90 -Question :The clinic nurse is reviewing the assessment findings for a client who has been taking spironolactone (Aldactone) for treatment of hypertension. Which of the following, if noted in the client ’s record, would indicate that the client is experiencing a side effect

related to the medication ?Options :

1 . A potassium level of 3.2 mEq/L 2 . A potassium level of 5.8 mEq/L 3 . Client complaint of constipation

4 . Client complaint of dry skin Answer :2 .

Rationale :Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.

91 -Question :

A nurse is providing instructions to the client with chronic atrial fibrillation who is being started on quinidine sulfate. The nurse plans

to instruct the client to :Options :

1 . Take the medication only on an empty stomach .

2 . Open the sustained-release capsules and

mix with applesauce if the medication is difficult to swallow. 3 . Wear a medical

identification bracelet .4 . Stop taking the prescribed digoxin

(Lanoxin) when this medication is started .Answer :3 .

Rationale :The client should be instructed to take quinidine sulfate exactly as prescribed. The client should not chew the sustained-release capsules or open the capsules and mix them with food. The client should be instructed to wear a medical identification bracelet or tag and to continue taking digoxin as prescribed. Quinidine sulfate is administered for atrial flutter or fibrillation only after the client has been digitalized .

92 -Question :A nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction . The nurse notes that the PR interval is 0.20

second . The nurse determines that this is :Options :

1 . A normal finding 2 . Indicative of atrial flutter

3 . Indicative of impending reinfarction 4 . Indicative of atrial fibrillation

Answer :1 .

Rationale :The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles . The normal range for

the PR interval is 0.12 to 0.20 second . Options 2 , 3 , and 4 are incorrect

93 -Question :A nurse is documenting information in a client ’s chart when the ECG telemetry alarm sounds and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client ’s bedside and performs

which assessment first ?Options :

1 . Blood pressure 2 . Cardiac rate

3 . Respiratory rate 4 . Responsiveness of the client

Answer :4 .

Rationale :VT is associated with a significant decrease in cardiac output. Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output . Although options 1 , 2 , and 3 may be a component of the assessment, the first action would be to determine responsiveness of the client .

94 -Question :A nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continuously changes the subject during the teaching session. The nurse interprets that this client ’s behavior is

most likely to indicate :

Options :1 . An attempt to ignore or deny the need to

make lifestyle changes 2 . Boredom resulting from having already

learned the material 3 . Anxiety related to the need to make

lifestyle changes 4 . Lack of understanding of the material

provided at the teaching session and embarrassment about asking questions Answer :1 .

Rationale :Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client ’s behavior as boredom or as either understanding or not understanding the material provided at the

teaching session .95 -Question :

A nurse is reviewing the laboratory results for a client who arrives at the health care clinic for follow-up assessment after insertion of a mechanical prosthetic heart valve. The international normalized ratio (INR) is analyzed because the client has been taking warfarin sodium (Coumadin) since discharge from the hospital. The nurse determines that the INR range is appropriate

if which of the following values is noted on the laboratory report ?Options :

1 . 2.0 2 . 2.3 3 . 3.0 4 . 5.0

Answer :3 .

Rationale :The recommended INR range for oral anticoagulant therapy is 2.0 to 3.0 , but this value may vary with the goals of therapy . A recommended INR range with mechanical prosthetic heart valve is 2.5 to 3.5 , and for survivors of acute myocardial infarction

(MI ) , 2.5 to 3.5 .

96 -Question :A clinic nurse is performing a cardiovascular assessment on a client. In preparing to assess the client ’s apical pulse, the nurse places the stethoscope over the heart ’s apex

in which of the following positions ?Options :

1 . At the midline of the chest just below the xiphoid process

2 . At the midclavicular line at the fifth left intercostal space

3 . At the midaxillary line on the left side of the chest

4 . Mid-sternum, equal with the nipple line Answer :2 .

Rationale :The heart is located in the mediastinum. Its

apex or distal end points to the left and lies at the level of the fifth intercostal space. A stethoscope should be placed in this area to pick up heart sounds most clearly. The other options are incorrect because they do not represent the anatomical positioning of the

heart ’s apex .97 -Question :

A nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L/min . The client asks why the oxygen is necessary . The nurse

accurately explains that :Options :

1 . Oxygen has a calming effect .2 . Oxygen will prevent the development of

any thrombus .3 . Oxygen dilates the blood vessels so they

can supply more nutrients to the heart muscle. 4 . The pain of angina pectoris occurs because of decreased oxygen supply to the

heart .Answer :4 .

Rationale :The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly

calm the client .98 -Question :

A nurse is assisting in performing an arterial blood gas analysis on a client. Which of the following is an appropriate nursing action

after the blood specimen is drawn ?Options :

1 . Cover the site with a 4 × 4 gauze . 2 . Apply warm packs to the site .

3 . Perform passive range of motion for the fingers of the hand .

4 . Apply pressure to the site .Answer :4 .

Rationale :Pressure should be applied to the site after an arterial blood gas specimen is drawn. The blood pressure in the artery is higher than in the veins, so applying pressure to the punctured artery is necessary to control bleeding. Covering the site with gauze may protect the site but would not control bleeding. Heat (by application of warm packs) causes vasodilation, which would increase bleeding to the site. Exercise would

increase circulation to the area .99 -Question :

A client is admitted to the critical care unit with a diagnosis of suspected myocardial infarction. The unit nurse is reviewing the laboratory test results for this client. Which of the following findings would most specifically indicate the presence of a

myocardial infarction (MI) ?Options :

1 . Increased CK-MB 2 . Increased CK-MM

3 . Increased blood urea nitrogen (BUN)

4 . Decreased white blood cell (WBC) count Answer :1 .

Rationale :The MM fraction of creatine kinase (CK-MB) is specific in determining the presence of MI. The CK-MM reflects injury to skeletal muscle. The WBC count would most likely be elevated in the client with an MI. The BUN is unrelated

to this disorder .100 -Question :

A nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The nurse administers morphine sulfate to the client as prescribed by the physician. After administration of the morphine sulfate, the

nurse plans to monitor :Options :

1 . Mental status 2 . Respirations and blood pressure

3 . Urinary output 4 . Temperature and blood pressure

Answer :2 .

Rationale :Morphine sulfate is an opioid analgesic that may be administered to relieve pain in a client with MI. Although monitoring mental status is a component of the nurse ’s assessment, it is not the priority after administration of morphine sulfate. The nurse would monitor the client ’s respirations and blood pressure. Signs of morphine toxicity include respiratory depression and

hypotension. Urinary output is unrelated to the administration of this medication. Monitoring the temperature also is not

associated with the use of this medication .101 -Question :

A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because she is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which of the following is the next appropriate nursing action for this

client ?Options :

1 . Administer another nitroglycerin tablet .2 . Increase the flow rate of oxygen .

3 . Contact the physician .4 . Call the client ’s family .

Answer :1 .

Rationale :Nitroglycerin tablets are administered one tablet every 5 minutes , for a total of three tablets per episode of chest pain , so long as the client maintains a systolic blood pressure of 100 mm Hg or higher. Increasing the flow rate of oxygen may be prescribed by the physician but would not be the next nursing action. If three nitroglycerin tablets did not relieve the client ’s chest pain, the physician needs to be notified. It is premature to call

the client ’s family .102 -Question :

A client with a diagnosis of angina pectoris is

hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which of the following statements if made by the client indicates an

understanding of the instructions ?Options :

1“ . I am so relieved that I can eat anything that I want to now” .

2“ . I need to cut down on cigarette smoking” .

3“ . I am so relieved that my heart is repaired” .

4“ . I need to adhere to my dietary restrictions” .

Answer :4 .

Rationale :After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart. Level of

103 -Question :A nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which of the following beverages would the nurse

instruct the client to select from the menu ?Options :

1 . Coffee 2 . Tea

3 . Lemonade 4 . Cola

Answer :3 .

Rationale :A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and

need to be avoided in the client with MI .104 -Question :

A nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment, the client complains of chest pain. The nurse immediately asks the client which of the

following questions ?Options :

1“ . Are you having any nausea” ?2“ . Where is the pain located” ?

3“ . Are you allergic to any medications” ?4“ . Do you have your nitroglycerin with

you” ?Answer :2 .

Rationale :If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity , location , duration , and quality . Although options 1 , 3 , and 4 all may be components of the assessment, none of these questions would

be the initial assessment question in this client .

105 -Question :A nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an

understanding of the dietary instructions ?Options :

1“ . I need to substitute eggs and whole milk for meat” .

2“ . I should eliminate all cholesterol and fat from my diet” .

3“ . I should use polyunsaturated oils in my diet” .

4“ . I ’ll need to become a strict vegetarian. ”

Answer :3 .

Rationale :The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.