a cough producing pink,
frothy sputum are late signs of pulmonary edema.
47. Answer: 4. A 76-year-old client who was admitted 1 hour ago with new-
onset atrial fibrillation and is receiving IV diltiazem (Cardizem).
The client with A-fib has the greatest potential to become unstable and is on IV
medication that requires close monitoring. After assessing this client, the nurse
should assess the client with thrombophlebitis who is receiving a heparin
infusion, and then go to the 58-year-old client admitted 2-days ago with heart
failure (her s/s are resolving and don’t require immediate attention). The lowest
priority is the 89-year-old with end stage right-sided heart failure, who requires
time-consuming supportive measures.
48. Answer: 1. “Report fever, anorexia, and night sweats to the physician.”
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50. Answer: 2. Digoxin (Lanoxin)
Digoxin exerts a positive inotropic effect on the heart while slowing the overall
rate through a variety of mechanisms. Digoxin is the medication of choice to treat
heart failure.
Pulmonary edema causes the client to be extremely agitated and anxious. The
client may complain of a sense of drowning, suffocation, or smothering.
The serum potassium level is measured in the client receiving digoxin and
furosemide. Heightened digitalis effect leading to digoxin toxicity can occur in the
client with hypokalemia. Hypokalemia also predisposes the client to ventricular
dysrhythmias.
The client who undergoes cardiac surgery is at risk for renal injury from poor
perfusion, hemolysis, low cardiac output, or vasopressor medication therapy.
Renal insult is signaled by decreased urine output and increased BUN and
creatinine levels. The client may need medications such as dopamine (Intropin)
to increase renal perfusion and possibly could need peritoneal dialysis or
hemodialysis.
The nurse should encourage regular use of pain medication for the first 48 to 72
hours after cardiac surgery because analgesia will promote rest, decrease
myocardial oxygen consumption resulting from pain, and allow better
participation in activities such as coughing, deep breathing, and ambulation.
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Ventricular tachycardia is a life-threatening dysrhythmia that results from an
irritable ectopic focus that takes over as the pacemaker for the heart.
The first signs and symptoms of digoxin toxicity in adults include abdominal pain,
N/V, visual disturbances (blurred, yellow, or green vision, halos around lights),
bradycardia, and other dysrhythmias.
IV nitro infusion requires an infusion pump for precise control of the medication.
Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary
reason ASA is administered to the client experiencing an MI is its antithrombotic
action.
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61. Answer: 4. Can perform personal self-care activities without pain
In older adults who are less active and do not exercise the heart muscle, atrophy
can result. Disuse or deconditioning can lead to abnormal changes in the
myocardium of the older adult. As a result, under sudden emotional or physical
stress, the left ventricle is less able to respond to the increased demands on the
myocardial muscle.
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Activity intolerance is a primary problem for clients with heart failure and
pulmonary edema. The decreased cardiac output associated with heart failure
leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and
fatigue.
ACE inhibitors have become the vasodilators of choice in the client with mild to
severe HF. Vasodilator drugs are the only class of drugs clearly shown to
improve survival in overt heart failure.
Canned foods and juices, such as tomato juice, are typically high in sodium and
should be avoided on a sodium-restricted diet.
A normal apical impulse is found under over the apex of the heart and is typically
located and auscultated in the left fifth intercostal space in the midclavicular line.
An apical impulse located or auscultated below the fifth intercostal space or
lateral to the midclavicular line may indicate left ventricular enlargement.
The left anterior descending artery is the primary source of blood for the anterior
wall of the heart.
● Options A, B, and D: The circumflex artery supplies the lateral wall, the
internal mammary artery supplies the mammary, and the right coronary
artery supplies the inferior wall of the heart.
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