Transcript Cardiovascular system cgfns questions

Cardiovascular System
CGFNS
Multiple Choice Questions
The term bradycardia means
A) A grossly irregular heartbeat
B) A heart rate of over 90 per minute
C) A heart of under 60 per minute
D) A heart beat that has regular skipped beats
The answer is C
Bradycardia refers to a heart rate of less than 60 per minute. It
may be a physiologic adaptation to long-term exercise, cardiac
disease, or digitalis toxicity. Grossly irregular heartbeat is
condition that is described
Thrombophlebitis is a common complication
following vascular surgery. The sign that indicates
a possible thrombus formation is :
A) Kernig’
B) Heagar’s sign
C) Homan’s sign
D) Brudzinski’s sign
The answer is C
Homan’s sign: on dorsiflexion of the foot, the client will
experience pain in the calf if a clot is present. Kernig’s sign
indicates presence of meningeal irritation. Hegar’s sign is
softening of the uterus. Erudzinski’s sign, in which flexion of
the head causes flexion of the knees and thighs, is also a sig of
meningeal irritation.
A child aged 2 has a congenital right to left shunt
defect of the heart. The nurse would expect to
observe:
A) Orthopnoea
B) An elevated haematocrit
C) Absence of pedal pulses
D) Oedema in the extermities.
The answer is B
Polycythemia is reflected in an elevated haematocrit level, which is a direct
attempt of the body to compensate for the decrease in oxygenation to all
body cells caused by the mixture of oxygenated and unoxygenated
circulating blood. Orthopnoea is not characteristic of right-to-left shunt
heart disease in children. Absence of pedal pulses is characteristic of
coarctation of the aorta ( a stenotic lesion heart disease). Oedema in the
extremities is not a common finding in right-to –left shunt heart disease
The normal range of CVP is :
A) 5 and 15 cm H2O
B) 10 and 15 cm H2O
C) 5 and 10 cm H2O
D) 10 and 20 cm H2O
The answer is C
The normal CVP reading is between 5 and 10 cm H2O. The rest
of the options are higher or lower than the normal range of CVP.
Oxygen via nasal cannula has been ordered for a
client with pulmonary disease. Ozygen via nasal
cannula is to be set at :
A) 2 L
B) 6 L
C) 8 L
D) 10 L
The answer is B
Six litres provide enough oxygen without adersely altering the
client’s blood gases, which would cause increased respiratory
distress. 2 L is insufficient. 8 L and 10 L are higher, which may
depress CO2 and raise O2 concentration, interfering with the
impetus to breathe.
In children with cardiac anomalies the most common
finding is :
A) Mental retardation
B) Delayed physical growth
C) Cyanosis and clubbing
D) A family history of cardiac anomalies
The answer is B
Oxygen is necessary for growth of cells. Decreased oxygen in
the developing child causes a slow growth rate. Mental
retardation is not a common finding in children with congenital
cardiac disease. Cyanosis and clubbing are not characteristic of
most children with cardiac anomalies, only of those with the
more serious hypoxia. Cardiac anomalies are more often a result
of prenatal rather than genetic factor.
A client with right heart failure is expected to complain of :
A) Dyspnoea, oedema and fatigue
B) Fatigue, vertigo and headache
C) Weakness, palpitations and nausea
D) A feeling of distress when breathing
The answer is A
Congestive heart failure is the failure of the heart to pump adequately to
meet the reel of the body, resulting in a backward builds of pressure in
the venous system. Adaptations by the body incluede oedema, ascites. If
hepatomegaly, tachycardia, dyspnoea and fatigue, fatigue, vertigo and
headache are generally not related to a specific disorder. Weakness,
palpitations and nausea might indicate coronary insuficiency or
infarction. A feeling of distress when breathing is a vague complaint and
is not specific to CHF it might indicate a variety of pulmonary
conditions.
The nurse would prioritize care and provide
treatment. The client who should get priority is the
one with :
A) Head injuries
B) A fractured femur
C) Ventricular fibrillation
D) A penetrating abdominal wound
The answer is C
Ventricular fibrillation will cause irreversible brain damage and
then death witin minutes because the heart is not pumping
blood. Defibrillation or CPR until defibrillatio if possible must
be irritated immediately. Although head injuries and penetrating
agdominal wounds requires prompt treatment. The reatment
can be withheld for several minutes. A fractured femur has no
priority over other conditions mentioned above.
The client returns to the clinic a week after discharge following a
leg fracture. The fracture was complicated by a clot in the right
leg for which the client was on Coumadin therapy. The client
now has a prothrombin time of 24 seconds. The followup care
plan for the client is based on the knowledge that these results
are :
A) Above normal and in the therapeutic range
B) Below normal and in the therapeutic range
C) Normal, within acceptable limits
The answer is A
D) Abnormal and test should be repeated
Normal prothrombin time is 12 to 14 seconds, but for clients on
coumadin therapy, the PT should be maintained between 18 and
28 seconds.
The cardiac defects associated with tetralogy of Fallot’s include :
A) Right ventricular hypertrophy, atrial and ventricular defects, and mitral
valve stenosis
B) Origin of the aorta from the right ventricular and of the pulmonary artery
from the left ventricle.
C) Right ventricular hypertrophy, ventricular septal defect stenosis of
pulmonary artery and overriding aorta
D) Abnormal connection between the pulmonary artery and the aorta, right
ventricular hypertrophy and atrial septal defects
The answer is C
Tetralogy of Fallot classically consists of four defects. Three of them are anatomic
ventricular septal defect, pulmonic stenosis, and overriding aorta. The fourth
defect, right ventricular hypertrophy, is secondary to increased resistance to blood
flow I that ventricle. Right ventricular hypertrophy is correct, the other anomalies
are not. Right ventricular hypertrophy, ventricular septal defect, stenosis of
pulmonary artery and overriding aorta are the characteristics of transposition of
the great vessels. Atrial septal defect is not found in Fallot tetralogy.
A client’s condition following cardiac catheterization
is evaluated by palpating the pulse:
A) In all extremities
B) At the insertion site
C) Distal to the catheter insertion
D) Above the catheter insertion
The answer is C
Palpating the pulse distal to the insertion site is important to
evaluate for thrombophlebitis and vessel occlusion. The pulse
should be bilateral and strong. The other options are
inappropriate.
Pacemaker is used in some clients to serve the functio that is
normally performed by the :
A) AV node
B) SA node
C) Bundle of His
D) Accelerator nerves to the heart
The answer is B
The SA node is the heart’s natural pacemaker. An electronic pacemaker is
used in some persons to supply an impulse that stimulates the heart more
efficiently. AV node is a modified cardiac muscle; which receives impulses
from the SA node and conducts them to the ventricular walls via the bundle
of His and Purkinje fibers. Bundle of His is special cardiac muscle, which
receives impulses from the AV node and conducts them to the ventricular
walls. Accelerator nerves to the heart are the sympathetic fibers to the
heart, which do notact as pacemakers to initiate and regulate the heart
beat.
When ventricular fibrillation occurs in a client in a coronary
care unit, the person reaching the client should first:
A) Administer oxygen
B) Defibrillate the client
C) Iniate cardiopulmonary resuscitation
D) Administer sodium bicarbonate intravenously
The answer is B
Ventricular fibrillation is a death producing dysrhythmia and once
identified must be terminated immediately by precordial shock
(defibrillation). This is usually a standing physician’s orsder in a cardiac
care unit. Oxygen is administered to correct hypoxia it does not take
priority over defibrillation. CPR is instituted only when defibrillation fails
to terminate the dysrhythmia. Bicarbonate is administered to treat acidosis;
it does not take priority over defibrillation.
Vasodilator has been administered to a client to lower the
hypertension. The effectiveness of the drug is assessed by
taking the client’s pulse and blood pressure :
A) Prior to administering the drug
B) Thrity minutes after giving the drug
C) Immediately after the client gets out of bed
D) After the client has been supine for 5 minutes
The answer is C
Many antihypertensive agents lower peripheral vascular resistance and
may cause orthostatic hypotension. Therefore, blood pressure should be
monitored in both a supine and an upright position, immediately after the
client gets out of bed. Assessment before to administration will not yield
information related to effectiveness. Thiry minutes after giving the drug
is too short a time for determination of the drug’s effect. Change in
position causes hypotension, when a position has been maintained for 5
minutes, the blood pressure has pbobably stabilized.
A client is admitted with atrial fibrillation and a rapid
ventricular response. The nurse prepares for cardioversion.
To avoid a potential danger of inducing ventricular
fibrillation during cardioversion, the nurse should ensure
that the :
A) Energy level is set its maximum level
B) Synchronizer switch is in the “on” position
The answer is B
C) Skin electrodes are applied after the T wave
D) Alarm system of the cardiac monitor is functioning simultaneously.
The precordial shock during cardioversion must not be delivered
on the T wave or ventricular fibrillation may ensue. By placing
he synchronizer in the “on” position, the physician presets the
machine so it will not deliver the shock on the T wave. The
energy level may be set from 50 to 400 watt-seconds. This skin
electrodes and alarm systems will not ensure that the shock is
not delivered on the T wave.
The parents of a young baby had discussions with the pediatric
cardiologist. The parents later ask the nurse to explain once again
what patent ductus arteriosus is. The nurse explains that it is :
A) A narrowing of the pulmonary artery
B) An enlarged aorta and pulmonary artery
C)
Connection between the pulmonary artery and aorta
D) An abnormal opening between the right and left ventricles
In the fetus oxygenated blood is shynted directly into the systemic
circulation via the ductus artederiosus, a connection between the
pulmonary artery and the aorta. Normally after birth the increased oxygen
tension causes a functional closure of the ductus arteriosus. Occasionally,
particularly in premature infants, this vessel remains open and is known as
patent ductus arteriosus. Narrowing of the pulmonary artery is known as
pulmonic stesosis. Enalarged aorta and pulmonary artery is not the
problem in patent ductus arteriosus abnormal opening between the right
and left ventricles patent ductus arteriosus does not involve ventricular
septal defets.
Following a bilateral lumbar sympathectomy a client
has a sudden drop in blood pressure but no
evidence of bleeding. This is most likely caused by:
A) An inadequate fluid intake
B) The after effects of anaesthesia
C) A reallocation of the blood supply
D) An increased level of epinephrine
The answer is C
The sympathectomy causes dilation of the blood vessels in the lower
extremities; the resulting shift in the fixed blood volume lowers
systemic blood pressure. Fluid losses associated with surgery may
gradually lower BP and are compensated by endocrine and renal
mechanisms. Although anaesthesia depresses vital signs, generally
there is not a sudden drop in BP postoperatively. Epinephrine would
increase BP by stimulating cardiac contractility.
A client is receiving digoxin (Lanoxin) and is ordered to continue
taking the drug after discharge. The nurse is primarily
concerned with:
A) Monitoring vital signs and encouraging gradual increase in activities of
daily living
B) Taking the apical pulse before drug administration and teaching the client
how to count the pulse rate
C) Observing the client for return of normal cardiac conduction patetterns and
for adverse effects of the drug
D) Assessing the client for changes in cardiac rhythm and planning activities at
home based on tolerance
Adverse effects of digoxin include many types of dysrrythmias. An apical
pulse rate less than 60 or above 120 contraindicates the administration of
the drug. Because the client will be taking the medication at home, teach
the client how to take an accurate pulse and to contact the physician if the
rate falls outside the parameters mentioned. Options A,Cand D . The client
will be assuming responsibility for drug administration at home; teaching
A male aged 30 years who was knifed in a street fight is now in
the ICU. An assessment of his condition reveals the following
symptoms: respirations shallow and rapid, paradoxical pulse,
CVP 15 cm H2O , BP 90 mm Hg systolic, skin cold andpale
urinary putput 60 to 100 ml/hr for the last 2 hours. Analyzing
these symptoms, the nurse will make a nursing diagnosis on
the conclusion that the client has which one of the following
conditions?
A) Hypovolemic shock
B) Cardiac tamponade
C) Wound dehiscence
D) Atelectasis
Option B is correct. Because all of the client’s symptoms are found in both
cardiac tamponade and hypovolemic shock except the incease in urinary
output. In shock, urinary outpt decreases to less than 30 ml/hr; thus, this is
the symptom that would distinguish hypovolemic shock from cardiac
tamponade and form the basis for a nursing diagnosis.
A client aged 60 years was put on quinidine ( a drug that decreases myocardial
excitability) to prevent atrial fibrillation. He also has kidney disease. The
nurse is aware that this drug, when given to a client with kidney disease may:
A)
Cause cardiac arrest
B)
Cause hypotension
C) Produce mild bradycardia
D) Be very toxic even in small doses
The answer is A
Kidney disease interferes with metabolism and excretion of quinidine.
Which results in higher drug concentrations in the body. Quinidine
can depress myocardial excitability enough to cause cardiac arrest.
Quinidine will not cause any of the problems indicated in options B,C
and D
The nurse observes a client’s cardiac monitor shows
asystole. This dysrrhmia requires nursing attention
because the heart is :
A) Not beating
B) Beating slowly
C) Beating irregularly
D) Beating very rapidly
The answer is A
Asystole refers to the absence of atrial and ventricular
contractions, which can cause death within minutes. Heart
beating slowly might be bradycardia(less than 60 beats per
minute)or heart block (a partial or complete interruption in
transmission of impulses from the sinoatrial node to the
ventricles.). Heart beating irregularly is because the heart has
The nurse is obtaining data from a client with thromboangitis
obliterans (Buerger’s disease). The nurse would expect the
client to demonstrate or report :
A) Easy fatigue of extremities, continuous
B) General blanching of skin, and intermittent claudication
C) Itermittent claudication, burning, pain after exposure to cold
D) Burning pain precipitated by cold exposure fatigue, blanching of skin
The answer is C
Burger’s disease (thromboangitis obliterans) is cahracterised by vascular
inflammation, usually in the lower extremities, leading to thrombus
formation. As a result of impaired circulation; there is burning pain and
intermittent claudication. Easy fatigue of extremities and continuous
claudication are not related to thromboangitis obliterans. Blanching is not
related to thromboangitis obliterans. Fatigue and blanching of the skin are
not related to thromboangitis obliterans.
In clients with the following problems, the nurse would
expect pulmonary oedema to be associated with ;
A) Mitral stenosis
B) Pulmonary valve stenosis
C) Severe arteriosclerosis of the coronary arteries
D) Calcification and incomplete closure of the tricuspid valve.
The answer is A
Mitral stenosis impaires blood flow from the left atrium to the left
ventricle. This backs up blood into the pulmonary veins and lungs. The
result may be pulmonary oedema. Pulmonic stenosis tends to cause a
bulging of the intraventricular septum. Severe arterial sclerosis of the
coronary arteries narrows the arterial lumen, which can result in a
decreased blood supply to the myocardium causing hypoxia and angina.
Tricuspid disease may cause jugular vein distention and hepatic
congestion.
A client in the outpatient clinic tells the nurse that he has leg pains
that begin when he walks but relieved when he stops walking.
The nurse would assess the client for which of the following
conditions?
A) An acute obstruction in the vessels of the legs
B) Peripheral vascular problems in both legs
C) Diabetes
D) Calcium deficiency
The answer is B
Intermittent claudication is a condition that indicates vascular
deficienties in the peripheral vascular system. If an obstruction
were present, the leg pain would persist even when the client
stops walking. Diabetes can cause pain as a result of diabetic
neuropathy, which is unrelated to walking. Low calcium level
may cause leg cramps but would not necessarily be related to
walking.
One of the most common complications of myocardial
infarction is :
A) Hypokalaemia
B) Anphylactic shock
C) Cardiac dysrrhythmia
D) Cardiac enlargement
The answer is C
Myocardial infarctio (MI) may cause increased irritability of tissue or
interruption of normal transmission of impulses. Dysrrhythmias occur in
about 90 % of clients after MI. hypokalaemia may result when client is
taking cardiac glycosides and diuretics; this is a complication associated
with herap and is not a pathologic entity related to the MI itself.
Anaphylactic shock is caused by an allergic reaction, not by an MI. cardiac
enlargement is a slow process and is not a complication that can be
observed.
The most informative measurement for determining
cardiogenic shock is :
A) Arterial blood pressure
B) Central venous pressure (CVP)
C) Pulmonary artery pressure
D) Cardiac index
The answer is A
The cardiac output is that amount of blood pumped by the left
ventricle eqch minute. It is a good indicator of left ventrcular
function. As the left ventricle fails, the pressure in the chamber
rises. Then the arterial blood pressure falls. The CVP would
increase later when peripheral flow is impeded into the ritht
atrium due to pulmonary congestion.
A client wants to know what the coronary arteries have to do with
anginal pain. When answering the client the nurse should take
into consideration that the coronary arteries:
A) Supply blood to ht eendocardium
B) Carry blood from the aorta to the myocardium
C) Carry reduced oxygen content blood to the lungs
D) Carry high oxygen content blood from the lungs toward the heart.
The answer is B
The two coronary arteries are the first branches of the aorta and
carry blood with a high oxygen content to the myocardium.
They carry blood with high oxygen content to the myocardium,
not to the endocardium. They carry blood with high oxygen
content to the myocardium. Carrying high oxygen content blood
from the lungs toward the heart is a funciton of the pulmonary
veins.
A client with severe hypertension has been prescribed to take 2 g
sodium diet. The client does not like the diet and the nurse hears the
client tell a friend to bring in some “ good home-cooked food.” the
most effective nursing plan would be to :
A) Call in the dietitian for client teaching
The answer is B
B) Wait for the client’s family and discuss the diet with the client and family
C) Tell the client that the use of salt is forbidden, because it will raise the
blood pressure
D) Catch the family members before they go into the client’s room and tell
them about the diet.
Clients and their families should be included in dietary teaching; families
provide support that promotes compliance. The dietitian is a resource person
who can give specific, practical information about diet and food preparation
once the client had basic understanding of the reasons for the diet. Foods
high in sodium will also have to be restricted; this teaching is inadequate.
The client should be included in own care the client will ultimately assume
the responsibility.
While caring for a client who has undergone cardiac
catheterization, it is most important that the nurse:
A) Provide for rest
B) Administer oxygen
C) Check the ECG every 30 minutes
D) Check the pulse distal to the insertion site
The answer is D
The pulse should be assessed because the trauma at the
insertion site may interfere with blood flow distal to the site.
There is also danger of bleeding or occlusion. The client does
not usually require additional rest after catheterization.
Administration of oxygen would be determined on an individual
basis; it is not routine. It is not necessary to check the ECG
every 30 minutes following the procedures.
A client is receiving anticoagulants. The nursing care
should include observations for:
A) Nausea
B) Epistaxis
C) Headache
D) Chest pain
The answer is B
The high vascularity of the nose, combined with its
susceptibility to trauma i.e. Sneezing, nose blowing, makes it a
frequent site of haemorrhage. Symptoms of nausea, headache
and chest pain are usually not associated with anticoagulant
therapy.
Cholesterol, is a substance that
A) May be controlled entirely by eliminating food sources
B) Is found in many foods. Both plant and animal sources.
C) All persons would be beter off without because it causes the
disease process
D) Circulates in the blood, the level of which responds usually
to dietary sbstitutions of unsaturated fats for saturated fats.
The answer is D
Cholesterol is a sterol found in blood and tissue; it is atributed in
part to diets high in saturated fats cholesterol is also produced
by the body. Only animal foods furnish dietary cholesterol.
Cholesterol is needed for the synthesis of bile salts,
adrenocortical and steroid sex hormones, and provitamin D.
When a client is collapsed and has no carotid pulse or
respirations, the nurse should:
A) Initiate a code
B) Check for a radial pulse
C) Give four full lung inflation
D) Compress the lower sternum 15 times
The answer is A
Help must be obtained immediately by initiating the code. The
nurse has already checked the carotid pulse; this action would
waste valuable time. Before pulmonary resuscitation, tilt the
head back, pinch the nose, and give two, rather than four, full
lung inflations. Compression of the lower sternum 15 times
would not be done until the airway is open, two breaths are given
and reasessment indicted that there was no carodid pulse.
In clients with congestive heart failure the associate
dyspnoea is primarily due to :
A) Blockage of a pulmonary artery by an embolus
B) Accumulation of fluid in the intestinal spaces and alveoli of
the lungs
C) Blockage of bronchi by mucous secretions
D) Compression of lungs by the dilated heart
The answer is B
Failure of the left ventricle to pump effectively causes damming
of blood of blood back into the pulmonary circuit, which
increases pressure, and cause extravasation of fluid into
intestitial spaces and alveoli.
A client has been admitted to the hospital with a
diagnosis of suspected bacterial endocarditis. The
nurse should constantly monitor for which of the
following complication ?
A) Presence of a heart murmur
B) Systemic emboli
The answer is B
C) Fever
D) Congestive heart failure
Emboli are the mafor problem; those arising in right heart
chambers will terminate in the lungs and left chamber emboli
may travel anywhere in the arteries. Heart murmurs fever and
night sweats may be present but do not indicate a complication
of emboli. Congestive heart failure may be a result but this is
not as dangerous an outcome as emboli. Emboli may occur in
the spleen kidneys brain lungs and in the extremities.
A client states his anginal pain increases on activity.
The angina pectoris is a sign of :
A) Mmural insufficiency
B) Myocardial ischaemia
C) Myocardial infarction
D) Coronary thrombosis
The answer is B
Angina pectoris is pain in the chest that is caused by hypoxia of
the cardiac muscle. Mitral insufficiency rfers to an incompetent
mitral valve; it could be only indirectly related to angina. There
is no cell death in angina. A coronary thrombosis is an
aggregation of platelets, clotting factors, and blood cellular
elements that reduces the lumen of the artery; it may progress
toa complete obstruction, resulting in a myocardial infarction.
Clients with peripheral vascular disease should stop smoking,
because nicotine :
A) Constricts the superficial vessels dilating the deep vessels
B) Constricts the peripheral vessels and increases the force of flow
C) Dilates the superficial vessels but constricts the collateral circulation
D) Dilates the peripheral vessels, causing a reflex constriction of visceral
vessels
The answer is B
Constriction of the peripheral blood vessels and the resulting
increadse in blood pressure impair circulation and limit the amount of
oxygen being delivered to body cells, particularly in the extremities.
Nicotine constricts all peripheral vessels, not just superficial ones; its
primary action is vasoconstriction; it will not dilate deep vessels.
Constriction of peripheral blood vessels and the resulting increase in
blood pressure impair circulation and limit the anount of oxygen
being delivered to body cells, particularly in the extremities.
Following a treadmill test and cardiac catheterization the client is diagnosed
to have inoperable coronary disease and is referred to the cardiac
rehabilitation unit. During his first visit to the unit he says that he doesn’t
understand why he needs to be there because there is nothing that can be
done to make him better. The best nursing response would be:
A) Cardiac rehabilitation is not a cure but can help restore you to many of your
former activities
B) Here we teach you to gradually change your lifestyle to accommodate your heart
disease
C) You are probably right but we can gradually increase your activities so that you
can live a more active life
D) Do you feel that you will have to make some changes in your life now?
A response such as “ cardiac rehabilitation is not a cure but can
help restore you to many of yur former activities” does not give
false hope to the client but is positive and realistic. This answer
tells the client what cardiac rehabilitation is and does not dwell
upon his negativity about it. The rest of the options are
inapproriate.
Prolonged bedrest after surgery promoteshaemostasis,
particularly in the deep veins of the calves. The most likely
pathologic result of such haemostasis may be thrombus
formation and :
A) Cerebral embolism
B) Coronary occlusion
C) Pulmonary embolism
D) Dry gangrene of a limb
The answer is C
The pulmonary capillary beds are the first small vessels
(capillary beds) that the embolus encounters once it is released
from the calf veins. Option A and B would not occur because
the embolus would enter the pulmonary system first. Dry
gangrene occurs when the arterial rather than the venous
circulation is compromised
When assessing the lower extremities of a client with right
ventricular heart failure, the presence of pitting oedema is
because of :
A) Increase in tissue colloid osmotic pressure
The answer is D
B) Decrease in the plasma colloid osmotic pressure
C) Increase to the tissue hydrostatic pressure at the arterial end of the capillary
bed
D) Elevation in plasma hydrostatic pressure at the venous end of the capillary
bed
In right ventricular failure, blood back up in the systemic capillary beds; the
increase in plasma hydrostatic pressure shufts fluid from the intravascular
compartment to the interstitial spaces, causing oedema. Increase in tissue colloid
osmotic pressure would occur eith crushing injuries or if proteins are
pathologically shifting from the intravascular compartment to the interstitial
spaces. Although a decrease in colloid osmotic (oncotic) pressure can cause
oedema, it result from lack of protein intake, not increased hydrostatic pressure
associated with rithg ventricular heart failure. Increased fluid pressures within the
tissue would result in fluid shifts into the intravascular compartment
A client with hypertension who recently started taking a daily dose of
methyldopa (aldomet) complains of drowsiness and lethargy. The
best nursing intervention would be to :
A) Notify the physician of the negative side effects so the dose can be
reduced
B) Ask the physician to prescribe anotheer anti hypertensive
C) Suggest that the client take the medication in the evening and reevaluate
on the next visit
D) Explain that these are expected side efects andhe will have to live with
them
The answer is C
These side effects may be present with this medication, which
can be alleviated by taking the drug in the evening. Often,
taking one dose in the evening will minimize the sedation. The
nurse needs to follow up with this client and report to the
physician.
One of the primary causes that affect the development
of hypertension is thought to be :
A) Kidney failure
B) Unresolved grief
C) Unexpressed rage
D) Generalized arteriosclerosis
The answer is C
Unexpressed rage or anger affects the sympatheticsystem, precipitating
the release of epinephrine and norepinephrine which constricts the
blood vessels and thus raising arterial blood pressure. Although the
renin-angiotensin mechanism may contribute to hypertension, the
kidney failure is not the primary cause of essential hypertension.
Unexpressed rage and generalized arteriosclerosis may contribute but
are not the primary cause.
The nurse suspects that a client is in cardiogenic shock. This type
of shock is :
A) An irreversible phenomenon
The answer is B
B) A failure of peripheral circulation
C) Usually a fleeting reaction to tissue injury
D) Generally caused by decreased blood volume
Shock may have different etiologies (e.g. hypovolemic,
cardiogenic, spetic, anaphylactic ) but always involves a drop in
blood pressure and failure of the pewripheral circulation
because of sympathetic nervous system involvement. Shock can
be reversed by the administration of fluids. Plasma expanders,
and vasoconstrictors. Fleeting reaction to tissue injury may be a
reaction to tissue injury but has many different etiologies (e.g.
Hypovolemia sepsis, anaphylaxis). Hypovolemia is only one
cause: shock may also be septic, cardiogenic, or anaphylactic; it
always involves a drop in blood pressure.
During a cardiac arrest, the nurse and the arrest team
must keep in mind the :
A) Age of the patient
B) Time the client is anoxic
C) Emergency medications available
D) Heart rate of the client before the arrest
The answer is B
Irreversible brain damage will occur if a client is anoxic for
more thatn 4 minutes. The age of the client does not affect the
code. Although a variety of emergency medicationsa mut be
available, their administrationis ordered by the physician. Earlier
heap rate is of minimal importance. Rhytm is more significant.
A nurse is taking the vital signs of a young child, who
has coarctation of the aorta. The nurse can expect
to observe:
A) Notching of the clavicle
B) Bounding femoral pulses
C) Weak, thready radial pulses
D) Higher BP in upper extremities
The answer is D
Coarctation of the aorta is a narrowing usually in the thoracic
segment, causing decreased blood flow below the constriction
and increased blood volume above it. Notching of the clavicle
has nothing to do with coarctation of the aorta. In coarctation
of the aorta, femoral pulses would be weak or absent, and blood
pressure in the lower extremities would be decreased. In
coarctation of the aorta, radial pulses would be full and
The arteriosclerosis of blood vessels leading to the brain may
not b ecome evident until there is an extremely severe
blockage or until a stroke occurs. Because the collateral
blood circulation is supplied through the :
A) Circle of Willis
B) Jugular vessels
The answer is A
C) The bicarotid trunk
D) Hypothalamic hypophyseal portal system
The vessels branching from the circle of Willis provide excellent
collateral circulation for the brain partial blockage of one vesssel
is compensated by flow through other vessels. Jugular vessels
take blood away from the brain. The bicarotid trunk and
hypothalamic hypopharyseal system are not collateral circulation
The P-R interval in an ECG represents the time it takes
for the :
A) Impulse to begin atrial contraction
B) Impulse to traverse the atria to the AV node.
C) SA node to discharge the impulse to begin atrial
depolarization
D) Impulse to travel to the ventrcles
The answer is
The PR interval is measured on the ECG strip from the
beginning of the P wave to the beginning of the QRS complex.
It is the time it takes for the impulse to travel to the ventricle.
The
A permanent demand pacemaker has been inserted in a
client. When teaching this client the nurse should:
A) Instruct the client to sleep on two pillows
B) Encourage the client to reduce the former levels of activity
C) Instruct the client to take the pulse daily and keep accurate records
D) Inform the client that the pacemaker will function continuously at a
set rate.
The answer is C
A demand pacdmaker functions only when the heart rate falls
below the set rate of the pacemaker. The client can detect
pacemaker malfunctions by monitoring the pulse rate and
noting a drop below the set rate. The client need not alter
previous sleeping habits. Normal activity may be resumed when
healins has occurred. Demand pacemakers function only when
the heart rate drops below a predetermined level.
A client is admitted to the hospital and has
ledematous ankles. The best way to limit the ankle
oedema is by :
A) Restricting fluids
B) Elevating the legs
C) Applying elastic bandages
D) Initiating range of motion exercises
The answer is B
Elevation of an extremity promotes venous and lymphatic
drainage by gravity. Restricting fluids is a dependent function of
the nurse. Applying elastic bandages and intitiating range-ofmotion exercises procedure will have little effect on oedema.
Postural changes immediately following spinal anaesthesia may
result in hypotensionbecause there is :
A) Dilatation of blood vessels
B) Decreased response of baroreceptors
The answer is A
C) Decreased strength of cardiac contraction
D) Interruption of cardiac accelerator pathways
Paralysis of the sympathetic vasomotor nerves after administration of
spinal anaesthesis results in dilatation of blood vessels which causes a
subsequent drop in blood pressure. Baroreceptors are sensitive to
oxygen and carbon dioxide tension; they are not related to postural
hypotension and are noe affected by spinal anaesthesis. The strength
of cardiac contractrions is not afffected by spinal anaesthesia and
postural hypotension. The cardiac accelerator center neurons in the
medulla regulate heart rate; they are not related to postural
hypotension and are not affected by spinal anaesthesia
The pain associated with a coronary occlusion is caused
primarily by :
A) Arterial spasm
B) Ischaemia of the heart muscle
C) Blocking of the coronary veins
D) Irritation of nerve endings is the cardiac plexus
The answer is B
Ischaemia causes tissue injury and the release of chemicals,
such as bradykinin that stimulate sensory nerves and produce
pain. Arterial spasm resulting in tissue hypoxia and pain, is
associated with angina pectoris. Arteries, not veins, are involved
in the etiology of a myocardial infarction. Tissue injury and pain
occur in the myocardium.
Following repair of congenital heart defect in weak
infants, gavage feeding is often indicated. Because :
A) Vomiting is prevented
B) The feeding can be given quickly, so handling is minimized
C) The amount of food given can be more accurately regulated
D) It conserves the infant’s strength and does not depend on the
swallowing reflex
The answer is D
Gavage feeding is preferred for weak infants, those with respiratory
distress or poor sucking-swallowing coordination, and those who are easily
fatigued because of physical stress such as surgery vomiting may be
lessened with gavage feeding because the amount and rapidity of feeding
can be controlled. Dfedding th e infant quickly is n ot desirable. Vomiting
with aspiration may occur. The amount of food given can be regulated with
bottle feeding as well.
A client enters the emergency department complaining of chest
pressure and severe epigastric distress. His vital signs are as
follows: BP 158/90, P 94, R 24, and T 99 ° F. the doctor orders
cardiac enzyme study. If this client were diagnosed with a
myocardial infarction, the nurse would expect which cardiac
enzyme to rise within the next 3 to 8 hours :
A) Creatine kinase (CK)
B) Lactic dehydrogenase (LDH)
The answer is A
C) LDH - 1
D) LDH - 2
Creatine kinase (CK formerly called CPK) rises in 3 to 8 hours if
an MI is present. When the myocardium is damaged. CK leaks
out of the cell membranes and into the bloodstream. Lactic
dehydrogenase rises in 24 to 48 hours, and LDH – 1 and LDI -2
rise in 8 to 24 hours
A client is instructed to use elastic stockings. The nurse
should teach the client that the stockings should be :
A) Alternately kept on 2 hours and off 2 hours
B) Worn only at night when activity is lessened
C) Put on before getting out of bed in the morning
D) Left in place until the physician advises otherwise
The answer is C
Support hose apply external pressure on the veins, preventing the
retrograde pressure or flow that may occur in the standing positions;
application before srising prevents the veins from having the opportunity to
become engorged. If the feet are permitted to be dependent before the
stockings are put on, venous pooling and oedema may occur; application
of elastic stockings at this time can cause tissue trauma. Because they
promote venous return, they do not need to be worn when the legs are
elevated when sleeping. Stockings must be reomved so the legs can be
washed ad dried at least daily. They usually need not be worn while in bed
with the feet elevated because gravity prevents venous pooling.
The nurse is preparing a client for insertion of pulmonary artery
catheter (e.g. Swan-Ganz catheter). The nurse teaches the client that
the catheter will be inserted to provide information about:
A) Stroke volume
B) Cardiac output
The answer is D
C) Venous pressure
D) Left ventricular heart failure
The catheter is placed in the pulmonary artery. Information regarding left
ventricular function is obtained when the catheter balloon is inflated .
Information on stroke volume, the amount of blood ejected by the left
ventricle with each contraction, will not be provided by a pulmonary
catheter. Cardiac output is not usually measured via the pulmonary artery
catheter used for continuous monitoring of the client. Although CVP can
be obtained with the pulmonary catheter it is not as specific as a
pulmonary wedge pressure, which reflects pressure in the left side of the
heart.
During a cardiac catheterization blood samples from the right atrium,
right ventricle, and pulmonary artery are analysed for their oxygen
content. Normally all the samples contain:
A) Less CO2 than does pulmonary vein blood
B) More oxygen than does, pulmonary vein blood
C) About the same amount of oxygen
D) Less oxygen than the pulmonary artery samples
The answer is C
Blood samples from the right atrium, right ventricle, and pulmonary artery
would contain about the same amount of oxygen. These blood samples
contains slightly less oxygen than does systemic arterial blood. Option A :
These contain slightly more carbon dioxide than does blood in pulmonary
vein, which has had some of its CO2 expelled into the alveoli. Option B :
These contain less oxygen than does the pulmonary vein, which will carry
oxygenated blood to the circulation. Option D : It contains the same
amount as do samples from the right atrium and right ventricle.
A client with myocardial infarction is in the coronary unit on a cardiac
monitor. The nurse observes ventricular irritability on the screen.
The nurse should prepare to administer:
A) Digoxin (Lanoxin)
B) Frusemide (Lasix)
C) Lidocaine (Xylocaine )
D) Levarterenol bitartrate (Levophed)
The answer is C
Lidocaine hydrochloride decreases the irritability of the ventricles and is
used in the treatment of ectopic beats originated by a ventricular focus.
Digoxin slows and strengthens ventricular contractions; it will not rapidly
correct ectopic beats. Furosemide , a diuretic does not affet ectopic foci.
Levarterenol bitartrate (Levophed ) is a sympathomimetic and is not the
drug of choice for ventricular irritability.
A client with cardiac problem is on high unsaturated fatty
acid diet. While teaching this client the nurse should
stress the importance of increasing the intake of :
A) Enriched whole milk
B) Red meats, such as beef
C) Vegetables and whole grains
D) Liver and other glandular organ meats
The answer is C
Vegetables and whole grains are low n fat and may reduce
therisk of heart disease. Option A,B and D are animal derived
products, which are high in saturated fats.
A client who is convalescing from abdominal surgery
develops thrombophlebitis. The sign that would
indicate this complication is :
A) Intermittent claudication
B) Pitting oedema of the lower extremities
C) Severe pain on extension of an extremity
D) Localized warmth and tenderness of the leg
The answer is D
Thrombophlebitis is inflammation of a vein that occurs with the
formation of a clot. Signs include pain (especially on
dorsiflexion of the foot), redness, warmth, tenderness and
oedema. Intermittent claudication (pain when walking resulting
from tissue ischaemia) may occur with peripheral vascular
disease. Pitting oedema does not occur in thrombophlebitis.
Pain occurs on flexion of the foot (Homar’s sign).
The nurse working in an ER is concerned when a client continues
to bleed from severe lacerations even after applying direct
pressure. The next action is to :
A) Apply ice to lower the body temperature
B) Monitor closely for signs of shock
C) Elevate the upper extremities and apply blnkets to raise body temperature
D) Maintain a patent airway and prevent vomiting
The answer is B
Blood loss results in shock; therefore, close montoring of vital
signs and shock symptoms is essential. Applying ice would not
be appropriate. With haemorrhage the temperature will be below
normal and need to be monitored. Maintaining a patent airway
and preventing vomiting vomiting will not stop bleeding.
A client enters the emergency department complaining of severe
chest pain. Myocardial infarctio is suspected. The 12 lead
ECG appears normal, but the doctor admits the client for
further testing until cardiac enzyme studies are returned. All
of the following will be included in the nursing care plan.
But which activity has highest priority?
A) Monitoring vital signs
B) Completing a physical assessment
C) Maintaining cardiac monitoring
The answer is C
D) Maintaining at least one IV access site
Even though initial tests seem to be within normal range, it
takes at least 3 hours for the cardiac anzyme studies to register.
In the meantime, the client needs to be watched for bradycardia,
tachycardia, heart block, ventricular irritability, and other
arrhythmia. The other activities can be accomplished around the
MI monitoring.
Thrombolytic therapy would be appropriate in which
of the following conditions?
A) Continual blood pressure above 200/720
B) History of diabetic retinopathy
C) History of significant kidney disease
D) Myocardial infarction
The answer is D
For clients with an MI thrombolytic therapy minimizes the
infarct size through lyses of the clot in the occluded coronary
artery. The patient artery. The patent artery then promotes
perfusion of the heart muscle. The other three responses are all
contraindications for the use of thrombolytic agents.
A client’s physician orders an appointment for a
thallium scan. The purpose of injecting a
radioisotope into the blood stream is to detect :
A) Normal versus abnormal tissue
B) Damage in areas of the heart
C) Ventricular function
D) Myocardial scarring and perfusion
The answer is D
Thallium scan detects myocardial damage and perfusion. It is a
more specific answer than option A or B. specific ventricular
function is tested by a gated cardiac blood pool scan
The degree of oedema in an extremity can be best
assessed by :
A) Weighing the client
B) Checking for pitting
C) Measuring the affected area
D) Observing intake and output
The answer is C
Measuring an area is an objective assessment and is not subject
to individual interpretation. Although monitoring the weight of
the client or intake and output helps in assessing fluid balance it
does not determine the degree of oedema in a specific
extremity. Checking for pitting is subjected to individual
interpretation.
A client’s demand pacemaker is effective if the pulse
retrains at least:
A) In a regular rhythm
B) Above the demand rate
C) Equal to thepacemaket
D) Palpable at distant sites
The answer is C
Functioning pacemakers initiate impulse when the client’s pulse
rate falls below the preset rate. Hence, a pulse rate of at least
equal to that of the preset rate indicates effective functioning.
The laboratory tests that would confirm a diagnosis of
myocardial infarction include:
A) LDH, CK-MB and AST
B) Serum calcium, and APPT
The answer is A
C) Sedimentation rate, and ALT
D) Paul-Bunnell and serum potassium
LDH, CK - MB and AST are enzymes released into the blood from cardiac
muscle cells when the myocardium is damaged. Calcium level will not
diagnose MI: there is no test called APPT; A PTT assesses blood clotting
time. The sedimentation rate identifies the presence of inflammation or
infection but is not specific; ALT identifies tissue destruction but it is more
specific for liver injury. The Paul – Bunnell test identifies heterophilic
antibodies in infectious mononucleosis; it would not be specific for
myocardial infarction.
A client with …
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A statement that explains the physiological basis of tachycardia is :
a. The demand for oxygen is decreased because of pleural involvement
b. The inflammatory process causes the body to demand more oxygen to meet
its needs.
c. The heart has to pump faster to meet the demand for oxygen for when there
is lowered arterial oxygen tension
d. Respirations are laboured.
The answer is C
The arterial oxygen supply is lowered and the demand for oxygen is
increased which results in the heart’s having to beat faster to meet body
needs for oxygen.
A client has oedema during the day which disappears at night. The client
states it is not painful andis located in the lower extremities. This is
indicative of :
a. Lung disease
b. Pulmonary oedema
c. Myocardial infarction
d. Right ventricular heart failure
The answer is D
Right ventricular heart failure causes increased pressure in the systemic
venous system, which leads to a fluid shift into the interstitial spaces.
Because of gravity, the lower extremities are first affected in an
ambulatory client. Pulmonary disease would not result in variying
degrees of oedema. Pulmonary oedema results in severe respiratory
distress and peripheral oedema. Myocardial infarction itself does not
cause peripheral oedema.
The nursing is assisting the physician in treating a client in shock. One
modality of treatment that employs the physical law explaining the
increased venous return accompanying mild vasoconstriction underlies
the use of
a. Adrenaline in treating shock
b. Digoxin to increase cardiac output
c. Sympathectomy in treating hypertension
d. Rotating tourniquets in pulmonary oedema
The answer is A
Adrenaline is used to treat shock because the induced arterial
constriction reduces blood pooling (vessels cannot hold as
much blood) and increases venous return and cardiac output.
Digoxin slow and strengthens the heartbeat; it does not
cause vasoconstriction. A sympathectomy interferes with
autonomic vasoconstriction; it reduces venous return.
Tourniquets constrict veins of the exstremities and reduce
venous return.
In which of the following condition that a pulmonary embolism is a most
unlikely complication during the postoperative period?
a. Hysterectomy
b. Prostatectomy
c. Appendicectomy
d. Saphenous vein ligation
The answer is C
An appendicectomy is a relatively simple and the client is generally out of
bed the same day. With an ambulatory client there is less risk of venous
stasis, a condition that predisposes the individual to thrombus formation
and emboli. Although the client after hysterectomy is generally
ambulated the first day postoperatively, the client is often hampdred by
pain; any pelvic surgery increases the risk. The client after prostatectomy
may or may not be out of bed the same day depending on the surgical
approach;mobility may be hampered because of Foley catheter.
Saphenous vein ligation is performed for varicose veins; the diseased vein
is removed, placing an additional burden on the deep venous system and
possibly increasing the risk of thrombus formatin.
A permanent pacemaker is implanted in a client with adams-Stokes
syndrome. The lethal dysrrhythmia requiring immediate intervention to
such clients is known as :
a. Atrial fibrillation
b. Sinus tachycardia
c. Ventricular fibrillation
d. Second – degree heart block
The answer is C
Ventricular fibrillation is a death producing arrhythmia because theheart is
not functioning as a pump . Immediate action is required or d eath will
occur as a result of anoxia to the grain and other vital organs. These
arterial fibrillation and sinus tachycardia are not lethal dysrryythmias.
Second degree heart block may require intervention and insertion of a
pacemaker but is not lethal.
A client is receiving dicoumarol ( a coumarin derivative). The
most specific test for calculating the daily dosage of this
anticoagulant would be the :
a. Clotting time
b. Bleeding time
c. Prothrombin time
d. Sedimentation rate
The answer is C
Coumarin derivatives are ordered day by day are ordered by day
based on the prothrombin time of the client This test gives
an index of the individual’s clotting ability. Clotting time is
the time required for blood to form a clot; it is not used for
dosage calculation. Bleeding time is the time required for
blood to cease flowing from a small wound; it is not used for
coumarin dosage calculation. Sedimentation rate is a test
used to determine the presence of inflammation or infection;
it does not indicate clotting ability.
Orthostatic hypotension can be modified by :
a. Wearing support hose continuously
b. Lying down for 30 minutes after taking medication
c. Avoiding tasks that require high energy expenditures
d. Sitting on the edge of the bed a short time before arising
The answer is D
Sitting on the edge of the bed before getting up is recommended because it
gives the body a chance to adjust to the effects of gravity on circulation
in the upright position. Support hose would not be worn continously and
would not prevent hypotension. Lying down for 30 minutes after taking
medication would not prevent episodes of orthostatic hypotension.
Energetic tasks do not modify hypotension
During the acute phase following a myocardial infarction, the nurse should
prepare the client’s bed by :
a. Changing the top linen and only the necessary bottom linen
b. Changing all the linen from top to bottom without lowering the head of
the bed
c. Lifting rather thatn rolling theclient from side to side while changing the
linen
d. Sliding the client onto a stretcher, remaking the bed, then sliding the
client back to the bed.
The answer is A
Until the client’s condition has reached some degree of stability after
myocardial infarction routine activities such as changing sheets are
avoided so that the client’s mov ements will be minimized and the
cardiac workload reduced. Changing all the linen causes unnecessary
movement, which increases oxygen demands and makes the heart work
harder. Lifing the client from side to side while changing the linen is
contraindicated because
beca
it increases oxygen consumption and cardiac
workload. Any
A client has atrial fibrillation. While auscultating the apical pulse of this
client the nurse would expect to hear a rhythm that is characterized by:
a. The presence of occasional coupled beats
b. Long pauses in an otherwise regular rhythm
c. A continuous and totally unpredictable irregularity
d. Slow but strong and regular beats
The answer is C
In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The
AV node is unable to transmit all of these impulses to the ventricles,
resulting in a pattern of highly irregular and unpredictable ventricular
contractions.
When cardiovascular disease is a concern, reduction of the saturated fat in
the diet and substitites made of polyunsaturted fat is desired. When
teaching the client about this diet the nurse should instruct the client to
avoid :
a. Fish
b. Corn oil
c. Whole milk
d. Soft margarine
The answer is C
Whole milk is highin saturated fat, which should be avoided. Most fish have
a low fat content. Corn oil is high in unsaturated fat. Soft maragaine is
high in unsaturated fat.
A client who has undergone surgery for a coronary artery bypass graft is
prepared for discharge. The nurse should tell the client that there will be:
a. No further drainage from the incisions after hiospitalization
b. Mild fever and extreme fatigue for several weeks following surgery
c. Little incisional pain and tenderness after 3 to 4 weeks following surgery
d. Some increase in oedema in the leg used for donor graft, with increased
activity
The answer is D
The client is up more at home so oedema usually increases. Serosanguinous
drainage will persist after discharge. Mild fever and extreme fatigue for
several weeks following surgery are in fact signs of postpericardotomy
syndrome. Little incisional pain and tenderness will persist longer, as it
takes 6 to 12 weeks for the sternum to heal
The children with cardiac problems who are awaiting corrective surgery are
placed on long term antibiotic prophylaxis. This is done to prevent :
a. Myocarditis
b. Pericarditis
c. Upper respiratory injections
d. Subacute bacterial endocarditis.
The answer is D
Prophylaxis before the procedure can prevent this disease, which often
occurs in clients with abnormal heart structures. Myocarditis is not
generally associated with congenital heart defects in children.
Avoidance of crowds is recommended to prevent upper respirators
infections, not antibiotics. Prophylaxis before the procedure can prevent
subacute bacterial endocarditis, which often occurs in clients with
abnormal heart structures.
The portion of cardiac monitor that is related to the alarm system for
detecting extremes in the heart rate is called the :
a. Voltmeter
b. Pacemaker
c. Oscilloscope
d. Synchronizer
The answer is A
The height of the ventricular complexes must be sufficient to be icked up
by the voltmeter, which will sound an alarm when the heart rate is
outside the high and low parameters. The pacemaker (pulse generator)
may be either an internal or an external device but is generally not part
of the monitor. The oscilloscope is the screen on which the electrical
signals from the heart are displayed The synchronizer is used only
during cardioversion to ensure that the electric shock is delivered during
the QRS complex.
The physiological adaptations in a client with Adam Stokes syndrome
would most likely include:
a. Nausea and vertigo
b. Flushing and slurred speech
c. Cephalgia and blurred vision
d. Syncope and low ventricular rate
The answer is D
Adam Stokes syndrome is a result of complete atrioventricular block. The
ventricles take over the pacemaker function in the heart, but at a much
slower rate than that of the SA node. As a result there is decreased
cerebral circulation, causing syncope. The symptoms of nausea and
vertigo, and flushing and slurred speech are unrelated to Adams-Stokes
syndrome. Cephlalgia and blurred vision are symptoms of a
cerebrovascular accident.
In the postanesthesia unit, a nurse is caring for a client who has received a
genreal anesthesia. The nurse should notify the physician if the :
a. Client pushes away the airway out
b. Client is snoring respirations
c. Respirations are regular but shallow
d. Systolic blood pressure drops from 130 to 100 mm Hg
The answer is A
A drop in systolic blood pressure rapid pulse, cold clammy skin and
oliguria are signs of shock, which, if not treated promptly can lead
to death. The client will push out the airway as the effects of
anesthesia subside. Snoring respirations are common because of
the depressant effects of anaesthesia. Shallow respirations are
common because of the depresssant effects of anaesthesia.
In a client on bedrest, the pulmonary embolus can be prevented by :
a. Limiting the client’s fluid intake
b. Encouraging deep breathing and coughing
c. Using the knee cap when the client is in bed
d. Teaching the client to move the legs when in bed.
The answer is D
The client who is on bedrest must do exercises such as dorsiflexion of the
feet, to prevent venous stasis and thrombus formation. Limiting fluid
intake may lead to haemoconcentration and subsequent thrombus
formation. Encouraging deep breathing and coughing improves
pulmonary function rather than prevents venous stasis. Using the knee
cap when in bed actually promotes venous stasis by compressing the
popliteal space.
A client is admitted with the diagnosis of cardiac disease. The client tells
the nurse that he is afraid of dying from a heart attack. Themost
therapeutic response is :
a. Perhaps you should discuss this with your physician
b. Of course you aren’t
c. Answer
d. Answer
The answer is D
A response such as “Tell me more about these fears of dying from a heart
attack”, opens up communication to allow the client to discuss his fesrs
of dying. Referring to his physician is nontherapeuratic. “of course you
aren’t going to die” is also nontherapeutic. It is giving false reassurance.
Questioning his feeings does not encourage him to express them.
A client after an abdominal surgery suddenly complains of numbness in the
left leg and a “funny feeling” in the toes. The nurse should first:
a. Elevate the legs and tell the patient to stay in bed
b. Tell the client to remain in bed and notify the physician
c. Rub the client’s legs to start circulation and cover the client with a warm
blanket.
d. Tell the client about the dangers of staying in bed too much and
encourage ambulation.
The answer is B
Localized sensory changes may indicate nerve damage; impaired
circulation, or thrombophlebitis. Activity should be limited, and the
physician notified. Symptoms may indicate a serious problem, and the
physician must be notified. Rubbing or massaging the legs is
contraindicated because of possible dislodging of a thrombus. Bedrest
is indicated to prevent the possibility of further damage or creqtion of
an embolus.
The central venous pressure (CVP) readings shold be recorded every 2
hours. The nurse is aware that
a. The normal reading is 60 to 120 mm of water
b. A high reading may be indicative of dehydration
c. The zero point of the manometer is level with the midaxilla
d. The client must be kept flat in bed while the catheter is in place
The answer is C
The CVP is a measure of the pressure within the right atrium. For an
accurate reading the zero point must be level with the right atrium. This
is at approximately the midaxillary line. Normal CVP reading ranges
from approximately 40 to 120 mm of water. A high reading indicates
circulatory overload. The client must be supine only when the reading is
taken
The nurse suggests to an elderly client with congestive heart faulure to use
airconditionin during summer. This suggestion is made based on the
koowledge:
a. The internal body temperature drops below 98.6 º F(37 º celcius)
b. The increased circulation in the skin gives the heart the exercise it
needs
c. The increased circulation in the skin causes excess body heat to radiate
away
d. The heart is relieved of the strain of pumping blood through many miles
of blood vessels in the skin.
The answer is D
Injured tissue cannot heal properly because of cellular deprivation of oxygen
and nutrients; ulceration and gangrene may result. Diminished sensation
decreases awareness of injury. Emotional stress does not cause tissue injury;
however, because of vasoconstriction it may prolong healing. Poor hygiene
is only one stress that may cause tissue trauma; protein is related to this
disease. Caffeine stimulates the cerebral cortex. It does not contribute to
ulceration or deprivation of oxygen
The nurse teaches to a client that the mechanism mediat6ing
long-term blood pressure regulation is:
a. The capillary fluid shifts
b. The fight or flight response
c. The adjustment of urinary output
d. The nervous system baroreceptors
The answer is C
A decrease in urinary output with increased conservation of
body fluid, will increase the blood pressure and vice versa.
Capillary fluid shifts and the nervous system baroceptors
causes a rapid response and have a short0term eefect. The
fight or flight response may cause a short term increase, but
does not have a long term effect.
A sudden episode of cyanosis and a change in respiration is noticed in a client
with caronary artery disease. The nurse starts oxygen administration
immediately. In this situation :
a. Oxygen had not been ordered and therefore should not be administered
b. The nurse’s observations were sufficient to begin administration of oxygen
c. The symptoms were too vague for the nurse to diagnose a need for oxygen
d. The physicican should have been called for an order before oxygen was
begun.
The answer is B
The nurse paractice act states that nurses diagnose human responses to
actual or potential health problems. The nurse used knowledge and
intervened. The other options are inappropriate. Because the client’s
symptoms reflected an immediate need for oxygen, postponement of
treatment could result in further deterioration of the client’s condition.
The nurse is caring for a child with a left to right shunt of the heart. The
nurse should be aware that th major common symptom of this type of
congenital disorder is ;
a. Polycythemia
b. Severe retarded growth
c. Severe clubbing
d. The presence of an audible heart murmur
The answer is D
In left to right shunt heart disease there are holes in the septum of the heart
that cause a murmuring sound as the blood is pumped through.
Polycythemia is not a common clinical finding in left to right shunt heart
disease. Severe retarded growth is not a common finding in left to righ
shunt heart disease, tissue perfusion is usually adequate. Clubbing is a
finding in right to left shunt heart disease.
To record central venous pressure reading, the nurse should place the
client in :
a. Low Fowler’s position
b. Supine in the contour position
c. The dorsal recumbent position
d. The side opposite to the manometer
The answer is C
The CVP is to be recorded when the client is horizontal and the zero point
of the manometer is at the midaxillary line (level of the right atrium).
Low Fowler’s position alters the relationship of the midaxillary line and
right atrium; inaccurate readings will be obtained . Supine in the contour
position and side opposite to the manometer are inappropriate positions.
While performing external cardiac compression, the nurse should exert
downward and vertical pressure on the lower sternum by placing :
a. The fleshy part of a clenched fist on the lower sternum
b. The heels of each hand side by side, extending the fingers over the chest
c. The fingers of one hand on the sternum and the fingers of the other hand on
top of them
d. The heel of one hand on thesternum and the heel of the other on top of it
interlocking the fingers
The answer is D
Option D provides the best leverage for depressing the sternum. Thus the
heart is adequately compressed and blood is forced into the arteries.
Grasping the fingers keeps them off the chest and concentrates the
energy expended in the heel of the hand while minimizing the
possibility of fracturing ribs. Both hands must be utilized; pressure on
the lower portion of the sternum may fractured
While performing external cardiac compression, the nurse should exert
downward and vertical pressure on the lower sternum by placing :
a. The fleshy part of a clenched fist on the lower sternum
b. The heels of each hand side by side, extending the fingers over the chest
c. The fingers of one hand on the sternum and the fingers of the other hand on
top of them
d. The heel of one hand on thesternum and the heel of the other on top of it
interlocking the fingers
The answer is D
Option D provides the best leverage for depressing the sternum. Thus the
heart is adequately compressed and blood is forced into the arteries.
Grasping the fingers keeps them off the chest and concentrates the
energy expended in the heel of the hand while minimizing the
possibility of fracturing ribs. Both hands must be utilized; pressure on
the lower portion of the sternum may fractured
A child aged 5 years is admitted for repair of tetralogy of Fallot. The
laboratory finding indicates a high red blood cell count. The nurse
recognizes polycythemia can best be understood as a compensatory
mechanism for :
a. Low BP
b. Cardiomegaly
c. Low iron level
d. Tissue oxygen need.
The answer is D
Decreased tissue oxygenation stimulates erythropoiesis resulting in excessive
production of red blood cells. Low BP is not associated with Fallot tetralogy.
Cardiomegaly would not be a direct cause of polycythemia. Low iron level
may or may not affect the production of red blood cells
A client has undergone an endarterectomy. The nurse should
observe for a change in :
a. Appetite
b. Skin colour
c. Bowel habits
d. Tissue turgor
The answer is A
After removal of an arterial obstruction by endarterecomy,
adequate circulation to the distal parts may be monitored by
observation of skin colour, pulses, and skin temperature.
Appetite does not change as a result of vascular surgery.
Bowel habits would not be altered after surgery. Turger
would be afected by change in hydration .
With chronic occlusive arterial disease the precipitating cause for
ulcerations in clients with chronic occlusive arterial disease is often :
a. Emotional stress, which is short lived
b. Poor hygiene and limited protein intake
c. Stimulants such as coffee, tea, or cola drinks
d. Trauma from mechanical, chemical or thermal sources
The answer is D
Injured tissue cannot heal properly because of cellular deprivation of
oxygen and nutrients, ulceration and gangrene may result; diminished
sensation decreases awareness of injury. Emotional stress does not cause
tissue injury however because of vasoconstriction. It may prolong
healing. Poor hygiene is only one stress that may cause tissue trauma;
protein is not related to this disease. Caffeine stimylates the cerebral
cortex; it does not contribute to ulceration or deprivation of oxygen.
A client aged 40 years with leg ulcers and arterial insufficiency is admitted
to the hospital. The leg ulcers of this nature are usually caused by:
a. Decreased arterial blood flow secondary to vasoconstriction
b. Decreased arterial blood flow leading to hyperemia
c. Atherosclerotic obstruction of arteries.
d. Trauma to the lower extremities
The answer is A
Decreased arterial blood flow as a result of vasopasm. The etiology is
unknown. It is more problematic in colder climates or when the personis
under stress. Hyperemia occurs when the vasospasm is relieved.
A simple test for diagnosing varicose veins is :
a. Arteriography
b. Babiniski reflex
c. Romberg’s sign
d. Trendelenberg test.
The answer is D
The trendelenburg test evaluates the back flow of blood through
defective valves. If , after raising the legs to empty the veins,
the client stands and the veins fill from above the site of the
suspected varicosity. The diagnosis is supported.
Arteriography is not a simple test that the nurse can perform.
Babinski reflex is used to determine injury of the pyramidal
tract in adults; if present it is obtained by firmly stroking the
lateral aspect of sole of foot. Romberg’s sign is a test for
position sense; the client loses balance when standing erect
with feet together and eyes closed.
A child undergoes heart surgery to repair the defects, associated with
tetralogy of Fallot. Postoperativel it is essential to prevent :
a. Crying
b. Coughing
c. Constipation
d. Unnecessary movement
The answer is C
Forceful evacuation rsults in the child’s taking a deep breath, holding it and
straining (Valsalva’s maneuvour). This increases intrathoracic pressure puts
excessive strain on the heart sutures. Crying is not a problem after cardiac
surgery; it may, in fact, help prevent respiratory complications. Coughing and
deep breathing are essential for the prevention of postoperative respiratory
complications. Activity is gradually increased postoperatively.
A client with arterial deficiency and Raynaud’s disease is prepared for
discharge. The client teaching instructions should include :
a. Walking several times each day as part of an exercise routine.
b. Keeping the heat up so that the environment is warm
c. Wearing TED hose during the day
d. Using hydrotherapy for increasing oxygenation
The answer is B
The client’s instructions should include keeping, the environment warm to
prevent vasoconstriction. Wearing gloves, warm clothes and socks will all
be useful in preventing vasoconstriction. Walking will most likely
increase pain. Wearing TED hose would not be therapeutic. Using
hydrotherapy will cause vasoconstriction.
An infant who had cardiac surgery for a congenital defect is to be discharged.
The nurse teaching to the parents regarding prophylactic use of ampicillin
therapy should stress the importance of :
a. Keeping the bottle of ampicillin in the refrigerator after it has been opened
b. Making sure the baby rceives the ampicillin prophylactically as prescribed
c. Shaking the bottle of ampicillin suspension throughly before giving it to the
baby
d. Waiting 2 hours after the last feeding before administering the ampicillin to
the baby
The answer is B
This is a priority because inadequate antibiotic therapy may predispose the
child to the development of endocarditis. Option A and C are not a
priority because instructions are usually printed on the label. Ampicillin
should be given with food
Following a streptococcal infection, a disorder characterized by swollen
joints, fever, and the possibility of endocarditis and death is :
a. Tetanus
b. Measles
c. Theumatic fever
d. Whooping cough
The answer is C
Rheumatic fever is an inflammatory disease involving the joints, heart,
CNS, and subcutaneous tissue. It is believed to be an autoimmune
process that causes connective tissue damage. Tetanus is not caused by a
streptococcal infection and does not Include the symptoms listed.
Measles is caused by a virus and does not include
The nurse knows that a pacemaker is used in some clients to serve the
function normally performed by the :
a. AV node
b. SA node
c. Bundle of His
d. Acclerator nerves to the heart
The answer is B
SA node is the heart’s natural pacemaker. An electronic pacemaker is used in
some persons to supply an implse that stimulates te4h heart to act more
effectively. AV node is modified cardiac muscle that receives impulse
from the SA node and conducts them to the ventricular walls via bundle
of His and Purkinje fibres. Bundle of His is a special cardiac muscle.
Accelerator nerves (sympathetic fibres) to th heart do not initiate and
regulate the heartbeat.
A child aged 5 years is admitted for repair of tetralogy of Fallot. The
laboratory finding indicates a high red blood cell count. The nurse
recognizes polycythemia can best be understood as a compensatory
mechanism for :
a. Low BP
b. Cardiomegaly
c. Low iron level
d. Tissue oxygen need.
The answer is D
Decreased tissue oxygenation stimulates erythropoiesis resulting in excessive
production of red blood cells. Low BP is not associated with Fallot tetralogy.
Cardiomegaly would not be a direct cause of polycythemia. Low iron level
may or may not affect the production of red blood cells
A client has undergone an endarterectomy. The nurse should
observe for a change in :
a. Appetite
b. Skin colour
c. Bowel habits
d. Tissue turgor
The answer is A
After removal of an arterial obstruction by endarterecomy,
adequate circulation to the distal parts may be monitored by
observation of skin colour, pulses, and skin temperature.
Appetite does not change as a result of vascular surgery.
Bowel habits would not be altered after surgery. Turger
would be afected by change in hydration .
With chronic occlusive arterial disease the precipitating cause for
ulcerations in clients with chronic occlusive arterial disease is often :
a. Emotional stress, which is short lived
b. Poor hygiene and limited protein intake
c. Stimulants such as coffee, tea, or cola drinks
d. Trauma from mechanical, chemical or thermal sources
The answer is D
Injured tissue cannot heal properly because of cellular deprivation of
oxygen and nutrients, ulceration and gangrene may result; diminished
sensation decreases awareness of injury. Emotional stress does not cause
tissue injury however because of vasoconstriction. It may prolong
healing. Poor hygiene is only one stress that may cause tissue trauma;
protein is not related to this disease. Caffeine stimylates the cerebral
cortex; it does not contribute to ulceration or deprivation of oxygen.
A client aged 40 years with leg ulcers and arterial insufficiency is admitted
to the hospital. The leg ulcers of this nature are usually caused by:
a. Decreased arterial blood flow secondary to vasoconstriction
b. Decreased arterial blood flow leading to hyperemia
c. Atherosclerotic obstruction of arteries.
d. Trauma to the lower extremities
The answer is A
Decreased arterial blood flow as a result of vasopasm. The etiology is
unknown. It is more problematic in colder climates or when the personis
under stress. Hyperemia occurs when the vasospasm is relieved.
A simple test for diagnosing varicose veins is :
a. Arteriography
b. Babiniski reflex
c. Romberg’s sign
d. Trendelenberg test.
The answer is A
The trendelenburg test evaluates the back flow of blood through defective
valves. If , after raising the legs to empty the veins, the client stands and
the veins fill from above the site of the suspected varicosity. The diagnosis
is supported. Arteriography is not a simple test that the nurse can
perform. Babinski reflex is used to determine injury of the pyramidal tract
in adults; if present it is obtained by firmly stroking the lateral aspect of
sole of foot. Romberg’s sign is a test for position sense; the client loses
balance when standing erect with feet together and eyes closed.
A child undergoes heart surgery to repair the defects, associated with
tetralogy of Fallot. Postoperativel it is essential to prevent :
a. Crying
b. Coughing
c. Constipation
d. Unnecessary movement
The answer is C
Forceful evacuation rsults in the child’s taking a deep breath, holding it and
straining (Valsalva’s maneuvour). This increases intrathoracic pressure puts
excessive strain on the heart sutures. Crying is not a problem after cardiac
surgery; it may, in fact, help prevent respiratory complications. Coughing and
deep breathing are essential for the prevention of postoperative respiratory
complications. Activity is gradually increased postoperatively.
A client with arterial deficiency and Raynaud’s disease is prepared for
discharge. The client teaching instructions should include :
a. Walking several times each day as part of an exercise routine.
b. Keeping the heat up so that the environment is warm
c. Wearing TED hose during the day
d. Using hydrotherapy for increasing oxygenation
The answer is B
The client’s instructions should include keeping, the environment warm to
prevent vasoconstriction. Wearing gloves, warm clothes and socks will all
be useful in preventing vasoconstriction. Walking will most likely
increase pain. Wearing TED hose would not be therapeutic. Using
hydrotherapy will cause vasoconstriction.
An infant who had cardiac surgery for a congenital defect is to be discharged.
The nurse teaching to the parents regarding prophylactic use of ampicillin
therapy should stress the importance of :
a. Keeping the bottle of ampicillin in the refrigerator after it has been opened
b. Making sure the baby rceives the ampicillin prophylactically as prescribed
c. Shaking the bottle of ampicillin suspension throughly before giving it to the
baby
d. Waiting 2 hours after the last feeding before administering the ampicillin to
the baby
The answer is B
This is a priority because inadequate antibiotic therapy may predispose the
child to the development of endocarditis. Option A and C are not a
priority because instructions are usually printed on the label. Ampicillin
should be given with food