179 - Question : A female client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse incorporates in a response that this would trigger: Options : 1 . Vagus nerve stimulation, causing a decrease in heart rate and cardiac contractility 2 . Vagus nerve stimulation, causing an increase in heart rate and cardiac contractility 3 . Sympathetic nerve stimulation, causing an increase in heart rate and cardiac contractility 4 . Sympathetic nerve stimulation, causing a decrease in heart rate and cardiac contractility Answer : 1 . Rationale : Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. The sympathetic nervous system stimulation has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain homeostasis . 180 - Question : A client is experiencing a decrease in cardiac output. The nurse understands that the client could benefit from greater endogenous production of which of the following substances, which also increases blood pressure ?
Transcript
179 -Question :A female client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse incorporates in
a response that this would trigger: Options :1 . Vagus nerve stimulation, causing a decrease in heart
rate and cardiac contractility 2 . Vagus nerve stimulation, causing an increase in heart
rate and cardiac contractility 3 . Sympathetic nerve stimulation, causing an increase in
heart rate and cardiac contractility 4 . Sympathetic nerve stimulation, causing a decrease in
heart rate and cardiac contractility Answer :1 . Rationale :
Bearing down as if straining to have a bowel movement can stimulate a vagal reflex. Stimulation of the vagus nerve causes a decrease in heart rate and cardiac contractility. The sympathetic nervous system stimulation has the opposite effect. These two branches of the autonomic nervous system oppose each other to maintain
homeostasis .180 -Question :
A client is experiencing a decrease in cardiac output. The nurse understands that the client could benefit from greater endogenous production of which of the following
substances, which also increases blood pressure ?Options :
1 . Epinephrine 2 . Norepinephrine
3 . Dopamine 4 . Serotonin
Answer :3 . Rationale :
Dopaminergic receptors are found in the renal blood vessels and in the nerves. When these are stimulated, they dilate renal arteries and help modulate release of this neurotransmitter. Renal artery dilation helps to improve urine output by increasing blood flow through the kidneys. Epinephrine and norepinephrine affect the α and β receptors in the body. Serotonin is a local hormone that is released from platelets after an injury. It
constricts arterioles but dilates capillaries .181 -Question :
A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse notes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Select the
interventions that the nurse would take. (Select all that apply.) Options :
1 . Defibrillate the client .2 . Assess airway, breathing, and circulation .
5 . Obtain an electrocardiogram (ECG) .6 . Contact the physician .
Answer :2.4.5.6 . Rationale :
With ventricular tachycardia in a stable client, the nurse assesses airway, breathing, and circulation; administers oxygen ; and confirms the rhythm via a 12- lead ECG . The physician is contacted and antiarrhythmics may be prescribed. With pulseless ventricular tachycardia, the physician or a specially trained nurse must immediately defibrillate the client or initiate CPR
followed by defibrillation as soon as possible .182 -Question :
Which of the following laboratory test results may be associated with peaked or tall, tented T waves on a
client ’s electrocardiogram (ECG) ?Options :
1 . Chloride level of 98 mEq/L 2 . Sodium level of 135 mEq/L
3 . Potassium level of 6.8 mEq/L 4 . Magnesium level of 1.6 mEq/L
Answer :3 . Rationale :
Hyperkalemia can cause tall peaked or tented T waves on the ECG . Levels of potassium of 5.1 mEq/L or greater indicate hyperkalemia . Options 1 , 2 , and 4 are normal
levels . 183 -Question :
A nurse is assessing a client with a history of cardiac problems. Where should the nurse place the stethoscope in
order to hear the first heart sound (S 1 ) the loudest ?Options :
1 . Over the second intercostal space at the left sternal border
2 . Over the fourth intercostal space at the right sternal border
3 . Over the second intercostal space at the right sternal border
4 . Over the fifth intercostal space in the left midclavicular line Answer :4 .
Rationale :The first heart sound (S 1 ) is heard loudest at the lower left sternal border or the apex of the heart . The apex is located at the fifth intercostal space at the left midclavicular line . Therefore , options 1 , 2 , and
3 are incorrect .184 -Question :
A nurse providing care for a client on cardiac telemetry notes this cardiac rhythm on the monitor. The nurse
interprets the rhythm as :Options :
1 . Normal sinus rhythm (NSR) 2 . Bradycardia
3 . Atrial fibrillation 4 . Tachycardia
Answer :3 . Rationale :
In atrial fibrillation, the P waves may be absent. There is no PR interval, and the QRS duration usually is normal and constant. In NSR, a P wave precedes each QRS complex, the rhythm is essentially regular, the PR interval is 0.12 to 0.20 second in duration , and the QRS interval is 0.06 to 0.10 second in duration. Bradycardia is a slowed
heart rate, and tachycardia is a fast heart rate .
185 -Question :A nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this
cardiac rhythm on the monitor. The nurse immediately :Options :
3 . Places a nitroglycerin tablet under the client ’s tongue
4 . Continues to monitor the client for 1 minute and then contacts the physician Answer :2 . Rationale :
This cardiac rhythm identifies a coarse ventricular fibrillation (VF). The goals of treatment are to terminate VF promptly and to convert it to an organized rhythm. The physician or an advanced cardiac life support (ACLS)-qualified nurse or other health care provider must immediately defibrillate the client. If a defibrillator is not readily available , CPR is initiated until the defibrillator arrives . Options 1 , 3 , and 4 are
incorrect actions and delay life-saving treatment .186 -Question :
A nurse is assigned the care of a client with a diagnosis of congestive heart failure who is receiving intravenous doses of furosemide (Lasix). The client is attached to cardiac telemetry, and the nurse is monitoring the client ’s cardiac status. The nurse notes that the client ’s cardiac rhythm has changed to this pattern. The nurse determines that the most likely cause of this cardiac
rhythm in this client is: Options :1 . The effectiveness of the furosemide
2 . The presence of hypokalemia 3 . Pacemaker dysfunction
This cardiac rhythm is normal sinus rhythm with unifocal premature ventricular complexes (PVCs). PVCs may be insignificant or may occur with myocardial ischemia or MI; congestive heart failure; hypokalemia; hypomagnesemia; medications; stress; nicotine, caffeine, or alcohol intake; infection; trauma; or surgery. This client is receiving furosemide, which is a diuretic that causes the excretion of potassium . The most likely cause of the PVCs in this client is hypokalemia . Option 1 is an incorrect interpretation. The question presents no data indicating that this client has a pacemaker or has
signs and symptoms of MI .187 -Question :
A client is attached to a cardiac monitor, and the nurse notes the presence of this cardiac rhythm on the monitor. The nurse quickly assesses the client, knowing that this
In VT, it usually is not possible to determine the atrial rhythm. The ventricular rhythm usually is regular or nearly regular. The P waves usually are not visible and are obscured in the QRS complexes. VT occurs with repetitive firing of an irritable ventricular ectopic focus , usually at a rate of 140 to 180 beats/min or
more .
188 -Question :A nurse is assessing a client ’s legs for the presence of
edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of
the leg. The nurse documents this finding as defining :Options :
Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, “pitting ”edema is present . Its presence is graded on the following 4- point scale : 1 + , mild pitting , slight indentation , no perceptible swelling of the leg ; 2 + , moderate pitting , indentation subsides rapidly ; 3 + , deep pitting , indentation remains for a short time , leg looks swollen ; 4 + , very deep pitting , indentation lasts a long time, leg is very
swollen .189 -Question :
A client is diagnosed with iron deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells
the client that it is best to take the medication with :Options :
1 . Milk 2 . Boiled
3 . Tomato juice 4 . Pineapple juice
Answer :3 . Rationale :
Ferrous sulfate is an iron preparation and the client is instructed to take the medication with orange juice or another vitamin C–containing product, to increase the absorption of the iron. Milk and eggs inhibit the absorption of the iron. Tomato juice is highest in
vitamin C from the options presented .190-Question :
A client is diagnosed with iron deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells
the client that it is best to take the medication with :Options :
1 . Milk 2 . Boiled
3 . Tomato juice 4 . Pineapple juice
Answer :3 . Rationale :
Ferrous sulfate is an iron preparation and the client is instructed to take the medication with orange juice or another vitamin C–containing product, to increase the absorption of the iron. Milk and eggs inhibit the absorption of the iron. Tomato juice is highest in
vitamin C from the options presented .191-Question :
A nurse is teaching a client with cardiomyopathy about home care safety measures. The nurse addresses which of the following as the most important measure to ensure
3 . Administering vasodilators 4 . Moving slowly from a sitting to a standing position
Answer :4 . Rationale :
Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy . Options 1 and 2 , although important , are not directly related to the issue of
safety .192 -Question :
A client with an acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia. In developing a plan of care for the client, the nurse
includes which of the following? Options :1 . Providing the client with short, frequent walks
2 . Measuring the client ’s pulse each shift 3 . Eliminating sources of caffeine from meal trays
Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Exercise and fluid restriction will not alleviate tachycardia . Option 2 will not decrease the heart rate . Additionally , the pulse should be taken more frequently
than each shift .193 -Question :
A client is scheduled for elective cardioversion to treat chronic high-rate atrial fibrillation. The nurse
determines that the client is not yet ready for the procedure after noting which of the following? Options :
1 . The client ’s digoxin (Lanoxin) has been withheld for the last 48 hours .
2 . The client has received a dose of midazolam (Versed) intravenously .
3 . The client is wearing a nasal cannula delivering oxygen at 2 L/min .
4 . The defibrillator has the synchronizer turned on and is set at 50 joules (J) .Answer :3 . Rationale :
Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular arrhythmias after the countershock. The client typically receives a dose of an intravenous sedative or antianxiety agent. The defibrillator is switched to synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS and avoid the T wave, which could cause ventricular fibrillation . Energy level typically is set at 50 to 100 J . During the procedure , any oxygen is removed temporarily, because oxygen supports combustion,
and a fire could result from electrical arcing .194 -Question :
A nurse is assisting in the care of a client scheduled for cardioversion. The nurse plans to set the defibrillator to which of the following starting energy
range levels, depending on the specific physician order ?Options :
1 . 50 to 100 joules 2 . 150 to 200 joules 3 . 250 to 300 joules 4 . 350 to 400 joules
Answer :1 . Rationale :
For cardioversion procedures, the defibrillator is charged to the energy level ordered by the physician. Countershock usually is started at 50 to 100 joules .
Options 2 , 3 , and 4 are incorrect . 195-Question :
A client has developed atrial fibrillation with a ventricular rate of 150 beats/min . The nurse assesses
the client for :Options :
1 . Hypotension and dizziness 2 . Nausea and vomiting
3 . Hypertension and headache 4 . Flat neck veins
Answer :1 . Rationale :
The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and
distended neck veins .196 -Question :
A nurse has provided self-care activity instructions to a client after insertion of an automatic internal cardioverter-defibrillator (AICD). The nurse determines that further instruction is needed if the client makes
which of the following statements ?Options :
1“ . I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate
cutoff on the AICD” .2“ . I should keep away from electromagnetic sources such
as transformers, large electrical generators, metal detectors, and leaning over running motors” .
3“ . I can perform activities such as swimming, driving, or operating heavy equipment as I need to. ”4 . “I need to avoid doing anything that could involve rough contact
with the AICD insertion site. ” Answer :3 . Rationale :
Postdischarge instructions typically include avoiding tight clothing or belts over AICD insertion sites, rough contact with the AICD insertion site, electromagnetic fields such as with electrical transformers, radio/TV/radar transmitters, metal detectors, and running motors of cars or boats. Clients also must alert physicians or dentists to the presence of the device, because certain procedures such as diathermy, electrocautery, and magnetic resonance imaging may need to be avoided to prevent device malfunction. Clients should follow the specific advice of a physician regarding activities that are potentially hazardous to self or others, such as swimming, driving, or operating
heavy equipment .197 -Question :
A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the impact of this medication on the diet if the client states to avoid which of the
following fruits ?Options :
1 . Apples
2 . Pears 3 . Bananas
4 . Cranberries Answer :3 . Rationale :
Triamterene is a potassium-sparing diuretic, so the client should avoid foods high in potassium. Fruits that are naturally higher in potassium include avocadoes, bananas, fresh oranges, mangoes, nectarines, papayas, and prunes.
198 -Question :The health care provider prescribes bedrest for a client in whom a deep vein thrombosis develops after surgery. From the following list, select all appropriate nursing
interventions to include in this client ’s plan of care .Options :
1 . Place in Fowler ’s position for eating .2 . Encourage increased oral intake of water daily .
3 . Encourage coughing with deep breathing .4 . Place thigh-length elastic stockings on the client .5 . Encourage the intake of dark, green leafy vegetables.
6 . Place sequential compression boots on the client .Answer :2.3.4 . Rationale :
The client with deep vein thrombosis requires bedrest to prevent embolization of the thrombus due to skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and compression stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler ’s position. The nurse avoids providing foods rich in vitamin K such as dark green leafy vegetables because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used to prevent DVT only, because they mimic skeletal muscle action and can disrupt an existing
thrombus, leading to pulmonary embolism .199 -Question :
Spironolactone (Aldactone), a diuretic, is prescribed for a client with congestive heart failure. In providing
dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which
Spironolactone is a potassium-sparing diuretic, and the client should avoid foods high in potassium. If the client does not avoid foods high in potassium, hyperkalemia could develop. The client does not need to avoid foods that contain calcium, magnesium, or phosphorus while taking this medication.
200 -Question :A client is seen in the urgent care center for complaints of chest pain that began 3 days earlier. Since that time the client has not been feeling well and fatigues easily. The nurse would suspect myocardial infarction at the time of chest pain if a test for which of the following isoenzymes for lactate dehydrogenase (LDH) came back
positive ?Options :
1 . LDH 1 2 . LDH 3 3 . LDH 4 4 . LDH 5
Answer :1 . Rationale :
The particular isoenzymes that are affected after acute myocardial infarction are LDH 1 and LDH 2 . The LDH level begins to elevate about 24 hours after myocardial infarction and peaks in 48 to 72 hours . Thereafter, it
returns to normal , usually within 7 to 14 days . 201 -Question :
In planning a low-sodium diet for the client who has recently been diagnosed with congestive heart failure, the nurse should ask the client if she would like to have
Chicken breast has 70 mg of sodium , compared with 457 for cottage cheese , 700 mg for grilled cheese , and 800
mg for beef bouillon . 202 -Question :
A clinic nurse is performing a cardiovascular assessment on a client and auscultates the chest over the apex of the heart. (Click on sound icon.) The nurse identifies
this sound as which of the following? Options :1 . First heart sound , S 1
2 . Ventricular gallop 3 . Third heart sound , S 3 4 . Fourth heart sound , S4
Answer :1 . Rationale :
The sound that the nurse hears is the first heart sound , S 1 . The first heart sound (S 1 ) is created by the closure of the mitral and triscupid valves (atrioventricular [AV] valves). It marks the onset of systole (ventricular contraction). When auscultated , the first heart sound (S 1 ) is softer and longer than the second heart sound (S2). S 1 is low in pitch and is best heard at the left lower sternal border or the apex of the heart . Disease and stiffened AV valves (as in rheumatic heart disease) may augment S 1 ; rhythms of asynchrony between the atria and ventricles (as in atrial fibrillation and with AV block) cause variable intensity of S 1 . Phonetically , if a typical heartbeat , composed of the heart sounds S 1 and S2 , is auscultated as “lub-dup , ”S 1 is the “lub . ”To assess S 1 , the nurse should assist the client to a supine position (the head of the bed may be elevated slightly if necessary). The second heart sound (S2) is related to closure of the pulmonic and aortic (semilunar) valves and is heard best with the diaphragm at the aortic area. Phonetically, it is the “dup ”of the “lub-dup ”of a typical heartbeat (the first heart sound, S 1 , is the “lub ”). It signifies the end of systole and the onset of diastole (ventricular filling). S2 is characteristically shorter and higher pitched than the first heart sound (S 1 ). Diastolic filling sounds or gallops (S 3 , the third heart sound , and S4 , the fourth heart sound) are produced when compliance of either or both ventricles is decreased . S 3 is termed ventricular gallop and S4 is referred to as atrial gallop . The S 3 heart sound (a gallop sound) occurs in early diastole , during passive , rapid filling of the ventricles . The S4 sound occurs in the later stage of diastole , during atrial contraction and active filling of the ventricles . It is a soft , low- pitched
sound and is heard immediately before S 1 . 203 -Question :
Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). The nurse assesses the client ’s heart rhythm to detect PVCs
by looking for :Options :
1 . Premature beats followed by a compensatory pause 2 . QRS complexes that are short and narrow 3 . Inverted P waves before the QRS complexes
4 . A P wave preceding every QRS complex Answer :1 . Rationale :
PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a
compensatory pause that follows the ectopy .204 -Question :
A nurse is assisting in positioning the client for pericardiocentesis to treat cardiac tamponade. The best
position for this client is :Options :
1 . Lying on the left side with a pillow under the chest wall
2 . Lying on the right side with a pillow under the head 3 . Supine with the head of bed elevated at a 45- to 60-
degree angle 4 . Supine with slight Trendelenburg position
Answer :3 . Rationale :
The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60- degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the
pericardial sac . Options 1 , 2 , and 4 are incorrect . 205 -Question :
A nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which of the following is
unassociated with this complication of pericarditis ?Options :
1 . Pulsus paradoxus 2 . Distant heart sounds
3 . Distended jugular veins 4 . Bradycardia
Answer :4 . Rationale :
Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure (BP),
accompanied by pulsus paradoxus (a drop in inspiratory BP by greater than 10 mm Hg) .
206 -Question :A nurse inquires about smoking history while conducting a hospital admission assessment for a client with coronary artery disease (CAD). The most important element of the
smoking history for this assessment is the :Options :
1 . Number of pack-years 2 . Brand of cigarettes used
3 . Desire to quit smoking 4 . Number of past attempts to quit smoking
Answer :1 . Rationale :
The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack-years, which is the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information is of no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan
with the client .
207 -Question :A 52-year- old male client is seen in the physician ’s office for a physical examination after experiencing unusual fatigue over the last several weeks . The client ’s height is 5 feet 8 inches and his weight is 220 pounds . Vital signs are as follows : temperature , 98.6° F orally ; pulse , 86 beats/min ; and respirations , 18 breaths/min . The blood pressure reading is 184/100 mm Hg . A random blood glucose level is 122 mg/dL. Which of the following questions should the nurse ask the client
first ?Options :
1“ . Do you exercise regularly” ?2“ . Are you considering trying to lose weight” ?
3“ . Is there a history of diabetes mellitus in your family” ?
4“ . When was the last time you had your blood pressure checked” ?Answer :4 . Rationale :
The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors not exhibited by this client include smoking and hypercholesterolemia. The
client is overweight, which is a contributing risk factor. The client ’s nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority of attention on the
client ’s major modifiable risk factors .208 -Question :
A nurse is developing a plan of care for a client with pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse identifies which client action as
contributing to this goal ?Options :
1 . Elevating the legs when in bed 2 . Sleeping in the supine position
3 . Using seasonings to improve the taste of food 4 . Using a bedside commode
Answer :4 . Rationale :
Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client ’s legs increases venous return to the heart, increasing cardiac workload. The supine position increases respiratory effort and decreases oxygenation. This increases cardiac workload. Seasonings may be high
in sodium .209- Question :
A nurse is performing an admission assessment on a client with a diagnosis of Raynaud ’s disease. The nurse
assesses for associated signs and symptoms by :Options :
1 . Observing for softening of the nails or nail beds 2 . Palpating for diminished or absent peripheral pulses
3 . Checking for a rash on the digits 4 . Palpating for a rapid or irregular peripheral pulse
Answer :2 . Rationale :
Raynaud ’s disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted. Peripheral pulses may be normal, absent, or diminished.
