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Reference:

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1. A 60-year-old male client comes into the emergency department with complaints of crushing
substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute
myocardial infraction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute,
blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate
given intravenously. The nurse should first:
a. Administer the morphine
b. Obtain a 12-lead ECG
c. Obtain the blood work
d. Order the chest radiograph
Ans: A ± although obtaining the ECG, chest radiograph, and blood work are all important, the nurse¶s
priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate
is priority action.

2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him
that the purpose of the drug is to:
a. Help keep him well hydrated
b. Dissolve clots that he may have
c. Prevent kidney failure
d. Treat potential cardiac dysrhythmias
Ans: B ± thrombolytic drugs are administered within the first 6 hours after of myocardial infarction to
lyse clots and reduce the extent of myocardial damage.

3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs should
the nurse expect to observe?
a. Oliguria
b. Bradycardia
c. Elevated blood pressure
d. Fever
Ans: A ± oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys.
Typically signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine
output, and signs of diminished blood flow to the brain, such as confusion and restlessness.
Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not
a typical sign of cardiogenic shock.
4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI. essential
nursing action include which of the following?
a. Obtaining an infusion pump for the medication
b. Monitoring blood pressure every 4 hours
c. Monitoring urine output hourly
d. Obtaining serum potassium levels daily
Ans: A ± intravenous nitroglycerin infusion requires an infusion pump for precise control of the
medication. Blood pressure monitoring would be done with a continuous system, and more frequently
than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is
not associated with nitroglycerin infusion.

5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused by:
a. Left ventricular overload
b. Impending circulatory collapse
c. Extracellular electrolyte imbalances
d. Insufficient oxygen reaching the heart muscle
Ans: D ± an MI interferes with or blocks circulation to the heart muscle. Decreased blood supply to the
heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of
oxygen to the cardiac muscle results in ischemic pain or angina.

6. Aspirin is administered to the client experiencing an MI because of its:


a. Antipyretic action
b. Antithrombotic action
c. Antiplatelet action
d. Analgesic action
Ans: B ± aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason
aspirin is administered to the client experiencing an MI is its antithrombotic action. In clinical trials, the
antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI.

7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the
cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and oxygen at
2 L/minute. The nurse¶s first course of action should be to:
a. Increase the intravenous infusion rate
b. Notify the physician promptly
c. Increase the oxygen concentration
d. Administer a prescribed analgesic
Ans: B ± PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia
and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate
greater than five or six per minute in the post-MI client, the physician should be notified immediately.
More than six PVCs per minute is considered serious and usually calls for decreasing ventricular
irritability by administering medications such as lidocaine hydrochloride. Increasing the intravenous
infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not
be the nurse¶s first course of action; rather, the nurse should notify the physician promptly.
Administering a prescribed analgesic would not decrease ventricular irritability.

8. Which of the following is an expected outcome for a client on the second day of hospitalization after
an MI? The client:
a. Has minimal chest pain
b. Can identify risk factors for MI
c. Agrees to participate in a cardiac rehabilitation program
d. Can perform personal self-care activities without pain
Ans: D ± by day 2 of hospitalization after an MI, clients are expected to be able to perform personal
care without chest pain. Day 2 of hospitalization may be too soon for clients to be able to identify risk
factors for MI or to be able to agree to participate in a cardiac rehabilitation program.

9. When teaching a client about the expected outcomes after intravenous administration of furosemide,
the nurse would include which outcome?
a. Increased blood pressure
b. Increased urine output
c. Decreased pain
d. Decreased PVCs
Ans: B ± furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase
blood pressure, decrease pain, or decrease dysrhythmias.

10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This type
of exercise is recommended primarily to help:
a. Prepare the client for ambulation
b. Promote urinary and intestinal elimination
c. Prevent thrombophlebitis and blood clot formation
d. Decrease the likelihood of decubitus ulcer formation
Ans: C ± although this type of exercise may decrease the likelihood of heel decubitus ulcer form
formation, it is taught to the MI client to prevent thrombophlebitis and blood clot formation. Movement
of the lower extremities provides muscular action and aids venous return. As a result, the activity helps
prevent stasis of blood, which predisposes the client to thrombophlebitis and blood clot formation. This
type of exercise is not associated with promoting urinary and intestinal elimination.

11. Which of the following reflects the principle on which a client¶s diet will most likely be based
during the acute phase of MI?
a. Liquids as desired
b. Small, easily digested meals
c. Three regular meals per day
d. Nothing by mouth
Ans: B ± recommended dietary principles in the acute phase of MI include avoiding large meals
because small, easily digested foods are better tolerated. Fluids are given according to the client¶s
needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart
failure. Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only
or restricted to nothing by mouth unless their condition is very unstable.

12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely
linked to the development of the disease?
a. Age
b. Medication usage
c. High cholesterol levels
d. Gender
Ans: C ± high cholesterol levels are considered a controllable risk factor for CAD and appear most
clearly linked to the development of the disease. High cholesterol levels can be modified through diet,
exercise, and medication. Age and gender are uncontrollable risk factors for CAD. Medication usage is
not considered a risk factor for CAD.

13. Which of the following is an uncontrollable risk factor that has been linked to the development of
CAD?
a. Exercise
b. Obesity
c. Stress
d. Heredity
Ans: D ± heredity has been linked to CAD and is an uncontrollable risk factor. Exercise, obesity, and
stress are controllable risk factor for CAD.

14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated
fat, or leading a sedentary lifestyle, technique of behavior modification may be used to help the client
change behavior. The nurse can best reinforce new adaptive behaviors by:
a. Explaining how the old behavior leads to poor health
b. Withholding praise until the new behavior is well established
c. Rewarding the client whenever the acceptable behavior is performed
d. Instilling mild fear into the client to extinguish the behavior
Ans: C ± a basic principle of behavior modification is that behavior that is learned and continued is
behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective
as reward.

15. Alteplase recombinant. Or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is


administered during the first 6 hours after onset of MI to:
a. Control chest pain
b. Reduce coronary artery vasospasm
c. Control the dysrhythmias associated with MI
d. Revascularize the blocked coronary artery
Ans: D ± the thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary
artery. The drug is most effective when administered within the first 6 hours after onset.

16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to:
a. Observe the client for chest pain
b. Monitor for fever
c. Monitor the 12-lead ECG every 4 hours
d. Monitor breath sounds
Ans: A ± although monitoring the 12-lead ECG and monitoring breath sounds are important, observing
the client for chest pain is the nursing assessment priority, because closure of the previously obstructed
coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of
the artery after t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin
time are essential to detect complications. Administration of t-PA should not cause fever.

17. When monitoring a client who is receiving t-PA, the nurse understands it is important to monitor
vital signs and have resuscitation equipment available because reperfusion of the cardiac tissue can
result in which of the following?
a. Cardiac dysrhythmias
b. Hypertension
c. Seizure
d. Hypothermia
Ans: A ± cardiac dysrhythmias are commonly observed with administration of t-PA. Cardiac
dysrhythmias associated with reperfusion of the cardiac tissue. Hypotension is commonly observed
with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of
the cardiac tissue.

18. Contraindication to the administration of t-PA include which of the following?


a. Age greater than 60 years
b. History of cerebral hemorrhage
c. History of heart failure
d. Cigarette smoking
Ans: B ± a past history of cerebral hemorrhage is a contraindication to administration of t-PA because
the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and
cigarette smoking are not contraindications.

19. A client has driven himself into the emergency room. He is 50 years old, has a history of
hypertension, and informs the nurse that his father died from a heart attack at 60 years of age. The
client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins
administering oxygen at 2 L/minute per nasal cannula. The nurse¶s next action would be to:
a. Call for the doctor
b. Start an intravenous line
c. Obtain a portable chest radiograph
d. Draw blood for laboratory studies
Ans: B ± advanced cardiac life support recommends that at least one or two intravenous lines be
inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest
radiograph, and drawing blood for the laboratory are important but secondary to starting the
intravenous line.

20. Crackles heard on lung auscultation indicate which of the following?


a. Cyanosis
b. Bronchospasm
c. Airway narrowing
d. Fluid-filled alveoli
Ans: D ± crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not
have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with
wheezing sounds.

21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to complain
of chest heaviness. The first nursing action should be to:
a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness
b. Administer oxygen via nasal cannula
c. Offer pain medication for the chest heaviness
d. Inform the physician of the chest heaviness
Ans: A ± further assessments is needed in this situation. It is premature to initiate other actions until
further data have been gathered. Inquiring about the onset, duration, location, severity, and
precipitating factors of the chest heaviness will provide pertinent information to convey to the
physician.

22. The nurse receives emergency laboratory results for a client with chest pain and immediately
informs the physician. An increased myoglobin level suggests which of the following?
a. Cancer
b. Hypertension
c. Liver disease
d. Myocardial damage
Ans: D ± detection of myoglobin is one diagnostic tool to determine whether myocardial damage has
occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks
within 4 to 6 hours after physician.

23. An older, sedentary adult may not respond to emotional or physical stress as well as a younger
individual because of:
a. Left ventricular atrophy
b. Irregular heart beats
c. Peripheral vascular occlusion
d. Pacemaker placement
Ans: A ± in older adults who are less active and do not exercise the heart muscle, atrophy can result.
Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a
result, under sudden able to respond to the increased demands on the myocardial muscle. Decreased
cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may
develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are
generally not associated with an older sedentary adult¶s lifestyle. Peripheral vascular occlusion of
pacemaker placement should not affect response to stress.

The Client With Heart Failure

24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency department
with heart failure complicated by pulmonary edema. On admission of this client, which of the
following should be assessed first?
a. Blood pressure
b. Skin breakdown
c. Serum potassium
d. Urine output
Ans: A ± it is a priority to assess the blood pressure first, because people with pulmonary edema
typically experience severe hypertension that requires early intervention.

25. In which of the following should the nurse place a client with suspected heart failure?
a. Semi-sitting (Low Fowler¶s position)
b. Lying on the right side (Sims¶ position)
c. Sitting almost upright (High Fowler¶s position)
d. Lying on the back with the head lowered (Trendelenburg position)
Ans: C ± sitting almost upright in bed with the feet and legs resting on the mattress decreases venous
return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum
space for lung expansion. Low Fowler¶s position would be used if the client could not tolerate high
Fowler¶s position for some reason. Lying on the right side would not be a good position for the client in
heart failure. The client in heart failure would not tolerate the Trendelenburg position.

26. Which of the following would be a priority nursing diagnosis for the client with heart failure and
pulmonary edema?
a. Risk for infection related to line placements
b. Impaired skin integrity related to pressure
c. Activity intolerance related to imbalance between oxygen supply and demand
d. Constipation related to immobility
Ans: C ± activity intolerance is a primary problem for clients with heart failure and pulmonary edema.
The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients
frequently complain of dyspnea and fatigue. The client could be at risk for infection related to line
placements or impaired skin integrity related to pressure. However, these are not the priority nursing
diagnoses for the client with heart failure and pulmonary edema, nor is constipation related to
immobility.
27. The major goal of therapy for a client with heart failure and pulmonary edema would be to:
a. Increase cardiac output
b. Improve respiratory edema
c. Decrease peripheral edema
d. Enhance comfort
Ans: A ± increasing cardiac output is the main goal of therapy for the client with heart failure or
pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention.
Respiratory status and comfort will be improved when cardiac output increases to an acceptable level.
Peripheral edema is not typically associated with pulmonary edema.

28. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts
to:
a. Dilate coronary arteries
b. Increase myocardial contractility
c. Decrease cardiac dysrhythmias
d. Decrease electrical conductivity in the heart
Ans: B ± digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes
increased strength of myocardial contractions and thereby increases output of blood from the left
ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias
and does decrease the electrical conductivity of the myocardium, this is not the primary reason for its
use in clients with heart failure and pulmonary edema.

29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client


with heart failure because it acts as a:
a. Vasopressor
b. Volume expander
c. Vasodilator
d. Potassium-sparing diuretic
Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe
congestive heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve
survival in overt heart failure.

30. Furosemide is administered intravenously to a client with heart failure. How soon after
administration should the nurse begin to see evidence of the drug¶s desired effect?
a. 5 to 10 minutes
b. 30 to 60 minutes
c. 2 to 4 hours
d. 6 to 8 hours
Ans: A ± after intravenous injection of furosemide, diuresis normally begins in about 5 minutes and
reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is
given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given
intravenously.

31. The nurse teaches a client with heart failure to take oral Furosemide in the morning. The primary
reason for this is to help:
a. Prevent electrolyte imbalances
b. Retard rapid drug absorption
c. Excrete excessive fluids accumulated during the night
d. Prevent sleep disturbances during the night
Ans: D ± when diuretics are given early in the day, the client will void frequently during the daytime
hours and will not need to void frequently during the night. Therefore, the client¶s sleep will not be
disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or
retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.

32. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse
would suspect atrial fibrillation when palpation of the radial pulse reveals:
a. Two regular beats followed by one irregular
b. An irregular pulse rhythm
c. Pulse rate below 60 bpm
d. A weak, thready pulse
Ans: B ± characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular
rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the
irregular rate and should report it to the physician. A weak, thready pulse is characteristic of a client in
shock.

33. When teaching the client about complications of atrial fibrillation, the nurse understands that the
complications can be caused by:
a. Stasis of blood in the atria
b. Increased cardiac output
c. Decreased pulse rate
d. Elevated blood pressure
Ans: A ± atrial fibrillation occurs when the sinoatrial node no longer functions as the heart¶s pacemaker
and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed,
atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some
estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not
associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is
associated with an increased pulse rate.

34. The nurse should teach the client that signs of digitalis toxicity include which of the following?
a. Skin rash over the chest and back
b. Increased appetite
c. Visual disturbances such as seeing yellow spots
d. Elevated blood pressure
Ans: C ± colored vision and seeing yellow spots are symptoms of digitalis toxicity. Abdominal pain,
anorexia, nausea, and vomiting are other common symptoms of digitalis toxicity. Additional signs of
toxicity include dysrhythmias, such as atrial fibrillation or bradycardia. Skin rash, increased appetite,
and elevated blood pressure are not associated with digitalis toxicity.

35. The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels
indicate that the client has a:
a. Low sodium level
b. High glucose level
c. High calcium level
d. Low potassium level
Ans: D ± a low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity.
Because potassium inhibits cardiac excitability, a low serum potassium level would mean that the client
would be prone to increased cardiac excitability.

36. Which of the following foods should the nurse teach a client with heart failure to avoid or limit
when following a 2-g sodium diet?
a. Apples
b. Tomato juice
c. Whole wheat bread
d. Beef tenderloin
Ans: B ± canned foods and juices, such as tomato juice, are typically high in sodium and should be
avoided in a sodium-restricted diet, canned foods and juices in which sodium has been removed or
limited are available. The client should be taught to read labels carefully. Apples and whole wheat
breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato
juice.

37. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic
should be encouraged to eat such foods as bananas, orange juice, and,
a. Spinach
b. Skimmed milk
c. Baked chicken
d. Brown rice
Ans: A ± foods rich in potassium include bananas, orange juice, and green leafy vegetables such as
spinach. Honeydew melon, cantaloupe, and watermelons are also rich in potassium. Other good sources
of potassium are grapefruit juice, nectarines, potatoes, dried prunes, raisins, and figs. Skimmed milk,
baked chicken, and brown rice are not considered high in potassium.

38. The nurse finds the apical impulses below the fifth intercostals space. The nurse suspects
a. Left atrial enlargement
b. Left ventricular enlargement
c. Right atrial enlargement
d. Right ventricular enlargement
Ans: B - a normal apical impulse is found over the apex of the heart and is typically located and
auscultated in the left fifth intercostals space in the midclavicular line. An apical impulse located or
auscultated below the fifth intercostals space or lateral to the midclavicular line may indicate left
ventricular enlargement.

39. The nurse is admitting a 69-year old man to the clinical unit. The client has a history of left
ventricular enlargement. During the assessment the nurse notes +3 pitting edema of the ankles
bilaterally. The client does not have chest pain. The nurse observes that the client does have dyspnea at
rest. The nurse infers that the client may have
a. Arteriosclerosis
b. Congestive heart failure
c. Chronic bronchitis
d. Acute myocardial infarction
Ans: B ± peripheral edema is a symptom of congestive heart failure. Congestive heart failure results
when the heart chronically pumps against increased resistance or is unable to contract forcefully to
pump the blood out into the systemic circulation. As a result, the ventricles become overfilled and there
is an accumulation of volume within the closed system. The client¶s symptoms do not indicate
arteriosclerosis, chronic bronchitis, or acute MI.

40. The nurse¶s discharge teaching plan for the client with congestive heart failure would stress the
significance of which of the following?
a. Maintaining a high-fiber diet
b. Walking 2 miles every day
c. Obtaining daily weights at the same time each day
d. Remaining sedentary for most of the day
Ans: C ± Congestive heart failure is a complex and chronic condition. Education should focus on health
promotion and preventive care in the home environment. Signs and symptoms can be monitored by the
client. Instructing the client to obtain daily weights at the same time each day is very important. The
client should be told to call the physician if there has been a weight gain of 2 pounds or more. This may
indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than
waiting until the symptoms become life threatening. Following a high-fiber diet id beneficial, but it is
not relevant to the teaching needs of the client with congestive heart failure. Prescribing an exercise
program for the client, such as walking 2 miles everyday, would not be appropriate at discharge. The
client¶s exercise program would need to be planned in consultation with the physician and based on his
history and the physical condition of the client. The client may require exercise tolerance testing before
an exercise plan is laid out. Although the nurse does not pre-lifestyle should not be recommended.

41. A 70-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis
and mitral regurgitation. Although the diagnosis was made during childhood, she did not have
symptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin
and furosemide. During the initial interview with the client, the nurse would most likely learn that the
client¶s childhood health history included:
a. Chicken pox
b. Poliomyelitis
c. Rheumatic fever
d. Meningitis
Ans: C ± Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis.
Chicken pox, poliomyelitis, and meningitis are not associated with mitral stenosis.

42. A client experiences some initial signs of excitation after having an intravenous infusion of
lidocaine hydrochloride started. The nurse would assess that the client is demonstrating a typical
adverse reaction to lidocaine hydrochloride when the client complains of:
a. Palpitations
b. Tinnitus
c. Urinary frequency
d. Lethargy
Ans: B ± Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision,
tremors, numbness and tingling of extremities, excessive perspiration, hypotension, convulsions, and
finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary
frequency, and lethargy are not considered typical adverse reactions to lidocaine hydrochloride.

43. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter
inserted. The physician orders pulmonary capillary wedge pressures. The purpose of this is to help
assess the:
a. Degree of coronary artery stenosis
b. Peripheral arterial pressure
c. Pressure from fluid within the left ventricle
d. Oxygen and carbon dioxide concentrations in the blood
Ans: C ± the pulmonary artery pressures are used to assess the heart¶s ability to receive and pump
blood. The pulmonary capillary wedge pressure reflects the left ventricular end-diastolic pressure and
guides the physician in determining fluid management for the client. The degree of coronary artery
stenosis is assessed during a cardiac catheterization. The peripheral arterial pressure is assessed with an
arterial line. The oxygen and carbon dioxide concentrations in the arterial blood can be measured by an
arterial blood gas determination.

44. Which of the following signs and symptoms would most likely be found in a client with mitral
regurgitation?
a. Exertional dyspnea
b. Confusion
c. Elevated creatine phosphokinase concentration
d. Chest pain
Ans: A ± weight gain due to fluid retention and worsening heart failure cause exertional dyspnea in
clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is
transmitted backward to the pulmonary veins, capillaries, and arterioles and eventually to he right
ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow. Confusion,
elevated creatine phosphokinase concentration, and chest pain are not typically associated with mitral
regurgitation.
45. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated with
congestion in the:
a. Aorta
b. Right atrium
c. Superior vena cava
d. Pulmonary circulation
Ans: D ± when mitral stenosis is present, the left atrium has difficulty emptying its contents into the left
ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the
pulmonary circulation is under pressure. functioning of the aorta, right atrium, and superior vena cava
is not immediately influenced by mitral stenosis.

46. Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively
assesses the client¶s past compliance with medical regimens. Lack of compliance with which of the
following regimens would pose the greatest health hazard to this client?
a. Medication therapy
b. Diet modification
c. Activity restrictions
d. Dental care
Ans: A ± preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart
disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with
bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage
schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism.
Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever.
Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper
respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and
dental care are important; however, they do not have as much significance postoperatively as
medication therapy does.

47. In preparing the client and the family for a postoperative stay in the intensive care unit after open
heart surgery, the nurse should explain that:
a. The client will remain in the intensive care unit for 5 days
b. The client will sleep most of the time while in the intensive care unit
c. Noise and activity within the intensive care unit are minimal
d. The client will receive medication to relieve pain
Ans: D ± management of postoperative pain is priority for the client after surgery, including valve
replacement surgery, according to the Agency for Health Care Policy and Research. The client and
family should be informed that pain will be assessed by the nurse and medications will be given to
relieve the pain. The client will stay in the intensive care unit as long as monitoring and intensive care
are needed. Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns
are some environmental factors that affect recovery from valve replacement surgery.

48. A client who has undergone a mitral valve replacement experiences persistent bleeding from the
surgical incision during the early postoperative period. Which of the following pharmaceutical agents
should the nurse be prepared to administer to this client?
a. Vitamin C
b. Protamine sulfate
c. Quinidine sulfate
d. Warfarin sodium (Coumadin)
Ans: B ± protamine sulfate is used to help combat persistent bleeding in a client who has had open
heart surgery. Vitamin C and quinidine sulfate do not influence blood clotting. Warfarin sodium is an
anticoagulant, as is heparin, and these two agents would tend to cause the client to bleed even more.

49. The most effective measure the nurse can use to prevent wound infection when changing a client¶s
dressing after coronary artery bypass surgery is to:
a. Observe careful handwashing procedures
b. Cleanse the incisional area with an antiseptic
c. Use prepackaged sterile dressings to cover the incision
d. Place soiled dressings in a waterproof bag before disposing of them
Ans: A ± many factors help prevent wound infections, including washing hands carefully, using the
sterile prepackaged supplies and equipment, cleansing the incisional area well, and disposing of soiled
dressings properly. However, most authorities say that the single most effective measure in preventing
wound infections is to wash the hands carefully before and after changing dressings. Careful
handwashing is also important in helping reduce other infections often acquired in hospitals, such as
urinary tract and respiratory system infections.

50. For a client who excretes excessive amounts of calcium during the postoperative period after open
surgery, which of the following measures should the nurse institute to help prevent complications
associated with excessive calcium excretion?
a. Ensure a liberal fluid intake
b. Provide an alkaline-ash diet
c. Prevent constipation
d. Enrich the client¶s diet with dairy products
Ans: A ± in an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid.
When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi.
Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless
contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the
solubility of calcium. Preventing constipation is not associated with excessive calcium excretion.
Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.

51. The nurse teaches the client who is receiving warfarin sodium that:
a. Partial thromboplastin time values determine the dosage of warfarin sodium
b. Protamine sulfate is used to reverse the effects of warfarin sodium
c. The international normalized ration (INR) is used to assess effectiveness
d. Warfarin sodium will facilitate clotting of the blood
Ans: C - the INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the
prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health
Organization was used for the plasma test. It is now the recommended method to monitor effectiveness
of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2
to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was
maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the
effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium¶s
anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will
help to prevent blood clots.

52. Good dental care is an important measure in reducing risk of endocarditis. A teaching plan to
promote good dental care in a client with mitral stenosis should include demonstration of the proper use
of:
a. A manual toothbrush
b. An electric toothbrush
c. An irrigation device
d. Dental floss
Ans: A ± daily dental care and frequent checkups by a dentist who is informed about the client¶s
condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device,
or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the
bloodstream, increasing the risk of endocarditis.

53. Before a client¶s disease discharge after mitral valve replacement surgery, the nurse should evaluate
the client¶s understanding of postsurgery activity restrictions. Which of the following should the client
not engage in until after the 1-month-old postdischarge appointment with the surgeon?
a. Showering
b. Lifting anything heavier than 10 pounds
c. A program of gradually progressive walking
d. Light housework
Ans: B ± most cardiac surgical clients have median sternotomy incisions, which take about 3 months to
heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning
exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is
well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.

54. Three days after mitral valve surgery, a 45-year-old woman comments that she hears a ³ clicking´
noise coming from her chest and her ³ rather large´ chest incision. The nurse¶s response should reflect
the understanding that the client may be experiencing which of the following?
a. Anxiety related to altered body image
b. Anxiety related to altered health status
c. Altered tissue perfusion
d. Lack of knowledge regarding the postoperative course
Ans: A ± verbalized concerns from the client may stem from her anxiety over the changes her body has
gone through after open heart surgery. Although the client may experience anxiety related to her altered
health status or may have a lack of knowledge regarding her postoperative course, she is pointing out
the changes in her body image. The client is not concerned about altered tissue perfusion.

The Client With Hypertension

55. An industrial health nurse at a large printing plant finds a male employee¶s blood pressure to be
elevated on two occasions 1 month apart and refers him to his provide physician. The employee is
about 25 pounds overweight and has smoked a pack of cigarettes daily for more than 20 years. The
client¶s physician prescribes atenolol for the hypertension. The nurse should instruct the client to:
a. Avoid sudden discontinuation of the drug
b. Monitor the blood pressure annually
c. Follow a 2-g sodium diet
d. Discontinue the medication if severe headaches develop
Ans: A ± atenolol is -adrenergic antagonists indicated for management of hypertension. Sudden
discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication should
not be discontinued without a doctor¶s order. Blood pressure needs to be monitored more frequently
than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually
placed on a 2-g sodium diet for hypertension.

56. The nurse teaches her client, who has recently been diagnosed with hypertension, about his dietary
restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would
best meet the client¶s?
a. Mixed green salad with blue cheese dressing, crackers, and cold cuts
b. Ham sandwich on rye bread and an orange
c. Baked chicken, an apple, and a slice of white bread
d. Hot dogs, baked beans, and celery and carrot sticks
Ans: C ± processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both
and fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions
of all types are complex and difficult to implement\ with clients who are basically asymptomatic.

57. A client¶s job involves working in a warm, dry room, frequently bending and crouching to check
the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should
assess the client for which of the following?
a. Muscle aches
b. Thirst
c. Lethargy
d. Postural hypotension
Ans: D ± possible dizziness from postural hypotension when rising a crouched or bent position
increases the client¶s risk of being injured by the equipment. The nurse should assess the client¶s blood
pressure in all three positions (lying, sitting, and standing) at all routine visits. The client may
experience muscle aches, or thirst from working in a warm, dry room, but these are not as potentially
dangerous as postural hypotension. The client should not be experiencing lethargy.

58. An exercise program is prescribed for the client with hypertension. Which intervention would be
most likely to assist the client in maintaining an exercise program?
a. Giving the client a written exercise program.
b. Explaining the exercise program to the client¶s spouse.
c. Reassuring the client that he or she can do the exercise program.
d. Tailoring a program to the client¶s needs and abilities.
Ans: D ± tailoring or individualizing a program to the client¶s lifestyle has been shown to be an
effective strategy for changing health behaviors. Providing a written program, explaining the program
to the client¶s spouse, and reassuring the client that he or she can do the program may be helpful but are
not as likely to promote adherence as individualizing the program.

59. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the
client achieve this goal. Which of the following nursing interventions should be the initial step in this
plan?
a. Review the negative effects of smoking on the body.
b. Discuss the effects of passive smoking on environmental pollution.
c. Established the client¶s smoking pattern.
d. Explain how smoking worsens high blood pressure.
Ans: C - a plan to reduce or stop smoking begins with establishing the client¶s personal daily smoking
pattern and activities associated with smoking. It is important that the client understands the associated
health and environmental risk, but this knowledge has not been shown to help clients change their
smoking behavior.

60. Essential Hypertension would be diagnosed in a 40-year-old man whose blood pressure readings
were consistently at or above which of the following?
a. 120/90 mmHg
b. 130/85 mmHg
c. 140/90 mmHg
d. 160/80 mmHg
Ans: C ± Heart Center of the Philippines standards define hypertension as a consistent systolic blood
pressure level greater than 140 mmHg and a consistent diastolic blood pressure level greater than 90
mmH.