LA#5 ( Cardio (2)) Chapters 37, 38, 39, 40 in Med Surg

Question 1

In analyzing a patient’s electrocardiogram (ECG) rhythm strip, the nurse uses the knowledge that the time of the conduction of an impulse through the Purkinje fibres is represented by which of the following changes?
a.	P wave
b.	PR interval
c.	QT interval
d.	QRS complex
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Answer 1

ANS: B
The PR interval represents depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and Purkinje fibres, up to the point of depolarization of the ventricular cells.
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Question 2

Which of the following is an abnormal ECG value for a PR interval duration?

a. 0.6 second
b. 0.12 second
c. 0.24 second
d. 0.30 second

Answer 2

ANS: B

The normal duration of a PR interval is 0.12 to 0.20 seconds.

Question 3

A patient has a sinus arrest with a junctional escape rhythm. What would the nurse expect the patient’s pulse rate to be?

a. 15 to 20 beats/min
b. 20 to 40 beats/min
c. 40 to 60 beats/min
d. 60 to 100 beats/min

Answer 3

ANS: C
If the sinoatrial node fails to discharge, the junction will automatically discharge at the normal junctional rate of 40 to 60 beats/min.

Question 4

A patient has a dysrhythmia that requires careful monitoring of atrial activity. Which lead will be best to use for continuous monitoring?

a. MCL1
b. AVF
c. V6
d. I

Answer 4

ANS: A

Leads II and MCL1 are the best leads for visualization of P waves, which reflect atrial activity.

Question 5

The nurse obtains a monitor strip on a patient admitted to the coronary care unit with a myocardial infarction (MI) and makes the following analysis: P wave not apparent; ventricular rate 142 beats/min, R-R interval regular; PR interval not measurable; and QRS complex wide and distorted, greater than 0.14 second. The nurse interprets this patient’s cardiac rhythm as which of the following?

a. Atrial fibrillation
b. Sinus tachycardia
c. Ventricular fibrillation
d. Ventricular tachycardia

Answer 5

ANS: D
The absence of P waves, wide QRS, rate greater than 150 beats/min, and regularity of the rhythm indicate ventricular tachycardia.

Question 6

The nurse determines that a patient has ventricular bigeminy when the rhythm strip indicates which of the following changes?

a. Conduction is originating in the AV node.
b. Every other QRS complex is wide and starts prematurely.
c. The ventricular rate is between 150 and 250 beats/min.
d. The rhythm of the SA node is coupled with long pauses between every two beats.

Answer 6

ANS: B

Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking.

Question 7

A patient has a normal cardiac rhythm strip, except that the PR interval is 0.34 seconds. What is the appropriate nursing intervention?

a. Notify the physician.
b. Administer atropine per protocol.
c. Prepare the patient for temporary pacemaker insertion.
d. Document the finding, and continue to monitor the patient.

Answer 7

ANS: D
First-degree AV block is asymptomatic and requires ongoing monitoring because it may progress to more serious forms of heart block.

Question 8

A patient with diabetes mellitus is admitted unresponsive to the emergency department (ED). Initial laboratory findings are serum potassium 2.8 mmol/L, serum sodium 138 mmol/L, serum chloride 90 mmol/L, and blood glucose 34.9 mmol/L (628 mg/dL). Cardiac monitoring shows multifocal premature ventricular contractions (PVCs). What does the nurse understand that the patient’s PVCs are most likely caused by?

a. Hypoxemia
b. Dehydration
c. Hypokalemia
d. Hyperglycemia

Answer 8

ANS: C
Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation.

Question 9

The nurse retrieves data from the cardiac monitor that indicates that a patient with an MI experienced a 45-second episode of ventricular tachycardia before a normal sinus rhythm and a heart rate of 98 were re-established. What is the most appropriate initial nursing action?

a. Notify the physician.
b. Administer antidysrhythmic drugs per protocol.
c. Elevate the head of the bed, and administer oxygen at 6 L/min.
d. Continue to monitor the patient’s cardiac rhythm without other interventions at this time.

Answer 9

ANS: B
The burst of sustained ventricular tachycardia indicates that the patient has significant ventricular irritability, and antidysrhythmic medication administration is needed to prevent further episodes.

Question 10

A patient with myocardial damage develops a type I, second-degree AV block. The nurse administers IV atropine as prescribed. The nurse determines that the medication has been effective on finding which of the following changes?

a. A decrease in ventricular response
b. A decrease in premature contractions
c. An increase in the patient’s heart rate
d. Increased carotid and peripheral pulse volume

Answer 10

ANS: C

Atropine will increase the heart rate and conduction through the AV node

Question 11

What is the most accurate way to calculate the heart rate from an ECG?

a. Count the number of R-R intervals in 6 seconds, and multiply by 10.
b. Count the number of small squares between the R-R interval, and divide by 1500.
c. Count the number of QRS complexes in 1 minute.
d. Count the large squares between one R-R interval, and divide by 300.

Answer 11

ANS: C

The most accurate way to obtain a heart rate from an ECG is to count the number of QRS complexes in 1 minute.

Question 12

The cardiac monitor alarm goes off for a patient being monitored in the coronary care unit, and the nurse notes a cardiac pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious, with no pulse or respirations. After calling for assistance, what should the nurse do?

a. Start basic cardiopulmonary resuscitation (CPR).
b. Administer a bolus dose of epinephrine.
c. Prepare the patient for endotracheal intubation.
d. Wait for the defibrillator to arrive at the bedside.

Answer 12

ANS: A
The patient’s rhythm and assessment indicate ventricular fibrillation and cardiac arrest; therefore, the initial actions include calling for help and initiating CPR until defibrillation is possible.

Question 13

During the change-of-shift report, the nurse learns that a patient with a large MI has been having frequent PVCs. What will the nurse check when monitoring the patient for the effects of PVCs?

a. The patient’s medications
b. The patient’s oxygen saturation
c. The patient’s apical–radial heart rate
d. The patient’s recent electrolyte values

Answer 13

ANS: C
It is important to assess the patient’s apical–radial pulse rate because PVCs often do not generate a sufficient ventricular contraction to result in a peripheral pulse, which can lead to a pulse deficit.

Question 14

How would the nurse document a dysrhythmia pattern that has a sawtooth-shape P wave, a variable PR interval, and a normal QRS complex?

a. Junctional rhythms
b. Atrial flutter
c. Sinus bradycardia
d. Atrial fibrillation

Answer 14

ANS: B
A dysrhythmia pattern that has a sawtooth-shape P wave, a variable PR interval, and a normal QRS complex is an atrial flutter.

Question 15

Which classification of antidysrhythmia drugs has no effect on ECG?

a. Class I: sodium channel blockers
b. Class II: β-adrenergic blockers
c. Class III: potassium channel blockers
d. Class IV: calcium channel blockers

Answer 15

ANS: A

Class I: sodium channel blockers have no effect on ECG.

Question 16

The nurse is doing discharge teaching with a patient who is going home with an implantable cardioverter–defibrillator (ICD). Which of the following instructions should the nurse give the patient?

a. Keep the incision dry for at least 2 weeks after ICD insertion.
b. The ICD will not set off a metal detector in an airport, so it is all right to travel.
c. You should have a routine ICD check every 2 to 3 months.
d. It is all right to drive as soon as you are discharged.

Answer 16

ANS: C

Routine ICD check with interrogator–programmer device is needed every 2 to 3 months.

Question 17

A patient has a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response. The nurse recognizes that the pacemaker is used for the patient to do which of the following?

a. Prevent ventricular irritability.
b. Override the ectopic stimulus in the atria.
c. Fire an impulse every second to maintain a heart rate of 60 beats/min.
d. Discharge an electrical stimulus when no ventricular depolarization is sensed.

Answer 17

ANS: D

The permanent pacemaker will discharge when the ventricular rate drops below the set rate.

Question 18

A patient has received instruction on the management of her permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient makes which of the following statements?

a. “I won’t lift the arm on the pacemaker side up very high until I see the doctor.”
b. “I will notify the airlines when I make a reservation that I have a pacemaker.”
c. “I must avoid cooking with a microwave oven or being near a microwave in use.”
d. “It will be 6 weeks before I can take a bath or return to my usual activities.”

Answer 18

ANS: A
The patient is instructed to avoid lifting the arm on the pacemaker side above the shoulder to avoid displacing the pacemaker leads.

Question 19

A patient who has been successfully resuscitated twice following sudden cardiac death has a transvenous ICD implanted for management of ventricular dysrhythmias. When performing discharge teaching with the patient, what is most important for the nurse to instruct the patient and family about?

a. He will no longer need to take medications to control his dysrhythmias.
b. If the ICD fires and he loses consciousness, 911 should be called.
c. His family will not need to learn CPR because he has the automatic defibrillator available.
d. The ICD device rarely sets off airport security alarms, and travel without restrictions is allowed.

Answer 19

ANS: B
If the ICD fires and the patient continues to have symptoms of cardiac arrest, activation of the emergency response system is indicated.

Question 20

A patient with supraventricular tachycardia is to receive cardioversion. What should the nurse know about the use of cardioversion?

a. A defibrillator is programmed to deliver a countershock on the T wave.
b. The amount of voltage used is 400 J.
c. The patient should be sedated before the procedure, if possible.
d. The procedure is the same as defibrillation, except that the patient is more hemodynamically stable.

Answer 20

ANS: C

When a patient has a nonemergency cardioversion, sedation is used just before the procedure.

Question 21

A patient’s sinus rhythm rate is 62 beats/min. The PR interval is 0.18 seconds at 0100 hours, 0.20 seconds at 1230 hours, and 0.23 seconds at 1600 hours. Which action should the nurse take?

a. Document the patient’s rhythm, and continue to monitor.
b. Prepare for possible pacemaker insertion.
c. Hold the ordered metoprolol (Lopressor), and call the physician.
d. Give the as-needed dose of lidocaine (Xylocaine).

Answer 21

ANS: C
The patient has progressive first-degree AV block, and the β-blocker should be held until discussing the medication with the physician.

Question 22

A patient develops sinus bradycardia at a rate of 32 beats/min, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take?

a. Continue to monitor the rhythm and BP.
b. Obtain and apply the transcutaneous pacemaker.
c. Give the scheduled dose of diltiazem (Cardizem).
d. Have the patient perform the Valsalva manoeuvre.

Answer 22

ANS: B

The patient is experiencing symptomatic bradycardia, and treatment with the transcutaneous pacemaker is appropriate.

Question 23

A 21-year-old college student arrives at the student health centre at the end of the quarter complaining, “My heart is skipping beats.” The nurse obtains an ECG and notes the presence of occasional PVCs. What action should the nurse take first?

a. Ask the patient about any history of coronary artery disease.
b. Question the patient about current stress level and coffee use.
c. Have the patient transported to the hospital ED.
d. Administer O2 to the patient at 2 to 3 L/min using nasal prongs.

Answer 23

ANS: B
In a patient with a normal heart, occasional PVCs are a benign finding. The timing of the PVCs suggests stress or caffeine as a possible etiological factor.

Question 24

A 19-year-old student has a mandatory ECG before participating on a university swim team and is found to have sinus bradycardia, rate 52 beats/min. BP is 114/54 mm Hg, and the student denies any health problems. Which nursing action is appropriate?

a. Refer the student to a cardiologist for further assessment.
b. Allow the student to participate on the swim team.
c. Obtain more detailed information about the student’s health history.
d. Tell the student to stop swimming immediately if any dyspnea occurs.

Answer 24

ANS: B
In an aerobically trained individual, sinus bradycardia is normal. The student’s normal BP and negative health history indicate that a cardiology referral or more detailed information about the health history is not necessary. Dyspnea during an aerobic activity such as swimming is normal.

Question 25

When analyzing the waveforms of a patient’s ECG, which finding will the nurse need to investigate further? a. PR interval of 0.18 second b. QRS interval of 0.14 second c. T wave of 0.16 second d. QT interval of 0.34 second

Answer 25

ANS: B Because the normal QRS interval is 0.06 to 0.10 second, the patient’s QRS interval of 0.14 second indicates that the conduction through the ventricular conduction system is prolonged.

Question 26

The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which is the most appropriate question for the nurse to ask? a. “Do you have a history of a heart attack?” b. “Have you had any recent immunizations?” c. “Have you been to the dentist lately?” d. “Do you have a family history of endocarditis?”

Answer 26

ANS: C | Dental procedures place the patient with a prosthetic mitral valve at risk for IE.

Question 27

The physician writes the following admitting orders for a patient with suspected IE who has fever and chills: ceftriaxone (Rocephin) 1.0 g intravenous (IV) piggyback every 12 hours, aspirin for a temperature above 38.9°C, blood cultures × 3, complete blood count, and electrocardiogram (ECG). When admitting the patient, to which of the following orders should the nurse give the highest priority? a. Scheduling the ECG b. Initiating the intravenous (IV) antibiotic c. Obtaining the blood cultures d. Administering the antipyretic agent

Answer 27

ANS: C Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results.

Question 28

During the assessment of a patient with IE, what would the nurse expect to find? a. A new regurgitant murmur b. Splinter hemorrhages of the lips c. Dyspnea and a dry, hacking cough d. Substernal chest pain and pressure

Answer 28

ANS: A | New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure.

Question 29

A patient is admitted to hospital with a diagnosis of myocarditis. The nurse knows that early cardiac manifestations will appear approximately how long after viral infection? a. 24 to 48 hours b. 3 to 5 days c. 7 to 10 days d. 2 to 3 weeks

Answer 29

ANS: C | Early cardiac manifestations appear 7 to 10 days after viral infection.

Question 30

A patient hospitalized with a streptococcal IE tells the nurse that the physician said treatment would require 4 to 6 weeks of antibiotic therapy and says she needs to get back to work as soon as possible. In advising the patient about the expected regimen for IE, what should the nurse explain about the treatment? a. After 2 weeks of IV antibiotic therapy, she may be discharged with oral antibiotics to take for another 4 weeks. b. Hospitalization for 4 to 6 weeks will be necessary to prevent a relapse while she receives IV antibiotic therapy. c. She may be able to receive outpatient IV antibiotic therapy with home nursing care if complications do not develop. d. She will be able to return to work as soon as her fever subsides if she does not develop any symptoms of heart failure.

Answer 30

ANS: C Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy to eradicate the bacteria, but patients frequently receive IV antibiotics on an outpatient basis.

Question 31

A patient who is hospitalized with IE develops sharp left flank pain and hematuria. The nurse notifies the physician, recognizing that these symptoms may indicate which of the following complications? a. Bacterial colonization in the kidneys b. Vegetative embolization to the kidneys c. Septicemia resulting in decreased glomerular blood flow d. Hemolysis of red blood cells by hemolytic microorganisms

Answer 31

ANS: B The patient’s clinical manifestations and history of IE indicate embolization. Sudden-onset flank pain is not typical of pyelonephritis, septicemia, or glomerulonephritis.

Question 32

A patient is admitted to the hospital with possible acute pericarditis. The nurse explains to the patient that to confirm a diagnosis of acute pericarditis, the physician will most likely use which of the following tests? a. Multiple ECGs b. Daily blood cultures c. Cardiac catheterization d. Fluid obtained by pericardiocentesis

Answer 32

ANS: A Pericarditis causes changes such as ST-segment elevation in multiple leads on the ECG, which evolve over the course of the inflammatory process, so multiple ECGs are warranted.

Question 33

To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse should undertake which of the following actions? a. Place the diaphragm of the stethoscope at the lower left sternal border of the chest. b. Ask the patient to stop breathing during auscultation to distinguish the sound from a pleural rub. c. Use the diaphragm of the stethoscope to listen for a rumbling, low-pitched sound that occurs during systole. d. Palpate the precordial area with the tips of the fingers to detect a vibration that occurs with each cardiac contraction.

Answer 33

ANS: A | Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border.

Question 34

The nurse suspects the development of cardiac tamponade in a patient with acute pericarditis on finding which of the following data? a. Blood pressure 166/96 mm Hg b. Jugular vein distension (JVD) to the level of the jaw c. A pulsus paradoxus of 8 mm Hg d. Level 6 chest pain on a 10-point scale with deep inspiration

Answer 34

ANS: B The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output.

Question 35

Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus paradoxus, what should the nurse do? a. Subtract one third of the diastolic BP from the systolic BP. b. Auscultate for a pericardial friction rub that increases in volume during inspiration. c. Evaluate the rhythm of the pulse in relation to the patient’s inspiration and expiration. d. Note the first Korotkoff sound occurring during both inspiration and expiration while deflating the blood pressure cuff.

Answer 35

ANS: D Pulsus paradoxus exists with a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle.

Question 36

The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. What is the most appropriate nursing intervention for this problem? a. Force fluids to 3000 mL/day to decrease fever and inflammation. b. Teach the patient to take deep, slow respirations to control the pain. c. Position the patient in a Fowler’s position, leaning forward on a padded overbed table. d. Consult with the physician to provide patient-controlled analgesia with a narcotic analgesic.

Answer 36

ANS: C | Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis.

Question 37

While obtaining a nursing history from a 23-year-old man with rheumatic fever, what information related by the patient does the nurse recognize as the most significant? a. Has used illicit IV drugs within the last 3 months b. Has been unemployed for 6 months and has been eating poorly c. Suffered chest trauma with a fractured rib during a fight 2 weeks ago d. Has had a recent sore throat

Answer 37

ANS: D | Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection.

Question 38

A 22-year-old patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis of multiple joints. What would the nurse document as an appropriate nursing diagnosis based on these findings? a. Activity intolerance related to fatigue and arthralgia b. Risk for infection related to open skin lesions c. Risk for impaired skin integrity related to pruritus and scratching d. Risk for impaired physical mobility related to permanent joint fixation

Answer 38

ANS: A | The clinical manifestations of rheumatic fever include fatigue and arthralgia.

Question 39

The nurse establishes the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge concerning long-term management of rheumatic fever when a patient recovering from rheumatic endocarditis makes which of the following remarks? a. “I will have to take prophylactic monthly antibiotic injections for at least 5 years.” b. “I should see my physician if I develop excessive fatigue or difficulty breathing.” c. “I will need to let my dentist know that I have had this rheumatic fever.” d. “I will be immune to further episodes of rheumatic fever after this infection.”

Answer 39

ANS: D | Patients with a history of rheumatic fever are more susceptible to a second episode.

Question 40

The community health nurse involved in programs to prevent rheumatic fever knows that which of the following interventions is the most important to decrease the incidence of the disease? a. Immunizing susceptible groups of people with streptococcal vaccine b. Providing prophylactic antibiotics to people with a family history of rheumatic fever c. Teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis d. Promoting hygienic measures to prevent the transmission of streptococcal infections

Answer 40

ANS: C Prevention involves early detection and immediate treatment of group A β-hemolytic streptococcal pharyngitis. Adequate treatment of streptococcal pharyngitis prevents initial attacks of rheumatic fever.

Question 41

Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important to report to the physician? a. A loud systolic murmur is audible along the right sternal border. b. The patient complains of chest pain associated with ambulation. c. The point of maximum impulse is at the left midclavicular line. d. A thrill is palpable at the second intercostal space, right sternal border.

Answer 41

ANS: B Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority.

Question 42

During assessment of a patient with mitral valve stenosis, which findings would the nurse recognize are characteristic of the pressure gradient differences occurring with mitral valve stenosis? a. Angina and syncope b. Dyspnea and hemoptysis c. JVD and peripheral edema d. Hypotension and paroxysmal nocturnal dyspnea

Answer 42

ANS: B The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in dyspnea and hemoptysis.

Question 43

A 21-year-old female student is scheduled for an open mitral valve commissurotomy for treatment of a mitral stenosis resulting from rheumatic endocarditis when she was a child. Which factor supports the choice of valve repair over valve replacement in this patient? a. No artificial valves are available yet to replace mitral valves. b. Valve repair has a lower operative mortality rate than does valve replacement. c. Biological replacement valves necessitate long-term immunosuppressive therapy. d. Long-term anticoagulation is necessary with mechanical valve replacement.

Answer 43

ANS: D | Long-term anticoagulation therapy is needed after mechanical valve replacement.

Question 44

While caring for a patient with mitral valve prolapse with mild valvular regurgitation, the nurse determines that discharge teaching has been effective when the patient tells the nurse that she will do which of the following? a. Take one aspirin a day to prevent embolization. b. Limit her physical activity to avoid stressing her heart valves. c. Schedule an appointment with her doctor every 6 months. d. Discuss the diagnosis of mitral valve prolapse with the dentist.

Answer 44

ANS: D Mitral valve prolapse with regurgitation is a risk factor for IE, and the patient needs to discuss the need for antibiotic prophylaxis with the health care provider before any invasive medical or dental procedure is done.

Question 45

Which pulse pattern would the nurse expect to diagnose on assessment of a patient who has mitral valve regurgitation? a. Bounding radial pulse b. Irregular radial pulse c. Thready peripheral pulses d. Absent peripheral pulses

Answer 45

ANS: C | Patients with acute mitral valve regurgitation will have thready, peripheral pulses and cool, clammy extremities.

Question 46

During postoperative teaching with a patient who has had a mitral valve replacement with a mechanical valve, what should the nurse instruct the patient about? a. The need to avoid high-voltage electrical fields b. The need for anticoagulation therapy for the duration of the valve c. The probability that the valve will need to be replaced in 7 to 10 years d. The need to check the pulse daily to determine the functioning of the valve

Answer 46

ANS: B Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve.

Question 47

A few days after an acute myocardial infarction, a patient complains of stabbing chest pain that increases with deep breathing. Which action will the nurse take first? a. Notify the patient’s physician. b. Auscultate the heart sounds. c. Check the patient’s oral temperature. d. Give the ordered acetaminophen (Tylenol).

Answer 47

ANS: B The patient’s clinical manifestations and history are consistent with pericarditis, and the nurse’s first action should be to listen for a pericardial friction rub.

Question 48

A patient who has had recent cardiac surgery develops pericarditis and complains of severe chest pain with deep breathing. Which of these ordered as-needed medications should the nurse administer? a. Oral acetaminophen (Tylenol) 650 mg b. Oral ibuprofen (Motrin) 800 mg c. IV morphine sulphate 6 mg d. Fentanyl (Sublimaze) 2 mg IV

Answer 48

ANS: B The pain associated with pericarditis is caused by inflammation, so nonsteroidal anti-inflammatory medications such as ibuprofen are most effective.

Question 49

Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be communicated to the physician immediately? a. The patient has a loud diastolic murmur all across the precordium. b. The patient has crackles audible to the lung apices. c. The patient has a palpable thrill felt over the left anterior chest. d. The patient has 4+ peripheral edema in both legs.

Answer 49

ANS: B Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure and needs immediate interventions such as diuretics.

Question 50

Which of the following is the primary symptom of mitral stenosis? a. Tachypnea b. Exertional dyspnea c. Atrial fibrillation d. Hemoptysis

Answer 50

ANS: B The primary symptom of mitral stenosis is exertional dyspnea, owing to reduced lung compliance. Patients may also have atrial fibrillation and hemoptysis, but these are not the primary symptoms of mitral stenosis.

Question 51

A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management of this disorder? a. Careful compliance with diet and medications will control the patient’s symptoms. b. Notify the doctor about any symptoms of heart failure such as shortness of breath. c. No more than one or two alcoholic drinks daily are permitted. d. Elevating the legs above the heart will help relieve angina.

Answer 51

ANS: B The patient should be instructed to notify the physician about any worsening of heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure.

Question 52

What is the term for flat, painless, small red spots on the palms and soles of a patient who has IE? a. Osler’s nodes b. Roth’s spots c. Janeway’s lesions d. Palmar surface paradoxus

Answer 52

ANS: C Janeway’s lesions is the term for the appearance of flat, painless, small red spots on the palms and soles of a patient with IE.

Question 53

Which of the following is the hallmark finding in a patient with acute pericarditis? a. Severe sharp chest pain. b. Pericardial friction rub. c. Referred pain to the trapezius muscle. d. Dyspnea

Answer 53

ANS: B | The hallmark finding in acute pericarditis is the pericardial friction rub.

Question 54

A patient with a history of a 4-cm fusiform abdominal aortic aneurysm (AAA) is admitted to the emergency department with severe back pain and bilateral flank ecchymosis. His vital signs are blood pressure (BP) 90/58 mm Hg, pulse 138 beats/min, and respiration 34 breaths/min. The nurse plans interventions for the patient based on the expectation that which of the following treatments will be included? a. Immediate surgery b. An immediate angiogram c. A paracentesis when vital signs are stabilized with fluid replacement d. Admission to the intensive care unit for observation while diagnostic tests are completed

Answer 54

ANS: A The patient’s history and clinical manifestations are consistent with rupture into the retroperitoneal space, and the patient will need immediate surgery to have a chance at survival.

Question 55

A 69-year old man is admitted to the hospital for elective repair of an AAA. His history includes hypertension for 25 years, dyslipidemia for 15 years, and smoking for 50 years. The patient’s wife asks the nurse what caused her husband’s aneurysm. The nurse’s best response will include which following information? a. A congenital weakness of an artery wall results in dilation of the artery after many years. b. Aneurysms are a type of vascular disease in which atherosclerotic plaques damage the artery. c. Chronic infections of the walls of the blood vessels are the most common cause of aneurysms. d. If her husband did not smoke or have hypertension and dyslipidemia, he would not have an aneurysm.

Answer 55

ANS: B The patient’s gender, age, and risk factor history indicate that the aneurysm was probably caused by atherosclerosis rather than a congenital weakness or chronic infection.

Question 56

A 65-year-old patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest X-ray examination. When obtaining a nursing history from the patient, what would the nurse specifically ask the patient about? a. Abdominal pain b. Dysphagia c. Intermittent back pain d. Weakness and palpitations

Answer 56

ANS: B | Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus.

Question 57

Several hours following an endovascular aneurysm repair, the patient develops left flank pain, and his urinary output has been 20 mL/hour for the past 2 hours. The nurse recognizes that these findings may indicate which of the following complications? a. Infection b. Hypovolemia c. Intestinal ischemia d. Renal artery occlusion

Answer 57

How frequently should the nurse check the operative extremity in the immediate postoperative period for a patient who has had surgical intervention for peripheral artery disease? a. Every 10 minutes b. Every 15 minutes c. Every 30 minutes d. Every 60 minutes

Question 58

After repair of an AAA, the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first? a. Review the preoperative assessment form for data about the pulses. b. Notify the surgeon and anaesthesiologist. c. Document that the pulses are absent, and recheck in 30 minutes. d. Elevate the lower extremities on pillows.

Answer 58

ANS: A Many patients with aortic aneurysms also have peripheral arterial disease (PAD), so the nurse should check the preoperative assessment to determine whether pulses were present before surgery before notifying the physicians about the absent pulses.

Question 59

What is a nursing intervention that is indicated for the collaborative problem of “potential complication: cardiac dysrhythmia” in a patient who has had a repair of a descending thoracic aortic aneurysm? a. Assess neurological signs hourly. b. Titrate oxygen to keep oxygen saturation greater than 90%. c. Maintain the patient on complete bed rest. d. Monitor urinary output and daily blood urea nitrogen and serum creatinine levels.

Answer 59

ANS: B | Hypoxemia may precipitate dysrhythmias in patients after aneurysm repair.

Question 60

When caring for a patient following an AAA repair, which information is most helpful to the nurse in assessing the patient’s gastrointestinal function? a. Serum lipase b. Bowel sounds c. Stool character d. Central venous pressure

Answer 60

ANS: B | The passing of flatus is the best indicator of returning bowel function.

Question 61

A 72-year-old man is hospitalized for an aortic dissection of the abdominal aorta that stabilizes with treatment. What emphasis should the nurse include when developing a teaching plan for the patient’s discharge? a. Performing leg exercises to increase peripheral collateral circulation b. Using nonsteroidal anti-inflammatory drugs (NSAIDs) to control his chronic pain c. Daily home monitoring of BP and pulse for signs of increased bleeding d. Using prescribed antihypertensive medications to keep his BP as low as possible to maintain vital perfusion

Answer 61

ANS: D | Antihypertensive medications are prescribed to help control BP and prevent redissection, leaking, or rupture.

Question 62

Which one of the following therapies is not recommended to treat claudication? a. Green tea b. Diet low in fruits and vegetables c. Vitamin E supplementation d. Treadmill exercise training

Answer 62

ANS: C | Vitamin E is not recommended to treat claudication.

Question 63

During an assessment of a 63-year-old man at the clinic, the patient tells the nurse that for years he has taken an evening walk, but lately even a short walk causes leg pain and muscle cramps. If he stops for a while, the pain goes away. What should the nurse do? a. Ask about any skin colour changes that occur in response to cold. b. Check for the presence of tortuous veins bilaterally on the legs. c. Assess for unilateral swelling, redness, and tenderness of either leg. d. Attempt to palpate the dorsalis pedis and posterior tibial pulses.

Answer 63

ANS: D The nurse should assess for other clinical manifestations of PAD in a patient who describes intermittent claudication, including palpating the dorsalis pedis and posterior tibial pulses.

Question 64

When performing an assessment with a patient who has chronic PAD, what should the nurse expect to find? a. Edema around the ankles and feet b. Ulceration around the medial malleoli c. Draining ulcer on the heel d. Prolonged capillary refill

Answer 64

ANS: D | Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery.

Question 65

To determine the extent of a patient’s PAD, how does the nurse perform an ankle–brachial index? a. By subtracting the mean ankle BP from the mean brachial BP b. By dividing the Doppler ultrasound-obtained ankle systolic BP by the highest brachial systolic BP c. By comparing the amplitude of blood flow of the brachial artery with that of the posterior tibial artery using a Doppler ultrasonograph d. By using a Doppler ultrasonograph to take blood pressures at the brachial artery, thigh, and ankle to determine the change in pressures

Answer 65

ANS: B The ankle–brachial index is determined by dividing the Doppler-obtained ankle systolic BP by the highest brachial systolic BP.

Question 66

The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient makes which of the following statements? a. “I will wear loose clothing that does not bind across my legs or waist.” b. “I will change my position every hour and avoid long periods of sitting with my legs down.” c. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.” d. “For about 40 minutes each day, I will walk to the point of pain, rest, and then walk again until I develop pain.”

Answer 66

ANS: C | Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns.

Question 67

Which of the following is a characteristic of PAD? a. Normal peripheral pulse b. Capillary refill 2 seconds c. Ankle–brachial index 0.98 d. No lower leg edema

Answer 67

ANS: D | A characteristic of PAD is the absence of lower leg edema as compared to lower leg edema in venous disease.

Question 68

A 36-year-old patient who has a history of thromboangiitis obliterans (Buerger’s disease) is admitted to the hospital with a gangrenous lesion of his right small toe. In planning expected outcomes with the patient, which outcome should the nurse give the highest priority? a. Cessation of smoking b. Maintenance of appropriate weight c. Control of serum lipid levels d. Demonstration of meticulous foot care

Answer 68

ANS: A | Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger’s disease.

Question 69

When teaching a patient with Raynaud’s phenomenon how to manage the condition, which of the following behaviours by the patient indicates that the teaching has been effective? a. The patient places the hands in hot water when they turn pale. b. The patient exercises indoors during the winter months. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids the use of aspirin and NSAIDs.

Answer 69

ANS: B | Patients should avoid temperature extremes by exercising indoors when it is cold.

Question 70

A patient admitted to the hospital with a chronic venous insufficiency has physician’s orders for bed rest with the feet elevated. How should the nurse elevate the patient’s feet? a. Place two pillows under the calf of her affected leg. b. Elevate the foot of the bed above the level of her heart. c. Elevate the bed at the knee, and place pillows under her feet. d. Place one pillow under her thighs and two pillows under her lower legs.

Answer 70

ANS: B The purpose of elevation of the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by elevating the foot of the bed above the level of the heart.

Question 71

Duplex scanning confirms the presence of a large deep-vein thrombosis (DVT), and the physician orders continuous IV heparin infusion for a patient who has swelling and pain of the upper leg. While the patient is receiving the heparin infusion, what should the nurse do? a. Avoid any intramuscular (IM) medications to prevent localized bleeding. b. Notify the physician if the partial thromboplastin time value is greater than 50 seconds. c. Have vitamin K available in case the patient bleeds from the action of heparin. d. Start instruction for self-administered subcutaneous heparin injections for long-term home therapy.

Answer 71

ANS: A | IM injections are avoided in patients receiving anticoagulation.

Question 72

Which of the following is a characteristic of a venous ulcer? a. Capillary refill 5 seconds b. Smooth, uniform ulcer margin. c. Skin warm to touch d. No dermatitis

Answer 72

ANS: C Skin temperature is warm with no temperature gradient with a venous ulcer. Capillary refill is less than 3 seconds, the ulcer margin is irregularly shaped, and the patient frequently has complaints of dermatitis.

Question 73

The nurse has identified the collaborative problem of “potential complication: pulmonary embolism” for a patient with DVT. What is an appropriate nursing intervention to prevent embolization of a thrombus? a. Maintain bed rest until edema resolves. b. Monitor vital signs and pulmonary status every 4 hours. c. Apply compression-gradient stockings while the patient is on bed rest. d. Perform passive range of motion of the affected extremity to increase venous return.

Answer 73

ANS: A | Decreasing muscle activity of the leg will help prevent thrombus dislodgement, so bed rest is warranted.

Question 74

A patient has been receiving IV heparin therapy for 6 days for treatment of DVT. The physician now orders warfarin (Coumadin) without discontinuing the heparin. The patient questions the nurse about the use of both drugs. What is the best response to the patient? a. “I will check with the doctor about this. You could be at risk for bleeding with both drugs.” b. “Because of the potential for a pulmonary embolism, it is important for you to have additional anticoagulants.” c. “It takes several days for the warfarin to have an effect, so we need to keep you on the heparin for a few more days.” d. “Because you are allowed more activity now, the heparin is metabolized faster and must be supplemented with the warfarin.”

Answer 74

ANS: C IV heparin is used because of the immediate effect on coagulation and is discontinued once the international normalized ratio value indicates that the warfarin has reached a therapeutic level.

Question 75

The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin following hospitalization for DVT. The nurse determines that additional teaching is needed when the patient makes which of the following statements? a. “I should change my diet to include more green, leafy vegetables.” b. “I will check with my physician before I begin or stop any medication.” c. “I should wear a MedicAlert bracelet to indicate I am on anticoagulant therapy.” d. “I will need to have my blood drawn routinely to monitor the effects of the warfarin.”

Answer 75

ANS: A Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables.

Question 76

A 42-year-old service counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient centre. What should the nurse teach the patient before discharge? a. Her exercise should be limited to leg raising and deep knee bends. b. She needs to revise her work station so that she can sit rather than stand at work. c. Taking one aspirin a day will help prevent clotting around incompetent venous valves. d. Elastic compression stockings should be applied before getting out of bed in the morning.

Answer 76

ANS: D | Compression stockings are applied with the legs elevated to reduce pressure in the lower legs.

Question 77

In planning care for a patient with a venous stasis ulcer on the right lower leg, what does the nurse understand is the most important intervention in promoting healing of the ulcer? a. Adequate dietary intake of proteins and vitamins b. Prevention of infection with prophylactic antibiotics c. Application of external compression to the lower leg d. Keeping the ulcer moist with hydrocolloid dressings

Answer 77

ANS: C Although all the above interventions are used, the most essential is compression of the leg to prevent the ulcer from becoming wider and deeper.

Question 78

A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of the following statements by the patient is most consistent with this diagnosis? a. “I have burning leg pains after I walk three blocks.” b. “I wake up during the night because my legs hurt.” c. “I can’t get my shoes on at the end of the day.” d. “I can never seem to get my feet warm enough.”

Answer 78

ANS: C Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day.

Question 79

Which statement by a patient who is being discharged on anticoagulant therapy 5 days after an AAA repair and graft indicates that the discharge teaching has been effective? a. “I will call the doctor if my temperature is higher than 38.8°C.” b. “I will tell my dentist about my anticoagulant therapy the next time I have an appointment.” c. “I should not need to take anything but acetaminophen (Tylenol) for my pain.” d. “I am eager to get home so that I can pick up my 6-year-old granddaughter.”

Answer 79

ANS: B Prophylactic antibiotics may be ordered to prevent graft infection when the patient has any invasive procedures, including dental procedures.

Question 80

A patient with PAD has a new prescription for clopidogrel (Plavix). Which information should the nurse include when teaching the patient about this medication? a. “Call if you notice that your stools are black or have blood in them.” b. “Take the clopidogrel on an empty stomach as soon as you get up.” c. “Change position slowly to avoid dizziness while you are taking clopidogrel.” d. “You should never use aspirin while you are taking clopidogrel.”

Answer 80

ANS: A Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding; therefore, patients should know that if their stools are black or have blood in them, they need to call their physician.

Question 81

A patient who is seen in the clinic tells the physician about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud’s phenomenon. The nurse will anticipate teaching the patient about screening tests for which of the following conditions? a. Coronary artery disease b. Familial dyslipidemia c. High BP d. Immune disorders

Answer 81

ANS: D Secondary Raynaud’s phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders.

Question 82

While working in the outpatient clinic, the nurse notes that the chart states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information? a. “My fingers hurt when I go outside in cold weather.” b. “Sometimes I get tired when I climb a lot of stairs.” c. “When I stand too long, my feet start to swell up.” d. “My legs cramp whenever I walk more than a block.”

Answer 82

ANS: D | Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication.

Question 83

Which of the following results of a D-dimer test would suggest that the patient has venous thromboembolism? a. 100 mcg/L b. 175 mcg/L c. 225 mcg/L d. 300 mcg/L

Answer 83

ANS: D | A normal D-dimer result is less than 250 mcg/L; an elevation indicates that the patient may have venous thromboembolism.

Question 84

Which of the following is an abnormal finding when performing an assessment of an 80-year-old patient? a. Loss of appetite and anorexia b. Difficulty chewing and swallowing food c. Complaints of indigestion and stomach fullness d. Consistent weight loss without change in dietary habits

Answer 84

ANS: D Unintentional weight loss is not a normal finding in older patients and may indicate a problem such as cancer or depression.

Question 85

To promote bowel evacuation in a patient with irregular bowel elimination, what should the nurse teach the patient about how to initiate the gastrocolic and duodenocolic reflexes, to facilitate bowel elimination when the patient attempts defecation? a. Try defecating after physical exercise. b. Try defecating after the first daily meal. c. Try defecating on arising in the morning. d. Try defecating on seeing and smelling food.

Answer 85

ANS: B | These reflexes are most active after the first daily meal.

Question 86

Upon doing a physical assessment of a patient’s gastrointestinal (GI) system, the nurse would expect to find the cecum and appendix in which quadrant? a. Right upper quadrant b. Left upper quadrant c. Right lower quadrant d. Left lower quadrant

Answer 86

ANS: C | The cecum and appendix are found in the right lower quadrant.

Question 87

A patient with an obstructed common bile duct has a T-tube placed in the common bile duct to drain bile produced by the liver. How much would the nurse expect the daily bile drainage to be? a. 50 mL b. 400 mL c. 1000 mL d. 2500 mL

Answer 87

ANS: C | The normal excretion of bile by the liver is about 1000 mL daily.

Question 88

A patient is complaining of heartburn and a burning sensation in the epigastric area. What is a possible etiology for these complaints? a. Cancer of the esophagus b. Hiatal hernia c. Peptic ulcer d. GI infection

Answer 88

ANS: B A patient who is complaining of heartburn and a burning in the epigastric area may have a hiatal hernia, esophagitis, or an incompetent lower esophageal sphincter.

Question 89

A 68-year-old patient awakens at night with heartburn and belching. The nurse recognizes that these symptoms may occur when which of the following structures relaxes abnormally? a. Epiglottis b. Ileocecal valve c. Pyloric sphincter d. Lower esophageal sphincter (LES)

Answer 89

ANS: D The LES at the distal end of the esophagus remains contracted except during swallowing, belching, or vomiting. The LES is an important barrier that prevents reflux of acidic gastric contents into the esophagus; therefore, with these symptoms, the patient is experiencing an abnormal relaxation of the LES.

Question 90

A patient has an abnormally high serum ammonia level. Which of the following does the nurse recognize this finding to be indicative of? a. A decreased bile flow into the intestine b. A decrease in the number of bowel bacteria that deaminate amino acids c. Failure of the liver to convert ammonia absorbed from the bowel to urea d. An increased reabsorption of urobilinogen from the bowel into the blood

Answer 90

ANS: C Conversion of ammonia to urea normally occurs in the liver. Elevation can result in hepatic encephalopathy secondary to liver cirrhosis.

Question 91

Following an episode of vomiting bright red blood, a patient is hospitalized for evaluation. During physical assessment of the patient, which of the following findings does the nurse identify as abnormal? a. Tympany on percussion of the abdomen b. The liver edge 3 cm below the costal margin c. Aortic pulsations visible in the epigastric area d. Bowel sounds of 30 per minute in each quadrant

Answer 91

ANS: B Normally, the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly. If the liver is palpable, it is not to extend beyond 1 to 2 cm below the ribs to remain within normal assessment findings.

Question 92

A patient returns to the nursing unit following an esophagogastroduodenoscopy (EGD). During postprocedure care, what is it most important for the nurse to do? a. Position the patient on the right side. b. Assess the patient’s respiratory pattern. c. Keep the patient on nothing by mouth (NPO) status until the gag reflex returns. d. Provide mouth care with saline rinses and gargles.

Answer 92

ANS: C Immediately after EGD, patients will have a decreased gag reflex and are at risk for aspiration; therefore, they are to be kept on NPO status until the gag reflex returns (usually 2 to 4 hours).

Question 93

While obtaining a nursing history from a patient, which over-the-counter medication that the patient uses does the nurse recognize as being significant to liver disorders? a. Aspirin b. Antacids c. Acetaminophen d. Cough suppressants

Answer 93

ANS: C | Chronic use of high doses of acetaminophen can be hepatotoxic.

Question 94

How should the nurse palpate the liver? a. Press slowly and firmly over the right costal margin with one hand, and withdraw the fingers quickly after the liver edge is felt. b. Place one hand on top of the other, and use the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. Place one hand on the patient’s back, and press upward and inward with the other hand below the patient’s right costal margin. d. Place one hand under the patient’s lower ribs, and press the left lower rib cage forward, palpating below the costal margin with the other hand.

Answer 94

ANS: C The liver is normally not palpable below the costal margin. The nurse needs to push inward below the right costal margin while lifting the patient’s back slightly with the left hand.

Question 95

Which following finding would the nurse expect to be present during auscultation of the abdomen of a patient with a bowel obstruction? a. Decreased, low-pitched bowel sounds b. Frequent clicking sounds c. Absence of bowel sounds d. Loud gurgles

Answer 95

ANS: C Normal bowel sounds occur 5 to 35 times per minute. The nurse should listen for bowel sounds in each quadrant for 2 to 5 minutes. With a bowel obstruction, there is an absence of bowel sounds.

Question 96

When caring for a patient following a needle biopsy of the liver at the bedside, what should the nurse do? a. Elevate the head of the bed to facilitate breathing. b. Check the patient’s postbiopsy coagulation studies. c. Place the patient on the right side with the bed flat. d. Instruct the patient to take shallow breaths to avoid pressure on the liver.

Answer 96

ANS: C | After a biopsy, the patient lies on the right side with the bed flat to splint the biopsy site.

Question 97

The nurse documents the absence of bowel sounds in all quadrants of a patient’s abdomen. How long should the nurse have auscultated the patient’s abdomen? a. 8 minutes b. 10 minutes c. 16 minutes d. 20 minutes

Answer 97

ANS: D | To document absent bowel sounds, the nurse should listen to each quadrant for 5 minutes, for a total of 20 minutes.

Question 98

A healthy adult produces approximately how much saliva on a daily basis? a. 500 mL b. 1000 mL c. 1500 mL d. 2000 mL

Answer 98

ANS: B | Approximately 1 L of saliva is produced each day.

Question 99

Which major GI hormone is responsible for stimulating pancreatic bicarbonate secretion? a. Gastrin b. Secretin c. Cholecystokinin d. Gastric inhibitory peptide

Answer 99

ANS: B Secretin is responsible for stimulating pancreatic bicarbonate secretion, as well as inhibiting gastric motility and acid secretion.

Question 100

Which one of the following is an age-related change in the GI system? a. Increased sense of smell b. Increased sensitivity of taste buds c. Atrophy of gingival tissue d. Increased motility of small intestine

Answer 100

ANS: C A normal age-related change in the GI system is atrophy of gingival tissue. Other age-related changes include a decreased sense of smell, a decreased sensitivity of taste buds, and decreased motility of the small intestine.