After noting a pulse deficit when assessing a patient who has
just arrived in the emergency department, the nurse will
anticipate that the patient may require
A) a. a 2-D echocardiogram.
B) b. a cardiac catheterization.
C) c. hourly blood pressure (BP) checks.
D) d. electrocardiographic (ECG) monitoring.
D electrocardiographic (ECG)
monitoring.
When reviewing the 12-lead electrocardiograph (ECG) for a
healthy 86-year-old patient who is having an annual physical
examination, which of the following will be of most concern to
the nurse?
A) a. The heart rate (HR) is 43 beats/minute.
B) b. The PR interval is 0.21 seconds.
C) c. There is a right bundle-branch block.
D) d. The QRS duration is 0.13 seconds.
A The heart rate (HR) is 43
beats/minute.
During a physical examination of a patient, the nurse palpates
the point of maximal impulse (PMI) in the sixth intercostal
space lateral to the left midclavicular line. The most
appropriate action for the nurse to take next will be to
A) a. document that the PMI is in the normal anatomic
location.
B) b. ask the patient about risk factors for coronary artery
disease.
C) c. auscultate both the carotid arteries for the presence of a
bruit.
D) d. assess the patient for symptoms of left ventricular
hypertrophy.
D assess the patient for
symptoms of left ventricular
hypertrophy.
To auscultate for S3 or S4 gallops in the mitral area, the nurse
listens with the
A) a. bell of the stethoscope with the patient in the left lateral
position.
B) b. bell of the stethoscope with the patient sitting and
leaning forward.
C) c. diaphragm of the stethoscope with the patient in a
reclining position.
D) d. diaphragm of the stethoscope with the patient lying flat
on the left side.
A bell of the stethoscope with
the patient in the left lateral
position.
To determine the effects of therapy for a patient who is being D B-type natriuretic peptide
treated for heart failure, which laboratory result will the nurse
plan to review?
A) a. Myoglobin
B) b. Homocysteine (Hcy)
C) c. Low-density lipoprotein (LDL)
D) d. B-type natriuretic peptide (BNP)
(BNP)
While doing the admission assessment for a thin 72-year-old
patient, the nurse observes pulsation of the abdominal aorta
in the epigastric area. Which action should the nurse take?
A) a. Notify the hospital rapid response team.
B) b. Instruct the patient to remain on bed rest.
C) c. Teach the patient about aortic aneurysms.
D) d. Document the finding in the patient chart.
D Document the finding in the
patient chart.
A patient is scheduled for a cardiac catheterization with
coronary angiography. Before the test, the nurse informs the
patient that
A) a. electrocardiographic (ECG) monitoring will be required
for 24 hours after the test.
B) b. it will be important to lie completely still during the
procedure.
C) c. a warm feeling may be noted when the contrast dye is
injected.
D) d. monitored anesthesia care will be provided during the
procedure.
C a warm feeling may be
noted when the contrast dye is
injected
While assessing a patient who was admitted with heart
failure, the nurse notes that the patient has jugular venous
distention (JVD) when lying flat in bed. Which action should
the nurse take next?
A) a. Use a ruler to measure the level of the JVD.
B) b. Document this finding in the patient's record.
C) c. Observe for JVD with the head at 30 degrees.
D) d. Have the patient perform the Valsalva maneuver.
C Observe for JVD with the
head at 30 degrees.
The nurse teaches the patient being evaluated for rhythm
disturbances with a Holter monitor to
A) a. exercise more than usual while the monitor is in place.
B) b. remove the electrodes when taking a shower or tub
bath.
C keep a diary of daily
activities while the monitor is
worn.
C) c. keep a diary of daily activities while the monitor is worn.
D) d. connect the recorder to a telephone transmitter once
daily.
When auscultating over the patient's abdominal aorta, the
nurse hears a humming sound. The nurse documents this
finding as a
A) a. thrill.
B) b. bruit.
C) c. heave.
D) d. murmur.
B bruit.
Which action will the nurse in the hypertension clinic take in
order to obtain an accurate baseline blood pressure (BP) for a
new patient?
A) a. Obtain a BP reading in each arm and average the
results.
B) b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per
second.
C) c. Have the patient sit in a chair with the feet flat on the
floor.
D) d. Assist the patient to the supine position for BP
measurements.
C Have the patient sit in a
chair with the feet flat on the
floor.
The nurse obtains this information from a patient with
prehypertension. Which finding is most important to address
with the patient?
A) a. Low dietary fiber intake
B) b. No regular aerobic exercise
C) c. Weight 5 pounds above ideal weight
D) d. Drinks wine with dinner once a week
B No regular aerobic exercise
After giving a patient the initial dose of oral labetalol
(Normodyne) for treatment of hypertension, which action
should the nurse take?
A) a. Encourage oral fluids to prevent dry mouth or
dehydration.
B) b. Instruct the patient to ask for help if heart palpitations
occur.
C) c. Ask the patient to request assistance when getting out of
bed.
C Ask the patient to request
assistance when getting out of
bed.
D) d. Teach the patient that headaches may occur with this
medication.
After the nurse teaches the patient with stage 1 hypertension
about diet modifications that should be implemented, which
diet choice indicates that the teaching has been effective?
A) a. The patient avoids eating nuts or nut butters.
B) b. The patient restricts intake of dietary protein.
C) c. The patient has only one cup of coffee in the morning.
D) d. The patient has a glass of low-fat milk with each meal.
D. The patient has a glass of
low-fat milk with each meal.
A patient has just been diagnosed with hypertension and has
a new prescription for captopril (Capoten). Which information
is important to include when teaching the patient?
A) a. Check BP daily before taking the medication.
B) b. Increase fluid intake if dryness of the mouth is a
problem.
C) c. Include high-potassium foods such as bananas in the
diet.
D) d. Change position slowly to help prevent dizziness and
falls.
D. Change position slowly to
help prevent dizziness and
falls.
A patient is diagnosed with hypertension and nadolol
(Corgard) is prescribed. The nurse should consult with the
health care provider before giving this medication upon
finding a history of
A) a. asthma.
B) b. peptic ulcer disease.
C) c. alcohol dependency.
D) d. myocardial infarction (MI).
A. asthma.
A 52-year-old patient who has no previous history of
hypertension or other health problems suddenly develops a
BP of 188/106 mm Hg. After reconfirming the BP, it is
appropriate for the nurse to tell the patient that
A) a. a BP recheck should be scheduled in a few weeks.
B) b. the dietary sodium and fat content should be decreased.
C) c. there is an immediate danger of a stroke and
hospitalization will be required.
D) d. more diagnostic testing may be needed to determine
the cause of the hypertension.
D. more diagnostic testing
may be needed to determine
the cause of the hypertension.
Which action will be included in the plan of care when the
nurse is caring for a patient who is receiving sodium
nitroprusside (Nipride) to treat a hypertensive emergency?
A) a. Organize nursing activities so that the patient has
undisturbed sleep for 6 to 8 hours at night.
B) b. Assist the patient up in the chair for meals to avoid
complications associated with immobility.
C) c. Use an automated noninvasive blood pressure machine
to obtain frequent BP measurements.
D) d. Place the patient on NPO status to prevent aspiration
caused by nausea and the associated vomiting.
C. Use an automated
noninvasive blood pressure
machine to obtain frequent BP
measurements.
The nurse has just finished teaching a hypertensive patient
about the newly prescribed quinapril (Accupril). Which patient
statement indicates that more teaching is needed?
A) a. "The medication may not work as well if I take any
aspirin."
B) b. "The doctor may order a blood potassium level
occasionally."
C) c. "I will call the doctor if I notice that I have a frequent
cough."
D) d. "I won't worry if I have a little swelling around my lips
and face."
D. "I won't worry if I have a
little swelling around my lips
and face."
During change-of-shift report, the nurse obtains this
information about a hypertensive patient who received the
first dose of propranolol (Inderal) during the previous shift.
Which information indicates that the patient needs immediate
intervention?
A) a. The patient's most recent BP reading is 156/94 mm Hg.
B) b. The patient's pulse has dropped from 64 to 58
beats/minute.
C) c. The patient has developed wheezes throughout the lung
fields.
D) d. The patient complains that the fingers and toes feel
quite cold
C The patient has developed
wheezes throughout the lung
fields.
When developing a health teaching plan for a 60-year-old
man with the following risk factors for coronary artery disease
(CAD), the nurse should focus on the
A) a. family history of coronary artery disease.
B) b. increased risk associated with the patient's gender.
D elevation of the patient's
serum low density lipoprotein
(LDL) level.
C) c. high incidence of cardiovascular disease in older people.
D) d. elevation of the patient's serum low density lipoprotein
(LDL) level.
To assist the patient with coronary artery disease (CAD) in
making appropriate dietary changes, which of these nursing
interventions will be most effective?
A) a. Instruct the patient that a diet containing no saturated
fat and minimal sodium will be necessary.
B) b. Emphasize the increased risk for cardiac problems
unless the patient makes the dietary changes.
C) c. Assist the patient to modify favorite high-fat recipes by
using monosaturated oils when possible.
D) d. Provide the patient with a list of low-sodium, low-
cholesterol foods that should be included in the diet.
C Assist the patient to modify
favorite high-fat recipes by
using monosaturated oils
when possible.
Which information collected by the nurse who is admitting a
patient with chest pain suggests that the pain is caused by an
acute myocardial infarction (AMI)?
A) a. The pain increases with deep breathing.
B) b. The pain has persisted longer than 30 minutes.
C) c. The pain worsens when the patient raises the arms.
D) d. The pain is relieved after the patient takes nitroglycerin.
B The pain has persisted
longer than 30 minutes.
Which information given by a patient admitted with chronic
stable angina will help the nurse confirm this diagnosis?
A) a. The patient rates the pain at a level 3 to 5 (0 to 10
scale).
B) b. The patient states that the pain "wakes me up at night."
C) c. The patient says that the frequency of the pain has
increased over the last few weeks.
D) d. The patient states that the pain is resolved after taking
one sublingual nitroglycerin tablet.
D The patient states that the
pain is resolved after taking
one sublingual nitroglycerin
tablet.
After the nurse has finished teaching a patient about use of
sublingual nitroglycerin (Nitrostat), which patient statement
indicates that the teaching has been effective?
A) a. "I can expect indigestion as a side effect of
nitroglycerin."
B) b. "I can only take the nitroglycerin if I start to have chest
pain."
C) c. "I will call an ambulance if I still have pain 5 minutes
C "I will call an ambulance if I
still have pain 5 minutes after
taking the nitroglycerin."
after taking the nitroglycerin."
D) d. "I will help slow down the progress of the plaque
formation by taking nitroglycerin."
Which of these statements made by a patient with coronary
artery disease after the nurse has completed teaching about
the therapeutic lifestyle changes (TLC) diet indicates that
further teaching is needed?
A) a. "I will switch from whole milk to 1% or nonfat milk."
B) b. "I like fresh salmon and I will plan to eat it more often."
C) c. "I will miss being able to eat peanut butter sandwiches."
D) d. "I can have a cup of coffee with breakfast if I want one."
C "I will miss being able to eat
peanut butter sandwiches."
After the nurse teaches the patient about the use of atenolol
(Tenormin) in preventing anginal episodes, which statement
by a patient indicates that the teaching has been effective?
A) a. "It is important not to suddenly stop taking the atenolol."
B) b. "Atenolol will increase the strength of my heart muscle."
C) c. "I can expect to feel short of breath when taking
atenolol."
D) d. "Atenolol will improve the blood flow to my coronary
arteries."
A "It is important not to
suddenly stop taking the
atenolol."
A patient who has had severe chest pain for several hours is
admitted with a diagnosis of possible acute myocardial
infarction (AMI). Which of these ordered laboratory tests
should the nurse monitor to help determine whether the
patient has had an AMI?
A) a. Homocysteine
B) b. C-reactive protein
C) c. Cardiac-specific troponin I and troponin T
D) d. High-density lipoprotein (HDL) cholesterol
C Cardiac-specific troponin I
and troponin T
Amlodipine (Norvasc) is ordered for a patient with newly
diagnosed Prinzmetal's (variant) angina. When teaching the
patient, the nurse will include the information that amlodipine
will
A) a. reduce the "fight or flight" response.
B) b. decrease spasm of the coronary arteries.
C) c. increase the force of myocardial contraction.
D) d. help prevent clotting in the coronary arteries.
B decrease spasm of the
coronary arteries.
The nurse will suspect that the patient with stable angina is
experiencing a side effect of the prescribed metoprolol
(Lopressor) if
A) a. the patient is restless and agitated.
B) b. the blood pressure is 190/110 mm Hg.
C) c. the patient complains about feeling anxious.
D) d. the cardiac monitor shows a heart rate of 45.
D the cardiac monitor shows a
heart rate of 45.
Nadolol (Corgard) is prescribed for a patient with angina. To
determine whether the drug is effective, the nurse will
monitor for
A) a. decreased blood pressure and apical pulse rate.
B) b. fewer complaints of having cold hands and feet.
C) c. improvement in the quality of the peripheral pulses.
D) d. the ability to do daily activities without chest discomfort.
D the ability to do daily
activities without chest
discomfort.
A patient with a non-ST-segment-elevation myocardial
infarction (NSTEMI) is receiving heparin. What is the purpose
of the heparin?
A) a. Platelet aggregation is enhanced by IV heparin infusion.
B) b. Heparin will dissolve the clot that is blocking blood flow
to the heart.
C) c. Coronary artery plaque size and adherence are
decreased with heparin.
D) d. Heparin will prevent the development of new clots in the
coronary arteries.
D Heparin will prevent the
development of new clots in
the coronary arteries.
. When administering IV nitroglycerin (Tridil) to a patient with
a myocardial infarction (MI), which action will the nurse take
to evaluate the effectiveness of the medication?
A) a. Check blood pressure.
B) b. Monitor apical pulse rate.
C) c. Monitor for dysrhythmias.
D) d. Ask about chest discomfort.
D Ask about chest discomfort.
A patient with ST segment elevation in several
electrocardiographic (ECG) leads is admitted to the
emergency department (ED) and diagnosed as having an ST-
segment-elevation myocardial infarction (STEMI). Which
question should the nurse ask to determine whether the
patient is a candidate for fibrinolytic therapy?
A) a. "Do you take aspirin on a daily basis?"
B "What time did your chest
pain begin?"
B) b. "What time did your chest pain begin?"
C) c. "Is there any family history of heart disease?"
D) d. "Can you describe the quality of your chest pain?"
Following an acute myocardial infarction (AMI), a patient
ambulates in the hospital hallway. When the nurse is
evaluating the patient's response, which of these assessment
data would indicate that the exercise level should be
decreased?
A) a. BP changes from 118/60 to 126/68 mm Hg.
B) b. Oxygen saturation drops from 100% to 98%.
C) c. Heart rate increases from 66 to 90 beats/minute.
D) d. Respiratory rate goes from 14 to 22 breaths/minute.
C) c. Heart rate increases from
66 to 90 beats/minute.
During the administration of the fibrinolytic agent to a patient
with an acute myocardial infarction (AMI), the nurse should
stop the drug infusion if the patient experiences
A) a. bleeding from the gums.
B) b. surface bleeding from the IV site.
C) c. a decrease in level of consciousness.
D) d. a nonsustained episode of ventricular tachycardia.
C) c. a decrease in level of
consciousness.
Three days after a myocardial infarction (MI), the patient
develops chest pain that increases when taking a deep breath
and is relieved by leaning forward. Which action should the
nurse take next?
A) a. Palpate the radial pulses bilaterally.
B) b. Assess the feet for peripheral edema.
C) c. Auscultate for a pericardial friction rub.
D) d. Check the cardiac monitor for dysrhythmias.
C) c. Auscultate for a
pericardial friction rub.
After the nurse teaches a patient with chronic stable angina
about how to use the prescribed short-acting and long-acting
nitrates, which statement by the patient indicates that the
teaching has been effective?
A) a. "I will put on the nitroglycerin patch as soon as I develop
any chest pain."
B) b. "I will check the pulse rate in my wrist just before I take
any nitroglycerin."
C) c. "I will be sure to remove the nitroglycerin patch before
using any sublingual nitroglycerin."
D) d. "I will stop what I am doing and sit down before I put the
D) d. "I will stop what I am
doing and sit down before I
put the nitroglycerin under my
tongue."
nitroglycerin under my tongue."
Four days after having a myocardial infarction (MI), a patient
who is scheduled for discharge asks for assistance with all the
daily activities, saying, "I am too nervous to take care of
myself." Based on this information, which nursing diagnosis is
appropriate?
A) a. Ineffective coping related to anxiety
B) b. Activity intolerance related to weakness
C) c. Denial related to lack of acceptance of the MI
D) d. Social isolation related to lack of support system
A) a. Ineffective coping related
to anxiety
When caring for a patient who has survived a sudden cardiac
death (SCD) event and has no evidence of an acute
myocardial infarction (AMI), the nurse will anticipate teaching
the patient
A) a. that sudden cardiac death events rarely reoccur.
B) b. about the purpose of outpatient Holter monitoring.
C) c. how to self-administer low-molecular-weight heparin.
D) d. to limit activities after discharge to prevent future
events.
B) b. about the purpose of
outpatient Holter monitoring.
To determine whether there is a delay in impulse conduction
through the atria, the nurse will measure the length of the
patient's
A) a. P wave.
B) b. PR interval.
C) c. QT interval.
D) d. QRS complex.
A) a. P wave.
The nurse needs to estimate quickly the heart rate for a
patient with a regular heart rhythm. Which method will be
best to use?
A) a. Print a 1-minute electrocardiogram (ECG) strip and count
the number of QRS complexes.
B) b. Count the number of large squares in the R-R interval
and divide by 300.
C) c. Use the 3-second markers to count the number of QRS
complexes in 6 seconds and multiply by 10.
D) d. Calculate the number of small squares between one QRS
complex and the next and divide into 1500.
C) c. Use the 3-second
markers to count the number
of QRS complexes in 6
seconds and multiply by 10.
A patient has a junctional escape rhythm on the monitor. The
nurse will expect the patient to have a heart rate of how
many beats/minute?
A) a. 15 to 20
B) b. 20 to 40
C) c. 40 to 60
D) d. 60 to 100
C) c. 40 to 60
The nurse obtains a monitor strip on a patient who has had a
myocardial infarction and makes the following analysis: P
wave not apparent, ventricular rate 162, R-R interval regular,
P-R interval not measurable, and QRS complex wide and
distorted, QRS duration 0.18 second. The nurse interprets the
patient's cardiac rhythm as
A) a. atrial fibrillation.
B) b. sinus tachycardia.
C) c. ventricular fibrillation.
D) d. ventricular tachycardia.
D) d. ventricular tachycardia.
The nurse notes that a patient's cardiac monitor shows that
every other beat is earlier than expected, has no P wave, and
has a QRS complex with a wide and bizarre shape. How will
the nurse document the rhythm?
A) a. Ventricular couplets
B) b. Ventricular bigeminy
C) c. Ventricular R-on-T phenomenon
D) d. Ventricular multifocal contractions
B) b. Ventricular bigeminy
A patient has a normal cardiac rhythm and a heart rate of 72
beats/minute, except that the PR interval is 0.24 seconds. The
appropriate intervention by the nurse is to
A) a. notify the patient's health care provider immediately.
B) b. administer atropine per agency bradycardia protocol.
C) c. prepare the patient for temporary pacemaker insertion.
D) d. document the finding and continue to monitor the
patient.
D) d. document the finding
and continue to monitor the
patient.
A patient who was admitted with a myocardial infarction
experiences a 50-second episode of ventricular tachycardia,
then converts to sinus rhythm with a heart rate of 98
beats/minute. Which action should the nurse take next?
A) a. Notify the health care provider.
C) c. Administer the PRN IV
lidocaine (Xylocaine).
B) b. Perform synchronized cardioversion.
C) c. Administer the PRN IV lidocaine (Xylocaine).
D) d. Document the rhythm and monitor the patient.
After the nurse administers IV atropine to a patient with
symptomatic type 1, second-degree atrioventricular (AV)
block, which finding indicates that the medication has been
effective?
A) a. Increase in the patient's heart rate
B) b. Decrease in premature contractions
C) c. Increase in peripheral pulse volume
D) d. Decrease in ventricular ectopic beats
A) a. Increase in the patient's
heart rate
A patient with dilated cardiomyopathy has an atrial fibrillation
that has been unresponsive to drug therapy for several days.
The nurse anticipates that the patient may need teaching
about
A) a. electrical cardioversion.
B) b. IV adenosine (Adenocard).
C) c. anticoagulant therapy with warfarin (Coumadin).
D) d. insertion of an implantable cardioverter-defibrillator
(ICD).
C) c. anticoagulant therapy
with warfarin (Coumadin).
Which information will the nurse include when teaching a
patient who is scheduled to have a permanent pacemaker
inserted for treatment of chronic atrial fibrillation with slow
ventricular response?
A) a. The pacemaker prevents or minimizes ventricular
irritability.
B) b. The pacemaker paces the atria at rates up to 500
impulses/minute.
C) c. The pacemaker discharges if ventricular fibrillation and
cardiac arrest occur.
D) d. The pacemaker stimulates a heart beat if the patient's
heart rate drops too low.
D) d. The pacemaker
stimulates a heart beat if the
patient's heart rate drops too
low.
A patient has received instruction on the management of a
new permanent pacemaker before discharge from the
hospital. The nurse recognizes that teaching has been
effective when the patient tells the nurse,
A) a. "It will be 6 weeks before I can take a bath or return to
my usual activities."
C) c. "I won't lift the arm on
the pacemaker side up very
high until I see the doctor."
B) b. "I will notify the airlines when I make a reservation that I
have a pacemaker."
C) c. "I won't lift the arm on the pacemaker side up very high
until I see the doctor."
D) d. "I must avoid cooking with a microwave oven or being
near a microwave in use."
Which action by a new nurse who is caring for a patient who
has just had an implantable cardioverter-defibrillator (ICD)
inserted indicates a need for more education about care of
patients with ICDs?
A) a. The nurse assists the patient to do active range of
motion exercises for all extremities.
B) b. The nurse assists the patient to fill out the application
for obtaining a Medic Alert ID and bracelet.
C) c. The nurse gives atenolol (Tenormin) to the patient
without consulting first with the health care provider.
D) d. The nurse teaches the patient that sexual activity
usually can be resumed once the surgical incision is healed.
A) a. The nurse assists the
patient to do active range of
motion exercises for all
extremities.
Which action should the nurse take when preparing for
cardioversion of a patient with supraventricular tachycardia
who is alert and has a blood pressure of 110/66 mm Hg?
A) a. Turn the synchronizer switch to the "off" position.
B) b. Perform cardiopulmonary resuscitation (CPR) until the
paddles are in correct position.
C) c. Set the defibrillator/cardioverter energy to 300 joules.
D) d. Administer a sedative before cardioversion is
implemented.
D) d. Administer a sedative
before cardioversion is
implemented.
A 19-year-old has a mandatory electrocardiogram (ECG)
before participating on a college swim team and is found to
have sinus bradycardia, rate 52. BP is 114/54, and the
student denies any health problems. What action by the nurse
is appropriate?
A) a. Allow the student to participate on the swim team.
B) b. Refer the student to a cardiologist for further
assessment.
C) c. Obtain more detailed information about the student's
health history.
D) d. Tell the student to stop swimming immediately if any
A) a. Allow the student to
participate on the swim team.
dyspnea occurs.
When analyzing the waveforms of a patient's
electrocardiogram (ECG), the nurse will need to investigate
further upon finding a
A) a. T wave of 0.16 second.
B) b. P-R interval of 0.18 second.
C) c. Q-T interval of 0.34 second.
D) d. QRS interval of 0.14 second.
D) d. QRS interval of 0.14
second.
A patient has ST segment changes that indicate an acute
inferior wall myocardial infarction. Which lead will be best for
monitoring the patient?
A) a. I
B) b. II
C) c. V6
D) d. MCL1
B) b. II
Which laboratory result for a patient whose cardiac monitor
shows multifocal premature ventricular contractions (PVCs) is
most important for the nurse to communicate to the health
care provider?
A) a. Blood glucose 228 mg/dL
B) b. Serum chloride 90 mEq/L
C) c. Serum sodium 133 mEq/L
D) d. Serum potassium 2.8 mEq/L
D) d. Serum potassium 2.8
mEq/L
. A patient's cardiac monitor has a pattern of undulations of
varying contours and amplitude with no measurable ECG
pattern. The patient is unconscious and pulseless. Which
action should the nurse take first?
A) a. Defibrillate at 360 joules.
B) b. Give O2 per bag-valve-mask.
C) c. Give epinephrine (Adrenalin) IV.
D) d. Prepare for endotracheal intubation.
A) a. Defibrillate at 360 joules.
A patient's cardiac monitor shows sinus rhythm, rate 60 to 70.
The P-R interval is 0.18 seconds at 1:00 AM, 0.20 seconds at
2:30 PM, and 0.23 seconds at 4:00 PM. Which action should
the nurse take at this time?
A) a. Prepare for possible temporary pacemaker insertion.
B) b. Administer atropine sulfate 1 mg IV per agency protocol.
D) d. Call the health care
provider before giving the
prescribed metoprolol
(Lopressor).
C) c. Document the patient's rhythm and assess the patient's
response to the rhythm.
D) d. Call the health care provider before giving the
prescribed metoprolol (Lopressor).
A patient develops sinus bradycardia at a rate of 32
beats/minute, has a BP of 80/36 mm Hg, and is complaining of
feeling faint. Which action should the nurse take?
A) a. Continue to monitor the rhythm and BP.
B) b. Apply the transcutaneous pacemaker (TCP).
C) c. Have the patient perform the Valsalva maneuver.
D) d. Give the scheduled dose of diltiazem (Cardizem).
B) b. Apply the
transcutaneous pacemaker
(TCP).
During the preoperative interview, a patient scheduled for an
elective hysterectomy tells the nurse, "I am afraid that I will
die in surgery like my mother did!" Which response by the
nurse is most appropriate?
A) a. "Tell me more about what happened to your mother."
B) b. "You will receive medications to reduce your anxiety."
C) c. "You should talk to the doctor again about the surgery."
D) d. "Surgical techniques have improved a lot in recent
years."
A) a. "Tell me more about
what happened to your
mother."
A patient arrives at the ambulatory surgery center for a
scheduled outpatient surgery. Which information is of most
concern to the nurse?
A) a. The patient has not had outpatient surgery before.
B) b. The patient is planning to drive home after surgery.
C) c. The patient's insurance does not cover outpatient
surgery.
D) d. The patient had a glass of water a few hours before
arriving.
B) b. The patient is planning to
drive home after surgery.
. A 36-year-old woman is admitted for an outpatient surgery.
Which information obtained by the nurse during the
preoperative assessment is most important to report to the
anesthesiologist before surgery?
A) a. The patient's lack of knowledge about postoperative
pain control measures
B) b. The patient's statement that her last menstrual period
was 8 weeks previously
C) c. The patient's history of a postoperative infection
B) b. The patient's statement
that her last menstrual period
was 8 weeks previously
following a prior cholecystectomy
D) d. The patient's concern that she will be unable to care for
her children postoperatively
. A patient who is scheduled for surgery in a week tells the
nurse doing the preoperative assessment about an allergy to
bananas, kiwifruit, and latex products. Which action is most
important for the nurse to take?
A) a. Notify the dietitian about the food allergies.
B) b. Alert the surgery center about the latex allergy.
C) c. Reassure the patient that all allergies are noted on the
medical record.
D) d. Ask whether the patient uses antihistamines to reduce
allergic reactions.
B) b. Alert the surgery center
about the latex allergy.
Any patient guilt about having a therapeutic abortion may be
identified when the nurse assesses the functional health
pattern of
A) a. value-belief.
B) b. cognitive-perceptual.
C) c. sexuality-reproductive.
D) d. coping-stress tolerance.
A) a. value-belief.
During the preoperative assessment of a patient scheduled
for a colon resection, the patient tells the nurse about using
St. John's wort to prevent depression. The nurse should alert
the staff in the postanesthesia recovery area that the patient
may
A) a. experience increased pain.
B) b. have hypertensive episodes.
C) c. take longer to recover from the anesthesia.
D) d. have more postoperative bleeding than expected.
C) c. take longer to recover
from the anesthesia.
On the day of surgery, the nurse is admitting a patient with a
history of cigarette smoking. Which action is most important
at this time?
A) a. Auscultate for adventitious breath sounds.
B) b. Ask whether the patient has smoked recently.
C) c. Remind the patient about harmful effects of smoking.
D) d. Calculate the cigarette smoking history in pack-years.
A) a. Auscultate for
adventitious breath sounds.
A patient is seen at the health care provider's office several B) b. discuss the supplement
weeks before hip surgery for preoperative assessment. The
patient reports use of echinacea, saw palmetto, and
glucosamine/chondroitin. The nurse should
A) a. ascertain that there will be no interactions with
anesthetic agents.
B) b. discuss the supplement use with the patient's health
care provider.
C) c. teach the patient that these products may be continued
preoperatively.
D) d. advise the patient to stop the use of all herbs and
supplements at this time.
use with the patient's health
care provider.
Before the administration of preoperative medications, the
nurse is preparing to witness the patient signing the operative
consent form when the patient says, "I do not really
understand what the doctor said." Which action is best for the
nurse to take?
A) a. Provide an explanation of the planned surgical
procedure.
B) b. Notify the surgeon that the informed consent process is
not complete.
C) c. Administer the prescribed preoperative antibiotics and
withhold any ordered sedative medications.
D) d. Notify the operating room staff that the surgeon needs
to give a more complete explanation of the procedure.
B) b. Notify the surgeon that
the informed consent process
is not complete.
Which topic is most important for the nurse to discuss
preoperatively with a patient who is scheduled for a colon
resection?
A) a. Care for the surgical incision
B) b. Medications used during surgery
C) c. Deep breathing and coughing techniques
D) d. Oral antibiotic therapy after discharge home
C) c. Deep breathing and
coughing techniques
Ten minutes after receiving the ordered preoperative opioid
by intravenous (IV) injection, the patient asks to get up to go
to the bathroom to urinate. The most appropriate action by
the nurse is to
A) a. assist the patient to the bathroom and stay with the
patient to prevent falls.
B) b. offer a urinal or bedpan and position the patient in bed
to promote voiding.
B) b. offer a urinal or bedpan
and position the patient in bed
to promote voiding.
C) c. allow the patient up to the bathroom because the onset
of the medication takes more than 10 minutes.
D) d. ask the patient to wait because catheterization is
performed at the beginning of the surgical procedure.
An alert 82-year-old who has poor hearing and vision is
receiving preoperative teaching from the nurse. His wife
answers most questions directed to the patient. Which action
should the nurse take when doing the teaching?
A) a. Use printed materials for instruction so that the patient
will have more time to review the material.
B) b. Direct the teaching toward the wife because she is the
obvious support and caregiver for the patient.
C) c. Provide additional time for the patient to understand
preoperative instructions and carry out procedures.
D) d. Ask the patient's wife to wait in the hall in order to focus
preoperative teaching with the patient himself.
C) c. Provide additional time
for the patient to understand
preoperative instructions and
carry out procedures.
A diabetic patient who uses insulin to control blood glucose
has been NPO since midnight before having a mastectomy.
The nurse will anticipate the need to
A) a. withhold the usual scheduled insulin dose because the
patient is NPO.
B) b. obtain a blood glucose measurement before any insulin
administration.
C) c. give the patient the usual insulin dose because stress
will increase the blood glucose.
D) d. administer a lower dose of insulin because there will be
no oral intake before surgery.
B) b. obtain a blood glucose
measurement before any
insulin administration.
The clinic nurse reviews the complete blood cell count (CBC)
results for a patient who is scheduled for surgery in a few
days. The results are white blood cell count (WBC) 10.2 ´
103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´
103/µL. Which action should the nurse take?
A) a. Send the CBC results to the surgery facility.
B) b. Call the surgeon and anesthesiologist immediately.
C) c. Ask the patient about any symptoms of a recent
infection.
D) d. Discuss the possibility of blood transfusion with the
patient
A) a. Send the CBC results to
the surgery facility.
As the nurse prepares a patient the morning of surgery, the
patient refuses to remove a wedding ring, saying, "I have
never taken it off since the day I was married." The nurse
should
A) a. have the patient sign a release and leave the ring on.
B) b. tape the wedding ring securely to the patient's finger.
C) c. tell the patient that the hospital is not liable for loss of
the ring.
D) d. suggest that the patient give the ring to a family
member to keep.
B) b. tape the wedding ring
securely to the patient's
finger.
The perioperative nurse encourages a family member or a
friend to remain with a patient in the preoperative holding
area until the patient is taken into the operating room
primarily to
A) a. ensure the proper identification of the patient before
surgery.
B) b. protect the patient from cross-contamination with other
patients.
C) c. assist the perioperative nurse to obtain a complete
patient history.
D) d. help relieve the stress of separation for the patient and
significant others.
D) d. help relieve the stress of
separation for the patient and
significant others.
Which description best defines the role of the nurse
anesthetist as a member of the surgical team?
A) a. Functions independently in the administration of
anesthetics
B) b. Has the same credentials and responsibilities as an
anesthesiologist
C) c. Is responsible for intraoperative administration of
anesthetics ordered by the anesthesiologist
D) d. Requires supervision by the anesthesiologist or surgeon
while administering anesthesia to a patient
A) a. Functions independently
in the administration of
anesthetics
Which outcome measure will be best for the operating room
(OR) nurse manager to use in determining the effectiveness
of the physical environment and traffic control measures in
the operating room?
A) a. Smooth functioning of the OR team
B) b. Effective protection of patient privacy
C) c. Rapid completion of surgical procedure
D) d. Low incidence of
perioperative infection
D) d. Low incidence of perioperative infection
Which action will the scrub nurse use to maintain aseptic
technique during surgery?
A) a. Use waterproof shoe covers.
B) b. Wear personal protective equipment.
C) c. Insist that all operating room (OR) staff perform a
surgical scrub.
D) d. Change gloves after touching the upper arm of the
surgeon's gown.
D) d. Change gloves after
touching the upper arm of the
surgeon's gown.
After orienting a new staff member to the scrub nurse role,
the nurse preceptor will know that the teaching was effective
if the new staff member
A) a. documents all patient care accurately.
B) b. labels all specimens to send to the lab.
C) c. keeps both hands above the operating table level.
D) d. takes the patient to the postanesthesia recovery area.
C) c. keeps both hands above
the operating table level.
Data that were obtained during the perioperative nurse's
assessment of a patient in the preoperative holding area that
would indicate a need for special protection techniques during
surgery include
A) a. a stated allergy to cats and dogs.
B) b. a history of spinal and hip arthritis.
C) c. verbalization of anxiety by the patient.
D) d. having a sip of water 2 hours previously.
B) b. a history of spinal and
hip arthritis.
The nurse from the general surgical unit is asked to bring the
patient's hearing aid to the surgical suite. The nurse will take
the hearing aid to the
A) a. clean core.
B) b. scrub sink areas.
C) c. nursing station or information desk.
D) d. corridors of the operating room area.
C) c. nursing station or
information desk.
preoperative patient in the holding area asks the nurse, "Will
the doctor put me to sleep with a mask over my face?" The
most appropriate response by the nurse is,
A) a. "A drug will be given to you through your IV line, which
will cause you to go to sleep almost immediately."
B) b. "Only your surgeon can tell you for sure what method of
A) a. "A drug will be given to
you through your IV line,
which will cause you to go to
sleep almost immediately"
anesthesia will be used. Should I ask your surgeon?"
C) c. "General anesthesia is now given by injecting medication
into your veins, so you will not need a mask over your face."
D) d. "Masks are not used anymore for anesthesia. A tube will
be inserted into your throat to deliver a gas that will put you
to sleep."
A surgical patient received a volatile liquid as an inhalation
anesthetic during surgery. Postoperatively the nurse should
monitor the patient for
A) a. tachypnea.
B) b. myoclonia.
C) c. hypertension.
D) d. incisional pain.
D) d. incisional pain.
When the nurse caring for a patient before surgery has a
question about a sedative medication to be given before
sending the patient to the surgical suite, the nurse will
communicate with the
A) a. surgeon.
B) b. anesthesiologist.
C) c. circulating nurse.
D) d. registered nurse first assistant (RNFA).
B) b. anesthesiologist.
A patient with a dislocated shoulder is prepared for a closed,
manual reduction of the dislocation with monitored
anesthesia care (MAC). The nurse anticipates the
administration of
A) a. IV midazolam (Versed).
B) b. inhaled desflurane (Suprane).
C) c. epidural lidocaine (Xylocaine).
D) d. eutectic mixture of local anesthetics (EMLA).
A) a. IV midazolam (Versed).
Which action will the nurse include in the plan of care
immediately after surgery for a patient who received
ketamine (Ketalar) as an anesthetic agent?
A) a. Administer larger doses of analgesic agents.
B) b. Monitor for severe slowing of the heart rate.
C) c. Provide a quiet environment in the postanesthesia care
unit.
D) d. Avoid the use of benzodiazepines in the postoperative
C) c. Provide a quiet
environment in the
postanesthesia care unit.
period.
A patient's family history reveals that the patient may be at
risk for malignant hyperthermia (MH) during anesthesia. The
nurse explains to the patient that
A) a. anesthesia can be administered with minimal risks with
the use of appropriate precautions and medications.
B) b. as long as succinylcholine (Anectine) is not administered
as a muscle relaxant, the reaction should not occur.
C) c. surgery must be performed under local anesthetic to
prevent development of a sudden, extreme increase in body
temperature.
D) d. surgery will be delayed until the patient is genetically
tested to determine whether he or she is susceptible to
malignant hyperthermia.
A) a. anesthesia can be
administered with minimal
risks with the use of
appropriate precautions and
medications.
A patient in surgery receives a neuromuscular blocking agent
as an adjunct to general anesthesia. At completion of the
surgery, it is most important that the nurse monitor the
patient for
A) a. nausea.
B) b. confusion.
C) c. bronchospasm.
D) d. weak chest-wall movement.
D) d. weak chest-wall
movement.
Which action by an inexperienced member of the surgical
team requires rapid intervention by the charge nurse?
A) a. Wearing street clothes into the nursing station
B) b. Wearing a surgical mask into the holding room
C) c. Walking into the hallway outside an operating room
without the hair covered
D) d. Putting on a surgical mask, cap, and scrubs before
entering the operating room
C) c. Walking into the hallway
outside an operating room
without the hair covered
A 42-year-old patient is recovering from anesthesia in the
postanesthesia care unit (PACU). On admission to the PACU,
the blood pressure (BP) is 124/70. Thirty minutes after
admission, the blood pressure falls to 112/60, with a pulse of
72 and warm, dry skin. The most appropriate action by the
nurse at this time is to
A) a. increase the rate of the IV fluid replacement.
B) b. continue to take vital signs every 15 minutes.
B) b. continue to take vital
signs every 15 minutes.
C) c. administer oxygen therapy at 100% per mask.
D) d. notify the anesthesia care provider (ACP) immediately.
During recovery from anesthesia in the postanesthesia care
unit (PACU), a patient's vital signs are blood pressure 118/72,
pulse 76, respirations 12, and SpO2 91%. The patient is
sleepy but awakens easily. Which action should the nurse
take at this time?
A) a. Place the patient in a side-lying position.
B) b. Encourage the patient to take deep breaths.
C) c. Prepare to transfer the patient from the PACU.
D) d. Increase the rate of the postoperative IV fluids.
B) b. Encourage the patient to
take deep breaths.
After a new nurse has been oriented to the postanesthesia
care unit (PACU), the charge nurse will evaluate that the
orientation has been successful when the new nurse
A) a. places a patient in the Trendelenburg position when the
blood pressure (BP) drops.
B) b. assists a patient to the prone position when the patient
is nauseated.
C) c. turns an unconscious patient to the side when the
patient arrives in the PACU.
D) d. positions a newly admitted unconscious patient supine
with the head elevated.
C) c. turns an unconscious
patient to the side when the
patient arrives in the PACU.
A 75-year-old is to be discharged from the ambulatory
surgical unit following left eye surgery. The patient tells the
nurse, "I do not know if I can take care of myself with this
patch over my eye." The most appropriate nursing action is to
A) a. refer the patient for home health care services.
B) b. discuss the specific concerns regarding self-care.
C) c. give the patient written instructions regarding care.
D) d. assess the patient's support system for care at home.
B) b. discuss the specific
concerns regarding self-care.
After removal of the nasogastric (NG) tube on the second
postoperative day, the patient is placed on a clear liquid diet.
Four hours later, the patient complains of sharp, cramping
gas pains. Which action should the nurse take?
A) a. Reinsert the NG tube.
B) b. Give the PRN IV opioid.
C) c. Assist the patient to ambulate.
C) c. Assist the patient to
ambulate.
D) d. Place the patient on NPO status.
Following gallbladder surgery, a patient's T-tube is draining
dark green fluid. Which action should the nurse take?
A) a. Place the patient on bed rest.
B) b. Notify the patient's surgeon.
C) c. Document the color and amount of drainage.
D) d. Irrigate the T-tube with sterile normal saline.
C) c. Document the color and
amount of drainage.
In intervening to promote ambulation, coughing, deep
breathing, and turning by a postoperative patient on the first
postoperative day, which action by the nurse is most helpful?
A) a. Discuss the complications of immobility and poor cough
effort.
B) b. Teach the patient the purpose of respiratory care and
ambulation.
C) c. Administer ordered analgesic medications before these
activities.
D) d. Give the patient positive reinforcement for
accomplishing these activities.
C) c. Administer ordered
analgesic medications before
these activities
The nurse evaluates that the interventions for the nursing
diagnosis of ineffective airway clearance in a postoperative
patient have been successful when the
A) a. patient drinks 2 to 3 L of fluid in 24 hours.
B) b. patient uses the spirometer 10 times every hour.
C) c. patient's breath sounds are clear to auscultation.
D) d. patient's temperature is less than 100.4° F orally.
C) c. patient's breath sounds
are clear to auscultation.
. A patient who has begun to awaken after 30 minutes in the
postanesthesia care unit (PACU) is restless and shouting at
the nurse. The patient's oxygen saturation is 99%, and recent
lab results are all normal. Which action by the nurse is most
appropriate?
A) a. Insert an oral or nasal airway.
B) b. Notify the anesthesia care provider.
C) c. Orient the patient to time, place, and person.
D) d. Be sure that the patient's IV lines are secure.
D) d. Be sure that the
patient's IV lines are secure.
Which action should the postanesthesia care unit (PACU)
nurse delegate to nursing assistive personnel (NAP) who help
with the transfer of a patient to the surgical unit?
A) a. Help with the transfer of
the patient onto a stretcher.
A) a. Help with the transfer of the patient onto a stretcher.
B) b. Give a verbal report to the surgical unit charge nurse.
C) c. Document the appearance of the patient's incision in the
chart.
D) d. Ensure that the receiving nurse understands the
postoperative orders.
When a patient is transferred from the postanesthesia care
unit (PACU) to the clinical surgical unit, the first action by the
nurse on the surgical unit should be to
A) a. assess the patient's pain.
B) b. take the patient's vital signs.
C) c. read the postoperative orders.
D) d. check the rate of the IV infusion.
B) b. take the patient's vital
signs.
An 83-year-old who had a surgical repair of a hip fracture 2
days previously has restrictions on ambulation. Based on this
information, the nurse identifies the priority collaborative
problem for the patient as
A) a. potential complication: hypovolemic shock.
B) b. potential complication: venous thromboembolism.
C) c. potential complication: fluid and electrolyte imbalance.
D) d. potential complication: impaired surgical wound healing.
B) b. potential complication:
venous thromboembolism.
A patient who is just waking up after having a general
anesthetic is agitated and confused. Which action should the
nurse take first?
A) a. Check the O2 saturation.
B) b. Administer the ordered opioid.
C) c. Take the blood pressure and pulse.
D) d. Notify the anesthesia care provider.
A) a. Check the O2 saturation.
A postoperative patient has not voided for 7 hours after
return to the postsurgical unit. Which action should the nurse
take first?
A) a. Notify the surgeon.
B) b. Perform a bladder scan.
C) c. Assist the patient to ambulate to the bathroom.
D) d. Insert a straight catheter as indicated on the PRN order.
B) b. Perform a bladder scan.
While caring for a patient with abdominal surgery the first
postoperative day, the nurse notices new bright-red drainage
B) b. take the patient's vital
about 6 cm in diameter on the dressing. In response to this
finding, the nurse should first
A) a. reinforce the dressing.
B) b. take the patient's vital signs.
C) c. recheck the dressing in 1 hour for increased drainage.
D) d. notify the patient's surgeon of a potential hemorrhage.
signs.
During assessment of a 72-year-old with ankle swelling, the
nurse notes jugular venous distention (JVD) with the head of
the patient's bed elevated 45 degrees. The nurse knows this
finding indicates
A) a. decreased fluid volume.
B) b. jugular vein atherosclerosis.
C) c. elevated right atrial pressure.
D) d. incompetent jugular vein valves.
C) c. elevated right atrial
pressure.
The nurse is caring for a patient who is receiving IV
furosemide (Lasix) and morphine for the treatment of acute
decompensated heart failure (ADHF) with severe orthopnea.
When evaluating the patient response to the medications, the
best indicator that the treatment has been effective is
A) a. weight loss of 2 pounds overnight.
B) b. hourly urine output greater than 60 mL.
C) c. reduction in patient complaints of chest pain.
D) d. decreased dyspnea with the head of bed at 30 degrees.
D) d. decreased dyspnea with
the head of bed at 30 degrees.
Which topic will the nurse plan to include in discharge
teaching for a patient with systolic heart failure and an
ejection fraction of 38%?
A) a. Need to participate in an aerobic exercise program
several times weekly
B) b. Use of salt substitutes to replace table salt when cooking
and at the table
C) c. Importance of making a yearly appointment with the
primary care provider
D) d. Benefits and side effects of angiotensin-converting
enzyme (ACE) inhibitors
D) d. Benefits and side effects
of angiotensin-converting
enzyme (ACE) inhibitors
Intravenous sodium nitroprusside (Nipride) is ordered for a
patient with acute pulmonary edema. During the first hours of
administration, the nurse will need to adjust the nitroprusside
rate if the patient develops
C) c. a systolic BP <90 mm
Hg.
A) a. a dry, hacking cough.
B) b. any ventricular ectopy.
C) c. a systolic BP <90 mm Hg.
D) d. a heart rate <50 beats/minute.
A patient who has chronic heart failure tells the nurse, "I felt
fine when I went to bed, but I woke up in the middle of the
night feeling like I was suffocating!" The nurse will document
this assessment information as
A) a. pulsus alternans.
B) b. two-pillow orthopnea.
C) c. acute bilateral pleural effusion.
D) d. paroxysmal nocturnal dyspnea.
D) d. paroxysmal nocturnal
dyspnea.
During a visit to a 72-year-old with chronic heart failure, the
home care nurse finds that the patient has ankle edema, a 2-
kg weight gain, and complains of "feeling too tired to do
anything." Based on these data, the best nursing diagnosis for
the patient is
A) a. activity intolerance related to fatigue.
B) b. disturbed body image related to leg swelling.
C) c. impaired skin integrity related to peripheral edema.
D) d. impaired gas exchange related to chronic heart failure.
A) a. activity intolerance
related to fatigue.
The nurse working in the heart failure clinic will know that
teaching for a 74-year-old patient with newly diagnosed heart
failure has been effective when the patient
A) a. uses an additional pillow to sleep when feeling short of
breath at night.
B) b. tells the home care nurse that furosemide (Lasix) is
taken daily at bedtime.
C) c. calls the clinic when the weight increases from 124 to
130 pounds in a week.
D) d. says that the nitroglycerin patch will be used for any
chest pain that develops.
C) c. calls the clinic when the
weight increases from 124 to
130 pounds in a week.
When teaching the patient with heart failure about a 2000-mg
sodium diet, the nurse explains that foods to be restricted
include
A) a. canned and frozen fruits.
B) b. fresh or frozen vegetables.
C) c. milk, yogurt, and other
milk products.
C) c. milk, yogurt, and other milk products.
D) d. eggs and other high-cholesterol foods.
The nurse plans discharge teaching for a patient with chronic
heart failure who has prescriptions for digoxin (Lanoxin) and
hydrochlorothiazide (HydroDIURIL). Appropriate instructions
for the patient include
A) a. avoid dietary sources of potassium.
B) b. take the hydrochlorothiazide before bedtime.
C) c. notify the health care provider about any nausea.
D) d. never take digoxin if the pulse is below 60 beats/minute
C) c. notify the health care
provider about any nausea.
While admitting an 80-year-old with heart failure to the
hospital, the nurse learns that the patient lives alone and
sometimes confuses the "water pill" with the "heart pill."
When planning for the patient's discharge the nurse will
facilitate
A) a. transfer to a dementia care service.
B) b. referral to a home health care agency.
C) c. placement in a long-term care facility.
D) d. arrangements for around-the-clock care.
B) b. referral to a home health
care agency.
Following an acute myocardial infarction, a previously healthy
67-year-old develops clinical manifestations of heart failure.
The nurse anticipates discharge teaching will include
information about
A) a. angiotensin-converting enzyme (ACE) inhibitors.
B) b. digitalis preparations.
C) c. b-adrenergic agonists.
D) d. calcium channel blockers.
A) a. angiotensin-converting
enzyme (ACE) inhibitors.
A 55-year-old with Stage D heart failure and type 2 diabetes
asks the nurse whether heart transplant is a possible therapy.
Which response by the nurse is appropriate?
A) a. "Since you are diabetic, you would not be a candidate
for a heart transplant."
B) b. "The choice of a patient for a heart transplant depends
on many different factors."
C) c. "Your heart failure has not reached the stage in which
heart transplants are considered."
D) d. "People who have heart transplants are at risk for
B) b. "The choice of a patient
for a heart transplant depends
on many different factors."
multiple complications after surgery."
. Which diagnostic test will be most useful to the nurse in
determining whether a patient admitted with acute shortness
of breath has heart failure?
A) a. Serum creatine kinase (CK)
B) b. Arterial blood gases (ABGs)
C) c. B-type natriuretic peptide (BNP)
D) d. 12-lead electrocardiogram (ECG)
C) c. B-type natriuretic
peptide (BNP)
Which action will the nurse include in the plan of care when
caring for a patient admitted with acute decompensated heart
failure (ADHF) who is receiving nesiritide (Natrecor)?
A) a. Monitor blood pressure frequently.
B) b. Encourage patient to ambulate in room.
C) c. Titrate nesiritide rate slowly before discontinuing.
D) d. Teach patient about safe home use of the medication.
A) a. Monitor blood pressure
frequently.
A patient with heart failure has a new order for captopril
(Capoten) 12.5 mg PO. After administering the first dose and
teaching the patient about captopril, which statement by the
patient indicates that teaching has been effective?
A) a. "I will call for help when I need to get up to use the
bathroom."
B) b. "I will be sure to take the medication after eating
something."
C) c. "I will need to include more high-potassium foods in my
diet."
D) d. "I will expect to feel more short of breath for the next
few days."
A) a. "I will call for help when I
need to get up to use the
bathroom."
1) Which of the following is not found in acute
decompensated heart failure?
A. ORTHOPNEA
B. TACHYCARDIA
C. DYSPNEA
D. UNPRODUCTIVE COUGH
D. UNPRODUCTIVE COUGH
2) Which patient should the nurse attend to first?
A. Diabetic patient experiencing an increased blood sugar at
8am in the morning.
B. Influenza patient experiencing a fever spike of 100.0 F
D. Heart failure patient
experiencing abnormal
(symptomatic) Bradycardia at
C. Pneumonia patient experiencing productive cough with
green sputum.
D. Heart failure patient experiencing abnormal (symptomatic)
Bradycardia at rest.
rest.
3) What statement by a pre-operative patient indicates the
need for further teaching by the nurse?
A. Someone will help take care of my home.
B. I can drive myself home after surgery.
C. My brother will bring his pet gerbil to keep me entertained.
D. I'll notify the health care provider if I develop a fever.
B. I can drive myself home
after surgery.
4) To improve gas exchange and oxygenation for a patient
with heart failure, what nursing management should be
implemented?
A. Check vital signs
B. Place patient in high Fowlers position.
C. Place patient in semi-Fowlers position.
D. Administer diuretic.
B. Place patient in high
Fowlers position.
5) Which of the following is not effective nursing
management of heart failure?
A. High Fowlers position
B. Assisting with rigorous exercise 2x a day
C. Daily weights, intake & output monitoring
D. Continuous EKG monitoring
B. Assisting with rigorous
exercise 2x a day
6) Which of the following is not a correct nursing and
collaborative management action for heart failure?
A. High Fowlers position
B. Improve gas exchange and oxygenation
C. Increase fluid intake
D. ECG monitoring
C. Increase fluid intake
7) Which test is most important for the nurse to carry out if
heart failure is suspected in a patient?
A.12-lead EKG
B. BNP
C. ABG
D. Exercise treadmill testing
B. BNP
8) A nurse is assessing the client with left sided heart failure. D. Paroxysmal nocturnal
The client states that he needs to use 3 pillows under the
head and chest at night to be able to breathe comfortably
while sleeping. The documents that the client is experience:
A. ORTHOPNEA
B. DYSPNEA at rest
C. DYSPNEA on exertion
D. Paroxysmal nocturnal dyspnea
dyspnea
9) How does a nurse assess for dysrhythmias?
A. 12 lead EKG
B. Listen to lung sounds
C. blood test
D. Urine sample
A. 12 lead EKG
10) A patient with potential heart failure enters the
emergency room. What symptom should the nurse not
consider for heart failure?
A. cyanosis, cold and clammy skin
B. lung sounds-- crackling and wheezing
C. orthopnea, shortness of breath
D. tightness & burning from the chest
D. tightness & burning from
the chest