Silvestri Chapter 50 Ed#56e

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 050 (edited file)—"Cardiovascular System" 10/14/08, Page 1 of 20, 0 Figure(s), 3 Table(s), 11 Box(es)

50: Cardiovascular System PRACTICE QUESTIONS 1. A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 1. Intake and output 2. Peripheral pulse rates 3. Height and weight 4. Allergy to iodine or shellfish Answer: 4 Rationale: This procedure requires a signed consent, because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious, and must be assessed before the procedure. Although options 1, 2, and 3 may be a component of data collection, they are not the most critical items. Test-Taking Strategy: Use prioritization skills and note the key words, most critical. Recalling the risk of anaphylaxis if an allergy exists will direct you to option 4. Review preprocedure interventions for a cardiac catheterization if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 327. 2. A client is scheduled for a dipyridamole (Persantine) thallium scan. The nurse would check to make sure that the client has not had which of the following before the procedure? 1. Milk products 2. Caffeine 3. Excess sugar 4. Fatty meal Answer: 2 Rationale: This test is an alternative to the exercise stress test. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline. Aminophylline is the antagonist to dipyridamole. Test-Taking Strategy: Use the process of elimination and note the key words, has not had. Remember, factors that put a strain on the heart, such as nicotine and caffeine, can interfere with cardiac diagnostic test results. Review preprocedure interventions for this test if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular

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Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 1026. 3. A client with no history of cardiovascular disease presents to the ambulatory clinic with flulike symptoms. While at the clinic, the client suddenly develops chest pain. Which question would best help the nurse to discriminate pain caused by a noncardiac problem? 1. “Have you ever had this pain before?” 2. “Can you describe the pain to me?” 3. “Does the pain get worse when you breathe in?” 4. “Can you rate the pain on a scale of 1 to 10, with 10 being the worst?” Answer: 3 Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. Test-Taking Strategy: Focus on the issue, a method of discriminating among the causes of pain. The three incorrect options, although appropriate to use in clinical practice, are general assessment questions only. Option 3 will discriminate between a cardiac and noncardiac cause of pain. Review pain data collection techniques if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 457. 4. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1. Strict bed rest for 24 hours 2. Bathroom privileges and self-care activities 3. Unsupervised hallway ambulation with distances less than 200 feet 4. Ad lib activities, because the client is monitored Answer: 2 Rationale: Upon transfer from CCU, the client is allowed self care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet). Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are excessive, given that the client has just transferred from CCU. Option 1 is not correct, because the client would be doing less activity than in CCU prior to transfer. Review activity prescriptions for the client with an MI if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular

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Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 313. 5. A nurse notes bilateral 2+ edema in the lower extremities of a client with myocardial infarction admitted 2 days ago. The nurse would plan to do which of the following next? 1. Review the intake and output records for the last 2 days. 2. Change the time of diuretic administration from morning to evening. 3. Request a sodium restriction of 1 g/day from the physician. 4. Order daily weights starting on the following morning. Answer: 1 Rationale: Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms. Test-Taking Strategy: Use the process of elimination. The question asks what the nurse would do next. Focusing on the issue will direct you to option 1. Option 1 can give the nurse immediate information about fluid balance. Review data collection methods for the client with edema if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 320. 6. A nurse is collecting data from a client with a primary diagnosis of heart failure. Which following disorder reported by the client is not associated with exacerbating the heart failure? 1. Recent upper respiratory infection 2. Nutritional anemia 3. Peptic ulcer disease 4. Atrial fibrillation Answer: 3 Rationale: Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget’s disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Test-Taking Strategy: Use the process of elimination and note the key words, not associated. This word indicates a false response question and that you need to select the item that is not related to the heart failure. Because heart failure is exacerbated by factors that increase the workload of the heart, options 1, 2, and 4 can be eliminated. Review the precipitating factors associated with heart failure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis:

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Mosby, pp. 320-321. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 580-581. 7. A nurse is collecting data from a client with heart failure who is being sent directly to the hospital from the physician’s office. The nurse reviews the physician’s orders and expects to note an order for which medication? 1. Diltiazem (Cardizem) 2. Digoxin (Lanoxin) 3. Propranolol (Inderal) 4. Metoprolol (Lopressor) Answer: 2 Rationale: Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. It is the medication of choice used to treat heart failure. Diltiazem (calcium channel blocker), propranolol, and metoprolol (beta-adrenergic blockers) have a negative inotropic effect, and would worsen the failing heart. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because they are similar and are both beta blockers. From the remaining options, it is necessary to know that digoxin is used to treat heart failure. Review the treatment for this disorder if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 324. 8. A nurse checks the sternotomy incision of a client on the third postoperative day after cardiac surgery. The incision shows some slight “puffiness” along the edges, is nonreddened, with no apparent drainage. The client’s temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500/mm3. The nurse interprets that the incision line: 1. Is slightly edematous but shows no active signs of infection 2. Shows no sign of infection although the WBC count is elevated 3. Shows early signs of infection although the temperature is near normal 4. Shows early signs of infection supported by an elevated WBC count Answer: 1 Rationale: Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, and induration. An elevated temperature and elevated WBC count after 3 to 4 days usually indicate infection. A WBC count of 7500/mm3 is within the normal range. Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 because the WBC count is normal. The lack of drainage and redness helps you choose option 1 over 3. Review the signs of an incisional infection if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection

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Content Area: Adult Health/Cardiovascular References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 406. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 579. 9. A postcardiac surgery client has a urine output averaging 20 mL/hour 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 that the blood urea nitrogen (BUN) level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. The nurse interprets that the client is at risk for: 1. Hypovolemia 2. Urinary tract infection 3. Glomerulonephritis 4. Acute renal failure Answer: 4 Rationale: 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 a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion, and could possibly need peritoneal dialysis or hemodialysis. Test-Taking Strategy: Use the process of elimination. The question provides no evidence of any infection, so eliminate options 2 and 3 first. Hypovolemia is eliminated next because of the high BUN and creatinine values and the poor response to the bolus of fluid. Review laboratory values and postcardiac surgery complications if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 585. 10. A nurse is preparing to ambulate the client on the third postoperative day following cardiac surgery. The nurse plans to do which of the following to enable the client to best tolerate the ambulation? 1. Encourage the client to cough and deep breathe. 2. Premedicate the client with an analgesic. 3. Provide the client with a walker. 4. Remove the telemetry equipment. Answer: 2 Rationale: 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 due to pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Test-Taking Strategy: Use the process of elimination. The question asks for the best action of the nurse to help a client tolerate ambulation. Coughing and deep breathing will not actively

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help endurance, so eliminate option 1. Eliminate option 4 because removal of telemetry equipment is contraindicated unless ordered. From the remaining options, noting that the client is postoperative will direct you to option 2. Review postoperative instructions if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 578. 11. A client is wearing a continuous cardiac monitor, which begins to alarms. The nurse sees no electrocardiographic complexes on the screen. The nurse would first: 1. Check the client status and lead placement. 2. Press the recorder button on the ECG console. 3. Call the physician. 4. Call a code blue. Answer: 1 Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Assessment of the client and equipment is the first action by the nurse. Test-Taking Strategy: Use the steps of the nursing process and remember that data collection is the first step. Options 3 and 4 are incorrect because they indicate calling for assistance prior to collecting data. Option 2 may sound reasonable, but the electrocardiographic monitor automatically starts recording when an alarm sounds. Option 1 is the best option, because you should always check the client directly before taking any action. Review care of a client on a cardiac monitor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 293-294. 12. A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: 1. Vagus nerve to slow the heart rate 2. Vagus nerve to increase the heart rate 3. Diaphragmatic nerve to slow the heart rate 4. Diaphragmatic nerve to increase the heart rate Answer: 1 Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm.

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Test-Taking Strategy: Use the process of elimination. Eliminate options 2 and 4 first because these options indicate increasing an already rapid rate. From the remaining options, use knowledge of anatomy and physiology. A rapid-rate dysrhythmia would need to be slowed, which is the function of the vagus nerve. The diaphragmatic nerve affects respiration. If you are unfamiliar with the functions of these nerves, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: (2002). Mosby’s medical, nursing, and allied health dictionary (6th ed.). St. Louis: Mosby, p. 301. 13. A nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia followed by ventricular fibrillation (VF). The client immediately loses consciousness. The nurse would immediately: 1. Call for help and initiate cardiopulmonary resuscitation (CPR). 2. Start oxygen by cannula at 10 L/minute and lower the head of the bed. 3. Go to the nurse’s station quickly and call a code. 4. Run to get a defibrillator from an adjacent nursing unit. Answer: 1 Rationale: When VF occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate options 3 and 4 first because you would never leave the client alone. From the remaining options, lowering the head of bed is appropriate (for resuscitation), but the oxygen by cannula at 10 L/minute is incorrect. Option 1 is the correct option. Review care of the client with VF if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 299. 14. A nurse is monitoring a client following cardioversion. Which of the following observations would be of highest priority to the nurse? 1. Oxygen flow rate 2. Status of airway 3. Blood pressure 4. Level of consciousness Answer: 2 Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Test-Taking Strategy: Use the ABCs—airway, breathing, and circulation—to answer the question. This will direct you to option 2. Remember, airway comes first. Review care of the

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client following cardioversion if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Delegating/Prioritizing Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 577, 586. 15. An automatic external defibrillator is available to treat the client who goes into cardiac arrest and is receiving cardiopulmonary resuscitation (CPR). With this device, the nurse checks the cardiac rhythm by: 1. Applying standard electrocardiographic monitoring leads to the client and observing the rhythm 2. Holding the defibrillator paddles firmly against the chest 3. Applying the adhesive patch electrodes to the skin and moving away from the client 4. Connecting standard electrocardiographic electrodes to a transtelephonic monitoring device Answer: 3 Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client’s chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Standard electrocardiographic monitoring leads do not play an active role once resuscitation is underway (options 1 and 4). Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. Test-Taking Strategy: If you are not familiar with this piece of equipment, look first at the word “automatic” in the name. This implies that someone is not as involved in the process as with a conventional defibrillator, and may help you eliminate option 2. Because standard electrocardiographic monitoring leads do not play an active role once resuscitation is underway (options 1 and 4), you can eliminate these similar, and incorrect, options. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes. Review the use of this device if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 701. 16. The nurse is caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse takes care not to dislodge the pacing catheter by: 1. Limiting movement and abduction of the right arm 2. Limiting movement and abduction of the left arm

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3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm Answer: 1 Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client’s activities. Test-Taking Strategy: Use the process of elimination. The question tells you that the pacemaker was inserted on the right side. Therefore, to prevent pacing electrode dislodgement, motion must be limited on that side. Options 3 and 4 involve movement of the right arm. Limiting the movement of the left arm (option 2) is of no benefit to the client. Thus, option 1 is correct. Review care of the client following pacemaker insertion if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 302. 17. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and is visibly anxious. The nurse immediately checks the client for other signs and symptoms of: 1. Myocardial infarction 2. Pneumonia 3. Pulmonary embolism 4. Pulmonary edema Answer: 3 Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. Test-Taking Strategy: Use the process of elimination. This question tests your ability to analyze signs and symptoms of pulmonary embolism in a client at risk. Each of the incorrect options should be eliminated because myocardial infarction and pulmonary edema are cardiac related problems and are therefore similar, and pneumonia is an infectious process. Review the complications of thrombophlebitis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 391. 18. A client seeks treatment in the physician’s office for unsightly varicose veins, and sclerotherapy is recommended. Before leaving the examining room, the client says to the nurse, “Can you tell me again how this sclerotherapy is done?” In formulating a response, the nurse

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informs the client that sclerotherapy consists of: 1. Injecting an agent into the vein to damage the vein wall and close off the vein 2. Tying off the vein at the upper end to prevent stasis from occurring 3. Tying off the vein at the lower end to prevent stasis from occurring 4. Surgical removal of the varicosity Answer: 1 Rationale: Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis, which results in vein closure. With no blood flow through the vessel, there is no distention. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries, and then removal of the vein with the use of hook and wires via multiple small incisions in the leg. Test-Taking Strategy: If you are uncertain of the response to this question, look at the word “sclerotherapy.” A vessel that is sclerosed is blocked. This may help you select the correct option. At the very least, you should be able to eliminate options 2 and 3 readily, because neither of these makes sense using principles of blood flow and gravity. Also, they are very similar, and so are likely to be incorrect. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular References: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 344. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 621. 19. A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of “pins and needles” in the affected leg. Based on evaluation of this comment, the nurse: 1. Reassures the client that this is only temporary 2. Advises the client to take acetaminophen (Tylenol) until it is gone 3. States that warm packs should help 4. Reports the complaint to the physician Answer: 4 Rationale: Hypersensitivity or a sensation of “pins and needles” in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and the saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported. Options 1, 2, and 3 are incorrect actions. Test-Taking Strategy: Use the process of elimination. Pins and needles sensations usually indicate nerve irritation or damage. Knowing this, options 2 and 3 can be eliminated as the least likely correct options. Reassuring the client about something being “only temporary” is not often a good choice, unless this is known to be absolutely true. By the process of elimination, therefore, the physician should be notified. Review the complications following vein ligation and stripping if you had difficulty with this question.

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Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 620-621. 20. A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next check the client for: 1. Familial tendency toward peripheral vascular disease 2. Smoking history 3. Recent exposure to allergens 4. History of recent insect bites Answer: 2 Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger’s disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown, but is suspected to have an autoimmune component. Test-Taking Strategy: Use the process of elimination. You can first eliminate options 3 and 4 because they would most likely cause local skin reactions. The question asks which item you should check “next.” It is often better to assess a modifiable factor before a nonmodifiable one. This will direct you to option 2. Review the causes of Buerger’s disease if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 629. 21. A nurse has given instructions to the client with Raynaud’s disease about self- management of the disease process. The nurse determines that the client needs further reinforcement if the client states that: 1. Smoking cessation is very important. 2. Sources of caffeine should be eliminated from the diet. 3. Taking nifedipine (Procardia) as prescribed will decrease vessel spasm. 4. Moving to a warmer climate should help. Answer: 4 Rationale: Raynaud’s disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial, because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

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Test-Taking Strategy: Note the key words, needs further reinforcement. These words indicate a false response question and that you need to select the incorrect client statement. All of the options seem reasonable. However, when you analyze each of them, note that relocation is the least favorable of all the options, from the viewpoints of practicality and encountering new environmental concerns. Review treatment measures for this disorder if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 628-629. 22. A nurse is checking the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following? 1. Seating the client with arm bared, supported, and at heart level 2. Measuring the blood pressure after the client is seated quietly for 5 minutes 3. Using a cuff with a rubber bladder that encircles at least 80% of the limb 4. Taking the blood pressure within 10 minutes following nicotine or caffeine ingestion Answer: 4 Rationale: The blood pressure should be taken with the client seated with the arm bared, positioned with support and at heart level. The client should sit with the legs on floor, feet uncrossed, and should not speak during the recording. The client should not have smoked tobacco or taken in caffeine during the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured. Gauges other than a mercury sphygmomanometer should be calibrated every 6 months to ensure accuracy. Finally, two or more readings should be averaged. Test-Taking Strategy: Note the key word, avoiding. This word indicates a false response question and that you need to select the incorrect action. Because blood pressure measurement is a basic skill, this should be fairly easy to answer. However, remember that in questions worded such as these, variables that interfere with accuracy (such as caffeine and nicotine in this instance) are likely to be the correct option. Review this procedure if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 223. 23. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. A nurse listens to breath sounds, expecting to hear bilateral: 1. Rhonchi

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2. Diminished breath sounds 3. Crackles 4. Wheezes Answer: 3 Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema. Test-Taking Strategy: Use the process of elimination. Recall that fluid produces sounds that are called crackles. This will assist in eliminating options 1, 2, and 4. If you had difficulty with this question, review the manifestations found in pulmonary edema. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 842. 24. 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 second client's room, the nurse would expect the client to be: 1. Slightly anxious 2. Mildly anxious 3. Moderately anxious 4. Extremely anxious Answer: 4 Rationale: Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. Test-Taking Strategy: Use the process of elimination. Noting the key word, severe, will direct you to option 4. Review the clinical manifestations associated with severe pulmonary edema if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Phipps, W., Monahan, F., Sands, J., Marek, J., & Neighbors, M. (2003). Medicalsurgical nursing: Health and illness perspectives (7th ed.). St. Louis: Mosby, p. 730. 25. A nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition? 1. Dyspnea 2. Crackles on lung auscultation 3. Hacking cough 4. Dependent edema Answer: 4 Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur

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as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Leftsided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough. Test-Taking Strategy: Focus on the issue, right-sided heart failure. Eliminate options 1, 2, and 3 because they are similar and are pulmonary signs. Review the signs of right- and left-sided heart failure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 753. 26. A client is admitted to the hospital with an arterial ischemic leg ulcer. The nurse assesses the ulcer, expecting to note that it: 1. Has a pink-colored base 2. Is superficial, with uneven edges 3. Has little granulation tissue 4. Has brown pigmentation surrounding it Answer: 3 Rationale: Arterial leg ulcers tend to be deep and pale, with uneven edges and little granulation tissue. The client usually has rest pain, and the ulcer site is painful. Options 1, 2, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. This question is asking you to differentiate between signs and symptoms of arterial and venous leg ulcers. Because arterial ulcers are caused by marked reduction in blood flow and tissue malnutrition, you can eliminate options 1 and 2. Brown discoloration (option 4) indicates clogging of peripheral tissue with waste products of metabolism, and indicates a venous problem. The answer is option 3, which is also consistent with tissue malnutrition. Review the characteristics of an arterial ischemic ulcer if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 345. 27. A nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: 1. Normal, caused by increased blood flow through the leg

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2. Slightly deteriorating, and should be monitored for another hour 3. Moderately impaired, and the surgeon should be called 4. Adequate from an arterial approach, but venous complications are arising Answer: 1 Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity cause by increased blood flow. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Option 3 can be eliminated because the pedal pulse is unchanged. Venous complications from immobilization due to surgery would not be apparent within 4 hours, so eliminate option 4 next. To choose between options 1 and 2, think about the effects of sudden reperfusion in an ischemic limb. There would be redness from new blood flow and edema from the sudden change in pressure in the blood vessels. Thus option 1 is correct. Review the expected findings following aortoiliac bypass graft if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 336. 28. A client with an abdominal aortic aneurysm (AAA) is not a candidate for surgery because the aneurysm is not yet large enough. The client is fearful that the aneurysm will rupture, causing death. The nurse plans to assist the client in coping with this fear by emphasizing what the client can do for self-monitoring. Which of the following items would be unnecessary for the nurse to include in discussions with the client? 1. Antibiotic prophylaxis before invasive procedures 2. Importance of follow-up computerized tomography (CT) scans 3. Management of hypertension 4. Reporting abdominal or back pain Answer: 1 Rationale: Psychosocial care of the client with medical management of an AAA includes listening to the client’s concerns and reinforcing the rationales for ongoing medical surveillance. This includes periodic CT scanning to monitor the size of the aneurysm and careful adherence to medication and diet therapy for hypertension. The client is instructed to report any sensation of abdominal fullness or abdominal or back pain to the physician without delay. Test-Taking Strategy: Use the process of elimination and note the key word, unnecessary. Options 2 and 4 can be eliminated because they are obviously good actions. From the remaining options, remember that increased blood pressure (option 3) could cause strain and rupture. This will direct you to option 1. Review care of the client with an AAA if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis:

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Mosby, p. 340. 29. A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client’s toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. The nurse interprets that the boot: 1. Is controlling leg edema 2. Has been applied too tightly 3. Is impairing venous return 4. Has not yet dried Answer: 2 Rationale: An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation to the foot and teaches the client to do the same. Options 1, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Note that the symptoms described in the question are signs of arterial compromise. Option 2 is the only option that is consistent with this circumstance. Review the signs of arterial compromise if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 345-346. 30. A nurse is planning care for an ambulatory client with a venous stasis leg ulcer. The nurse anticipates that which type of dressing will be used in the care of this client? 1. Damp to dry isotonic saline dressings 2. Half-strength Betadine dressings 3. Dry sterile dressings 4. Zinc oxide dressings (Unna boot) Answer: 4 Rationale: For the ambulatory client, the physician may apply a gauze dressing moistened with zinc oxide to the leg, which hardens like a cast (Unna boot). This dressing then prevents venous stasis and provides a sterile environment for the wound. The dressing is changed on a weekly basis. Betadine is not used; it is a strong agent that could cause further damage to friable tissues. Dry sterile dressings do not keep the wound moist. Damp to dry dressings are not as effective. Test-Taking Strategy: Focus on the issue, a venous stasis ulcer. Recalling the treatment associated with this type of ulcer will direct you to option 4. Review this form of treatment if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Cardiovascular Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 346.

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31. A nurse is caring for a client receiving digoxin (Lanoxin) for the treatment of heart failure. The nurse would monitor the client for which signs that indicate toxicity? 1. Thrombocytopenia and weight gain 2. Anorexia, nausea, and visual disturbances 3. Diarrhea and hypotension 4. Fatigue and muscle twitching Answer: 2 Rationale: The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea, vomiting, visual disturbances (blurred, yellow or green vision, halos around lights), bradycardia, and other dysrhythmias. Options 1, 3, and 4 are not associated with this medication. Test-Taking Strategy: Focus on the issue, toxicity. Remember gastrointestinal disturbances and visual disturbances are signs of toxicity. Digoxin is a commonly used medication, so review the signs of toxicity if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, pp. 325-326. 32. A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the 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 Answer: 3 Rationale: Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity, or at rest, is less predictable, and is often a precursor of myocardial infarction. Variant angina, or Prinzmetal’s angina, is prolonged and severe, and occurs at the same time each day, most often in the morning. Test-Taking Strategy: Focus on the data in the question and use knowledge regarding the various types of angina to answer the question. This will assist in eliminating options 1, 2, and 4. Review the characteristics of the various types of angina if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 1704. 33. A nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation would indicate that the procedure was unsuccessful?

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1. Clear breath sounds 2. A fall in blood pressure (BP) 3. Client expressions of relief 4. Clearly audible heart sounds Answer: 2 Rationale: Following pericardiocentesis, a rise in blood pressure is expected. The client usually expresses immediate relief. Heart sounds are no longer muffled or distant. Clear breath sounds are a positive sign. A drop in the central venous pressure is also expected. Test-Taking Strategy: Note the key word, unsuccessful. Successful therapy is measured by the disappearance of the original signs and symptoms of cardiac tamponade. Therefore, look for the option that identifies a sign consistent with continued tamponade. Review signs of cardiac tamponade and the expected effects of pericardiocentesis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Cardiovascular Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, pp. 860-861. 34. A nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? 1. Pulsatile abdominal mass 2. Hyperactive bowel sounds in the area 3. Systolic bruit over the area of the mass 4. Subjective sensation of “heart beating” in the abdomen Answer: 2 Rationale: Not all clients with AAA exhibit symptoms. Those who do may describe a feeling of the “heart beating” in the abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds is not specifically related to an AAA. Test-Taking Strategy: Use the process of elimination. Note the key word, unrelated. Note that options 1, 3, and 4 are similar in that they identify a circulatory component. Review the signs of AAA if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Cardiovascular Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 629. 35. A client arrives in the emergency department after complaining of unrelieved chest pain for 2 days. The pain has subsided slightly, but has not disappeared completely. When the nurse approaches the client with a nitroglycerin sublingual tablet, the client states, “I don't need that. My dad takes that for his heart. There's nothing wrong with my heart.” Which of the following best describes the client's response?

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1. Obsessive-compulsive 2. Denial 3. Phobic 4. Angry Answer: 2 Rationale: Denial is the most common reaction when a client has a myocardial infarction or anginal pain. No angry behavior was identified in the question. Phobias and obsessive-compulsive disorders are mental health diagnoses. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 3 first because these are medical diagnoses. Recalling that denial is the most common reaction when a person has chest pain will direct you to option 2. Review psychosocial responses in the client experiencing chest pain if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology References: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes (7th ed.). Philadelphia: W.B. Saunders, p. 526. Christensen, B., & Kockrow, E. (2003). Foundations of nursing (4th ed.). St. Louis: Mosby, p. 931. 36. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares the client for which priority interventions? ____Administration of furosemide (Lasix) ____Transport to the coronary care unit ____Administration of oxygen ____Placing the client in a low-Fowler’s side-lying position ____Administration of intravenous morphine sulfate Answers: Administration of furosemide (Lasix) Administration of oxygen Administration of intravenous morphine sulfate Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed and the client is placed in a high-Fowler’s position to ease the work of breathing. Furosemide, a rapid- acting diuretic, will eliminate accumulated fluid. Intravenous morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful. Test-Taking Strategy: Note the key words, priority interventions, and focus on the client’s diagnosis. Recalling the pathophysiology associated with pulmonary edema and using the ABCs —airway, breathing, and circulation—will assist in determining the priority interventions.

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Review priority interventions for the client with pulmonary edema if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Cardiovascular Reference: Ignatavicius, D., & Workman, M. (2006). Medical surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders, p. 760.