Reason: A low urine output and confusion are signs of decreased tissue perfusion.Orthopnea is a sign of left-sided heart failure. Crackles, edema and weight gain should be monitored closely, but the levels are not as high a priority. With atrial fi brillation there is a loss of atrial kick,but the blood pressure and heart rate are stable.
2. Answer b
Reason: Thrombolytic drugs are administered within the fi rst 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage.
3. Answer d.
Reason:The nurse should fi rst assess the client’s tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if Atropine is needed. If the client is symptomatic,Atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.
4. Answer a.
Reason:Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse,decreased
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.
5.Answer a
Reason:An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles. To distinguish an S3 from a physiologic S2 split,a split S2 occurs during
inspiration and S3 remains constant during the respiratory cycle. Its pitch is softer and best heard with the bell at the apex and it is one of the first clinical findings in left ventricular failure. An S4 is heard in late diastole when atrial contraction pumps volume into a stiff, noncompliant ventricle.An S4 is not heard in a client with atrial fi brillation because there is no atrial contraction. Murmurs are sounds created by turbulent blood fl ow through an incompetent
or stenotic valve.
6.Answer a
Reason:I.V. 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.
7.Answer d
Reason: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.
8. Answer a
Reason:The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected,
and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn-mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities.
9.Answer c
Reason: Coumadin is an anticoagulant, which is used in the treatment of atrial fi brillation and decreased left ventricular ejection fraction (less than 20%) to prevent thrombus formation and release of emboli into the circulation. The client may also take other medication as needed to manage the heart failure. Coumadin does not reduce circulatory load or improve myocardial workload. Coumadin does not affect cardiac rhythm.
10.Answer a
Reason: 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.
11.Answer c
Reason: Colored vision and seeing yellow spots are symptoms of digoxin toxicity. Abdominal pain,anorexia, nausea, and vomiting are other common symptoms of digoxin toxicity. Additional signs of toxicity include arrhythmias, such as atrial fibrillation or bradycardia. Rash, increased appetite, and elevated blood pressure are not associated with
digoxin toxicity.
12. Answer d
Reason: A low serum potassium level (hypokalemia) predisposes the client to digoxin toxicity. Because potassium inhibits cardiac excitability,a low serum potassium level would mean that the client would be prone to increased cardiac excitability. Sodium, glucose, and calcium levels do not affect digoxin or contribute to digoxin toxicity.
13.Answer b
Reason: A normal apical impulse is found over the apex of the heart and is typically located and auscultated in the left fi fth intercostal space in the midclavicular line. An apical impulse located
or auscultated below the fi fth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.
14.Answer c
Reason: 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 lb 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 lifethreatening.Following a high-fi ber diet is beneficial, but it is not relevant to the teaching needs of the client with heart failure. Prescribing an exercise program for the client, such as walking 2 miles every day,would not be appropriate at discharge. The client’s exercise
program would need to be planned in consultation with the physician and based on the history and the physical condition of the client.
The client may sting before an exercise plan is laid out. Although
the nurse does not prescribe an exercise program for the client, a sedentary lifestyle should not be recommended.
15. Answer c
Reason: Assessment of circulatory status, including observation of the puncture site,is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
16. Answer a
Reason: Many factors help prevent wound infections,including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning 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 hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
17. Answer c
Reason: 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.
18. Answer c
Reason: Compliance is the most critical element of hypertension therapy. In most cases,hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension.
19.Answer a
Reason: Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems,
the hypertension may go undetected. CVAs can be related to long-term
hypertension. Liver or pulmonary disease is not generally associated with hypertension.Myocardial infarction is generally related to coronary artery disease.
20.Answer b
Reason: The client may be asymptomatic and the underlying cause should be assessed. Drugs that block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers, digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing.There is no indication for a fl uid bolus, cardioversion,or arterial line.
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