50 -Question :Postoperatively, a nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for

evidence of which of the following ?Options :

1 . Bleeding and infection 2 . Thrombosis and infection

3 . Bleeding and wound dehiscence 4 . Wound dehiscence and evisceration

Answer :1 .

Rationale :After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any other

postoperative client .51 -Question :

A client with angina has a 12- lead electrocardiogram taken during an episode of chest pain . A nurse examines the tracing for which electrocardiographic change caused by

myocardial ischemia? Options :1 . Tall peaked T waves 2 . Prolonged PR interval 3 . Widened QRS complex

4 . ST segment elevation or depression Answer :4 .

Rationale :An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or

depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle

branch block .52 -Question :

A client is scheduled for a dipyridamole (Persantine) thallium -201 scan . A nurse would assess to make sure that the client avoided which of the following before the

procedure ?Options :

1 . Caffeine 2 . Fatty meal

3 . Excess sugar 4 . Milk products

Answer :1 .

Rationale :This test is an alternative to the exercise thallium -201 scan . Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as should bronchodilators such as theophylline. Theophylline may decrease the effects of dipyridamole. The client does not have to avoid the items identified in options 2 , 3 ,

and 4 . 53 -Question :

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and

edema. The pedal pulse is palpable and unchanged from admission. How would the nurse correctly interpret the client ’s

neurovascular status ?Options :

1 . The neurovascular status is normal because of increased blood flow through the

leg .2 . The neurovascular status is moderately

impaired, and the surgeon should be called .3 . The neurovascular status is slightly

deteriorating and should be monitored for another hour .

4 . The neurovascular status is adequate from an arterial approach, but venous

complications are arising .Answer :1 .

Rationale :An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow . Therefore , options 2 , 3 , and 4 are incorrect

interpretations . 54 -Question :

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How would the nurse correctly interpret the client ’s

neurovascular status ?Options :

1 . The neurovascular status is normal

because of increased blood flow through the leg .

2 . The neurovascular status is moderately impaired, and the surgeon should be called .

3 . The neurovascular status is slightly deteriorating and should be monitored for another hour. 4 . The neurovascular status is adequate from an arterial approach, but

venous complications are arising .Answer :1 .

Rationale :An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow . Therefore , options 2 , 3 , and 4 are incorrect

interpretations . 55 -Question :

A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which of the following observations would indicate that the

procedure was unsuccessful? Options :1 . Rising blood pressure

2 . Clearly audible heart sounds 3 . Client expressions of relief

4 . Rising central venous pressure Answer :4 .

Rationale :Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are expected. The client usually expresses immediate relief. Heart sounds are

no longer muffled or distant .56 -Question :

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is

probably unrelated to the aneurysm ?Options :

1 . Pulsatile abdominal mass 2 . Hyperactive bowel sounds in the area 3 . Systolic bruit over the area of the mass

4 . Subjective sensation of “heart beating ”in the abdomen Answer :2 .

Rationale :Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the “heart beating ”in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal

aortic aneurysm .57 -Question :

A nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous infusion with a rate of 150 mL/hr, unchanged for the last 10 hours . The client ’s urine output for the last 3 hours was 90 , 50 , and 28 mL (28 mL most recent). The client ’s blood urea nitrogen level is 35 mg/dL and serum creatinine level is 1.8 mg/dL , measured this morning . Which of the following actions should the nurse take next?

Options :1 . Call the physician .

2 . Check the urine specific gravity .3 . Check to see if the client had a sample

for serum albumin level drawn .4 . Put the intravenous line on a pump so

that the infusion rate is sure to stay stable .Answer :1 .

Rationale :Following abdominal aortic aneurysm resection or repair, the nurse monitors the client for signs of renal failure. Renal failure can occur because often much blood is lost during the surgery and, depending on the aneurysm location, the renal arteries may be hypoperfused for a short period during surgery. The nurse monitors hourly intake and output and notes the results of daily blood urea nitrogen and creatinine levels . Urine output lower than 30 to 50 mL/hr is

reported to the physician . 58 -Question :

A client is admitted to the hospital with a venous stasis leg ulcer. Which of the following characteristics would be an

expected finding of this type of ulcer ?Options :

1 . Pale-colored base 2 . Deep, with even edges

3 . Has little granulation tissue 4 . Has brown pigmentation surrounding it

Answer :4 .

Rationale :Venous leg ulcers, also called stasis ulcers,

tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis.

The client also exhibits peripheral edema .59 -Question :

A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for which of the

following ?Options :

1 . Diarrhea and hypotension 2 . Fatigue and muscle twitching

3 . Thrombocytopenia and weight gain 4 . Anorexia, nausea, and visual

disturbances Answer :4 .

Rationale :The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea, vomiting, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias . Options 1 , 2 , and 3 are

unrelated to digoxin therapy . 60 -Question :

Cardiac magnetic resonance imaging (MRI) is prescribed for a client. The nurse identifies that which of the following is a contraindication for performance of this

diagnostic study ?Options :

1 . Client has a pacemaker .2 . Client is allergic to iodine .

3 . Client has diabetes mellitus .4 . Client has a biological porcine valve .

Answer :1 .

Rationale :The magnetic fields used for magnetic resonance imaging (MRI) can deactivate the pacemaker. Options 2 , 3 , and 4 are not

contraindications for an MRI . 61 -Question :

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe

this type of anginal pain ?Options :

1 . Stable angina 2 . Variant angina 3 . Unstable angina 4 . Nonanginal pain

Answer :2 .

Rationale :Variant angina, or Prinzmetal ’s angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a

precursor of myocardial infarction .62 -Question :

Intravenous heparin therapy is ordered for a

client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit?

Options :1 . Protamine sulfate 2 . Potassium chloride

3 . Aminocaproic acid (Amicar) 4 . Vitamin K (AquaMEPHYTON)

Answer :1 .

Rationale :The antidote to heparin is protamine sulfate; it should be readily available for use if excessive bleeding or hemorrhage should occur. Vitamin K is an antidote for warfarin sodium. Aminocaproic acid is the antidote for thrombolytic therapy. Potassium chloride is

administered for a potassium deficit .63 -Question :

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The client ’s prothrombin time is 20 seconds , with a control of 11 seconds . How would the nurse

interpret these results ?Options :

1 . Client needs to have test repeated .2 . Client results are within the therapeutic

range .3 . Client results are higher than the

therapeutic range .4 . Client results are lower than the needed

therapeutic level .Answer :2 .

Rationale :The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus . Based on the client ’s control value , the therapeutic range for this individual would be 16.5 to 22 seconds . Therefore the result is within the therapeutic

range. 64 -Question :

A client who has been receiving heparin therapy also is started on warfarin sodium (Coumadin). The client asks a nurse why both medications are being administered. Which of the following statements reflects

appropriate teaching by the nurse ?Options :

1 . Warfarin sodium stimulates production of the body ’s own thrombolytic substances ,

but it takes 2 to 4 days for this to begin .2 . Warfarin sodium stimulates breakdown

of specific clotting factors by the liver, and it takes 2 to 3 days for this to exert an

anticoagulant effect .3 . Warfarin sodium inhibits synthesis of

specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert

an anticoagulant effect .4 . Warfarin sodium has the same

mechanism of action as heparin, and the crossover time is needed for the serum level

of warfarin sodium to be therapeutic .Answer :3 .

Rationale :Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-

dependent clotting factors (X, IX , VII , and II ) , but it takes 3 to 4 days before the

therapeutic effect of warfarin is exhibited.. 65 -Question :

A client is receiving thrombolytic therapy with a continuous infusion of streptokinase (Streptase). The client suddenly becomes extremely anxious and complains of itching. A nurse hears stridor and on examination of the client notes generalized urticaria and hypotension. Which of the following should

be the priority action of the nurse ?Options :

1 . Administer oxygen and protamine sulfate .

2 . Stop the infusion and call the physician.

3 . Cut the infusion rate in half and sit the client up in bed .

4 . Administer diphenhydramine (Benadryl) and continue the infusion .Answer :2 .

Rationale :The client is experiencing an anaphylactic reaction to streptokinase, which is allergenic. The infusion should be stopped, the physician notified, and the client treated with epinephrine, antihistamines, and

corticosteroids .66 -Question :

A nurse has an order to begin administering warfarin sodium (Coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit

as the antidote for warfarin sodium ?Options :

1 . Protamine sulfate 2 . Potassium chloride

3 . Aminocaproic acid (Amicar) 4 . Vitamin K (AquaMEPHYTON)

Answer :4 .

Rationale :The antidote to warfarin sodium (Coumadin) is vitamin K and should be readily available for use if excessive bleeding or hemorrhage occurs. Aminocaproic acid is the antidote for thrombolytic agents. Protamine sulfate is the antidote for heparin. Potassium chloride is

administered to treat potassium deficit .67 -Question :

A client is admitted with pulmonary embolism and is to be treated with streptokinase (Streptase). A nurse would report which of the following assessments to the physician before initiating this therapy?

Options :1 . Adventitious breath sounds 2 . Temperature of 99.4° F orally

3 . Blood pressure of 198/110 mm Hg 4 . Respiratory rate of 28 breaths/min

Answer :3 .

Rationale :Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because

of the risk of cerebral hemorrhage. Therefore, the nurse would report the results of the blood pressure to the physician before

initiating therapy .68 -Question :

The client is brought into the emergency room in ventricular fibrillation (VF). The advanced cardiac life support (ACLS) nurse prepares to defibrillate by placing conductive

gel pads on which part of the chest ?Options :

1 . The upper and lower halves of the sternum

2 . The right of the sternum, just below the clavicle and to the left of the precordium

3 . The right shoulder and the back of the left shoulder

4 . Parallel between the umbilicus and the right nipple Answer :2 .

Rationale :The ACLS nurse would place one gel pad to the right of the sternum just below the clavicle and the other gel pad to the left of the precordium. The nurse would then place the electrode paddles over the pads. Options

1 , 3 , and 4 identify incorrect positions . 69 -Question :

The nurse has given discharge instructions to the client who has undergone vein ligation and stripping early in the day. The nurse evaluates that the client understands activity and positioning limitations if the client states

that it is appropriate to :Options :

1 . Lie down with the legs elevated and avoid sitting .

2 . Cross the ankles at the ankle only, but not at the knee .

3 . Sit in the chair 3 times a day for 3 hours at a time .

4 . Walk upright for as much as possible each day .Answer :1 .

Rationale :The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days following the procedure. Prolonged standing and sitting increase the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same

70 -Question :To perform cardiopulmonary resuscitation (CPR), the nurse would use the method shown in the Figure to open the airway in

which of the following situations ?Options :

1 . In all situations requiring CPR 2 . If neck trauma is suspected 3 . If the client is unconscious

4 . If the client has a history of headaches Answer :2 .

Rationale :The jaw thrust without the head tilt maneuver is used when head and/or neck

trauma is suspected. This maneuver opens the airway while maintaining proper head and neck alignment, thus reducing the risk of further damage to the neck . Option 1 is incorrect . In situations requiring CPR , the client will be unconscious . Option 4 is also incorrect . Additionally , it is unlikely that the

nurse will be able to obtain these data .71 -Question :

The client with heart disease is provided instructions regarding a low-fat diet. The nurse determines that the client understands the diet if the client states that a food item

to avoid is :Options :

1 . Apples .2 . Oranges .3 . Avocado .4 . Cherries .

Answer :3 .

Rationale :Fruits and vegetables, except avocado, olives, and coconut, contain minimal

amounts of fat .72 -Question :

A nurse is performing an assessment on a client admitted to the hospital who was diagnosed with toxic shock syndrome (TSS). Which of the following assessment questions would assist in eliciting more specific data

regarding the cause of this syndrome ?Options :

1“ . Have your menstrual periods been irregular” ?

2“ . Do you use tampons during your

menstrual period” ?3“ . Have you been consuming a high intake

of green leafy vegetables” ?4“ . Did you start your menses at an early

age” ?Answer :2 .

Rationale :TSS is caused by infection and is often associated with tampon use. Disseminated intravascular coagulation is a complication of TSS . Options 1 , 3 , and 4 are unrelated to

the etiology of TSS . 73 -Question :

A nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding would indicate the

presence of this complication ?Options :

1 . A pulse rate of 60 beats/min 2 . Flat neck veins

3 . Muffled or distant heart sounds 4 . A blood pressure (BP) of 128/82 mm Hg

Answer: 3. Rationale :

Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory BP greater than 10 mm Hg). Bradycardia is not a

sign of cardiac tamponade . 74 -Question :

A home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care

management. Which statement if made by the client indicates a need for further

instruction ?Options :

1“ . I need to be sure not to go barefoot around the house” .

2“ . I need to be sure that I elevate my leg above my heart level for at least an hour every day. ”3 . “If I cut my toenails I need to

be sure that I cut them straight across” .4“ . It is all right to apply lanolin to my feet,

but I shouldn ’t place it between my toes” .Answer :2 .

Rationale :Foot care instructions for the client with peripheral arterial disease are the same instructions as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program, such as Buerger- Allen exercises, or

unless venous stasis is also present .75 -Question :

A clinic nurse is providing instructions to a client with hypertension who will be taking captopril (Capoten). Which statement by the client indicates a need for further

instruction ?Options :

1“ . I need to drink increased amounts of water” .

2“ . I need to change positions slowly” .3“ . I need to avoid taking hot baths or

showers” .

4“ . I need to sit down and rest if dizziness or lightheadedness occurs” .

Answer :1 .

Rationale :Captopril is an antihypertensive medication (angiotension-converting enzyme inhibitor). Orthostatic hypotension can occur in clients taking this medication. Clients are advised to avoid standing in one position for long periods of time, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client should be instructed to monitor for signs of orthostatic hypotension such as dizziness, lightheadedness, weakness, and syncope. An increased intake of water could actually aggravate the

hypertension .76 -Question :

A nurse is providing instructions regarding high-sodium food items to avoid to a client with a diagnosis of hypertension. The nurse

instructs the client to avoid :Options :

1 . Cantaloupe 2 . Broccoli

3 . Mineral water 4 . Bananas

Answer :3 .

Rationale :The sodium level can increase by the use of several types of products including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids,

laxatives, and sedatives; and softened water, as well as some mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, and demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. The client would avoid

consuming mineral water .77 -Question :

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to touch. The nurse should document that these findings identify which

type of ulcer ?Options :

1 . A vascular ulcer 2 . A venous stasis ulcer

3 . An arterial ulcer 4 . A stage 1 ulcer

Answer :3 .

Rationale :Arterial ulcers have a pale, deep base and are surrounded by tissue that is cool with trophic changes such as dry, skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A venous stasis ulcer is one that has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared , as a result

of venous congestion . A stage 1 ulcer indicates a reddened area with an intact skin

surface .

78 -Question :A nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan expecting that the physician will

prescribe which of the following ?Options :

1 . Maintain the affected leg in a dependent position .

2 . Apply cool packs to the affected leg for 20 minutes every 4 hours .

3 . Maintain bedrest .4 . Administer a opioid analgesic every 4

hours around the clock . Answer :3 .

Rationale :Standard management for the client with DVT includes bed rest for 5 to 7 days , limb elevation , relief of discomfort with warm moist heat, and analgesics as needed. Ambulation is contraindicated because such activity can cause the thrombus to dislodge and travel to the lungs. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen

(Tylenol) .Question :

A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and asks the nurse to describe the

procedure. The appropriate nursing response is which of the following ?Options :

1“ . It involves tying off the veins to prevent sluggishness of blood from occurring” .

2“ . It involves tying off the veins so that circulation is redirected in another area” .

3“ . It involves surgically removing the varicosity, so anesthesia will be required” .

4“ . It involves injecting an agent into the vein to damage the vein wall and close it off. ”

Answer :4 .

Rationale :Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the vessel and causes aseptic thrombosis that results in vein closure. With no blood flow through the vessel, distention will not occur. The surgical procedure for varicose veins is vein ligation and stripping. This procedure involves tying off the varicose vein and large tributaries and then removal of the vein with the use of a hook and wires applied

through multiple small incisions in the leg .

80 -Question :A female client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. Which

response to the client is appropriate ?Options :

1“ . Keep the leg elevated as much as

possible” .2“ . Apply warm packs to the leg” .

3“ . This normally occurs after surgery and will subside when the edema goes down” .

4“ . Contact your physician right away to report this problem” .

Answer :4 .

Rationale :A sensation of pins and needles, or feeling as though the surgical limb is falling asleep, may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias . Options 1 , 2 , and 3 are

inaccurate responses .81 -Question :

A nurse in the emergency department is caring for a client who was in a motor vehicle accident and is experiencing hypovolemic shock. A pneumatic antishock garment (PASG) is applied for treatment until the client can be transferred to the intensive care unit (ICU). While awaiting client transfer to the ICU, the emergency department nurse

performs which critical assessment ?Options :

1 . Monitoring hemoglobin and hematocrit levels

2 . Monitoring vascular status of the lower extremities

3 . Assessing radial pulses 4 . Assessing vascular status of the upper

extremities Answer :

2 . Rationale :

A PASG may be useful in the treatment of hypovolemic shock associated with traumatic injury to provide circulatory assistance. The device is used only as a temporary measure until definitive treatment is given because it can compromise blood flow to the lower half of the body. The critical nursing assessment includes monitoring the vascular status of the lower extremities . Although options 1 , 3 , and 4 may be components of the nursing assessment , these actions are not part of the critical assessment required with use of a

PASG .82 -Question :

A left atrial catheter is inserted into a client during cardiac surgery. The nurse is monitoring the left atrial pressure (LAP) and documents that the pressure is normal if

which of the following LAP values is noted ?Options :

1 . 8 mm Hg 2 . 15 mm Hg 3 . 25 mm Hg 4 . 32 mm Hg

Answer :1 .

Rationale :The normal LAP is 1 to 10 mm Hg . Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure is recorded as an average (mean) pressure, rather than as a systolic or diastolic pressure . Options 2 , 3 , and 4 are

incorrect .

83 -Question :A female client is at risk for developing disseminated intravascular coagulopathy (DIC). On reviewing the laboratory test results for this client, the nurse determines that the fibrinogen level is normal if which of the following values is noted on the

laboratory report ?Options :

1 . 180 mg/dL 2 . 400 mg/dL 3 . 480 mg/dL 4 . 500 mg/dL

Answer :2 .

Rationale :The normal fibrinogen level is 180 to 340 mg/dL for males and 190 to 420 mg/dL for females . A critical value is one that is less than 100 mg/dL . With DIC , the fibrinogen level drops because fibrinogen is used up in the clotting process . Option 2 is the only

option that identifies a normal level .

84 -Question :A nurse is preparing discharge instructions for a client with Raynaud ’s disease. The

nurse plans to tell the client to :Options :

1 . Stop smoking because it causes cutaneous vasospasm .

2 . Always wear warm clothing even in warm climates to prevent vasoconstriction .

3 . Use nail polish to protect the nail beds from injury .

4 . Wear gloves for all activities involving use of both hands .Answer :1 .

Rationale :Raynaud ’s disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client needs to make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community . Options 2 and 3 are incorrect . It is not necessary to wear

gloves for all activities .85 -Question :

A nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. A priority intervention in the plan of care is to:

Options :1 . Keep the legs aligned with the heart .2 . Position the client onto the side every

shift .3 . Clean the skin with alcohol every hour .4 . Elevate the legs higher than the heart .

Answer :4 .

Rationale :In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the

heart . Option 2 specifies infrequent care intervals , so it is not the priority intervention. Alcohol is very irritating and drying to tissues and should not be used in

areas of skin breakdown .86 -Question :

A nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which of the following

conditions ?Options :

1 . Congestive heart failure 2 . Cardiogenic shock 3 . Pulmonary edema 4 . Aortic insufficiency

Answer :2 .

Rationale :IABP therapy most often is used in the treatment of cardiogenic shock and is most effective if instituted early in the course of treatment. Use of the IABP is contraindicated in clients with aortic insufficiency and thoracic and abdominal aneurysms. This therapy is not used in the treatment of congestive heart failure or pulmonary

edema .87 -Question :

A nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit. The nurse notes that a cardiac troponin

T level assay was performed while the client was in the intensive care unit. The nurse determines that this test was performed to assist in diagnosing which of the following

conditions ?Options :

1 . Myocardial infarction 2 . Congestive heart failure 3 . Ventricular tachycardia

4 . Atrial fibrillation Answer :1 .

Rationale :Cardiac troponin T or cardiac troponin I has been found to be a protein marker in the detection of myocardial infarction, and assay for this protein is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose congestive heart failure, ventricular

tachycardia, or atrial fibrillation .88 -Question :

A nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min . The nurse should next assess the client for which of the

following ?Options :

1 . Flat neck veins 2 . Complaints of nausea

3 . Complaints of headache 4 . Hypotension

Answer :4 .

Rationale :The client with uncontrolled atrial fibrillation with a ventricular rate higher than 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck

veins .89 -Question :

A nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the

client's left-sided heart function? Options :1 . Listening to lung sounds

2 . Assessing for peripheral and sacral edema

3 . Assessing for jugular vein distention 4 . Monitoring for organomegaly

Answer: 1 . Rationale :

The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.