1.A nurse has given instructions to the client with Raynaud ’s disease about self-management of the disease process. The nurse determines that the client needs further reinforcement of teaching if the client states which of the following?
a . “Smoking cessation is important. ”
b . “Moving to a warmer climate is needed. ”
c . “Sources of caffeine should be eliminated from the diet. ”
d . “Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."
2.A 24-year- old man seeks medical attention for complaints of claudication in the arch of the foot . A nurse also notes superficial thrombophlebitis of the lower leg. For which risk factor should the nurse assess based on these clinical findings?
a . Smoking history
b . Recent exposure to allergens
c . History of recent insect bites
d . Familial tendency toward peripheral vascular disease
3.A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of “pins and needles ”in the affected leg. Which of the following would be an appropriate action by the nurse based on evaluation of the client ’s comment?
a . Instruct the client to apply warm packs.
b . Report the complaint to the physician.
c . Reassure the client that this is only temporary.
d . Advise the client to take acetaminophen (Tylenol) until it is gone.
4.A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of which of the following?
a . Pneumonia
b . Pulmonary edema
c . Pulmonary embolism
d . Myocardial infarction
5.A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which of the following activities will assist with preventing dislodgement of the pacing catheter?
a . Limiting movement and abduction of the left arm
b . Limiting movement and abduction of the right arm
c . Assisting the client to get out of bed and ambulate with a walker
d . Having the physical therapist do active range-of-motion exercises to the right arm
6.A nurse employed in a cardiac unit determines that which of the following clients is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)?
a . A client with syncopal episodes related to ventricular tachycardia
b . A client with ventricular dysrhythmias despite medication therapy
c . A client with an episode of cardiac arrest related to myocardial infarction
d . A client with three episodes of cardiac arrest unrelated to myocardial infarction
7.A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client ’s cardiac rhythm?
a. Hold the defibrillator paddles firmly against the chest.
b . Apply adhesive patch electrodes to the chest and move away from the client.
c . Apply standard electrocardiographic monitoring leads to the client and observe the rhythm.
d . Connect standard electrocardiographic electrodes to a transtelephonic monitoring device.
8.A nurse would evaluate that defibrillation of a client was most successful if which of the following observations was made?
a . Arousable , sinus rhythm , BP 116/72 mm Hg
b . Arousable , marked bradycardia , BP 86/54 mm Hg
c . Nonarousable , supraventricular tachycardia , BP 122/60 mm Hg
d . Nonarousable , sinus rhythm , BP 88/60 mm Hg
9.A client in ventricular fibrillation is about to be defibrillated. A nurse knows that to convert this rhythm effectively, the machine should be set at which of the following energy levels (in joules, J) for the first delivery?
a . 50 J
b . 100 J
c . 200 J
d . 360 J
10.A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client ’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How would the nurse correctly interpret this rhythm?
a . Asystole
b . Atrial fibrillation
c . Ventricular fibrillation
d . Ventricular tachycardia
11.A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client ’s rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How would the nurse correctly interpret this rhythm?
a . Asystole
b . Atrial fibrillation
c . Ventricular fibrillation
d . Ventricular tachycardia
12.A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid sinus massage. Which of the following would be reflective of a correct explanation provided by the nurse?
a . The vagus nerve slows the heart rate.
b . The diaphragmatic nerve slows the heart rate.
c . The diaphragmatic nerve overdrives the rhythm.
d . The vagus nerve increases the heart rate, overdriving the rhythm.
13.A nurse is watching the cardiac monitor, and a client ’s rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse correctly interpret the client ’s heart rhythm?
a. Atrial fibrillation
b . Sinus tachycardia
c . Ventricular fibrillation
d . Ventricular tachycardia
14.A client has developed atrial fibrillation , with a ventricular rate of 150 beats/min . The nurse should assess the client for which associated signs or symptoms?
a . Flat neck veins
b . Nausea and vomiting
c . Hypotension and dizziness
d . Hypertension and headache
15.A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia?
a . Lie down flat in bed.
b . Remove any metal jewelry.
c . Breathe deeply, regularly, and easily.
d . Inhale deeply and cough forcefully every 1 to 3 seconds .
16.A nurse is viewing the cardiac monitor in a client ’s room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?
a . Immediately defibrillate.
b . Prepare for pacemaker insertion.
c . Administer amiodarone (Cordarone) intravenously.
d . Administer epinephrine (Adrenalin) intravenously.
17.most concerned about with this dysrhythmia?
a . It can develop into ventricular fibrillation at any time.
b . It is almost impossible to convert to a normal rhythm.
c . It is uncomfortable for the client, giving a sense of impending doom.
d . It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.
18.A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves , the QRS complexes are wide , and the ventricular rate is regular but over 100 beats/min . The nurse determines that the client is experiencing which of the following dysrhythmias?
a . Sinus tachycardia
b . Ventricular fibrillation
c . Ventricular tachycardia
d . Premature ventricular contractions
19.A client ’s electrocardiogram strip shows atrial and ventricular rates of 110 beats/min . The PR interval is 0.14 second , the QRS complex measures 0.08 second , and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?
a. Sinus arrhythmia
b . Sinus tachycardia
c . Sinus bradycardia
d . Normal sinus rhythm
20.A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?
a . Remove telemetry equipment.
b . Provide the client with a walker.
c . Premedicate the client with an analgesic.
d . Encourage the client to cough and deep breathe.
21.A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours . The client received a single bolus of 500 mL of intravenous fluid . Urine output for the subsequent hour was 25 mL . Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL . Based on these findings , the nurse would anticipate that the client is at risk for which of the following?
a . Hypovolemia
b . Acute renal failure
c . Glomerulonephritis
d . Urinary tract infection
22.A client with myocardial infarction is going into cardiogenic shock. Because of the risk of myocardial ischemia, for which of the following should the nurse carefully assess the client?
a. Bradycardia
b . Ventricular dysrhythmias
c . Rising diastolic blood pressure
d . Falling central venous pressure
23.A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client ’s breath sounds?
a . Stridor
b . Crackles
c . Scattered rhonchi
d . Diminished breath sounds
24.A nurse is preparing for the admission of a client with heart failure who is being sent directly to the hospital from the physician ’s office. The nurse would plan on having which of the following medications readily available for use?
a . Digoxin (Lanoxin)
b . Verapamil (Calan)
c . Propranolol (Inderal)
d . Diltiazem (Cardizem)
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