1.Answer: b .
Rationale:Raynaud ’s disease responds favorably to eliminating caffeine from the diet and cessation of smoking. Medications may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms still could occur with the use of air conditioning and during periods of cooler weather
2.Answer:a .
Rationale:The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger ’s disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component
3.Answer:b .
Rationale:Hypersensitivity or a sensation of “pins and needles ”in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Because complications from this surgery are relatively rare, this symptom should be reported.
4.Answer:c .
Rationale:Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset, and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.
5.Answer:b .
Rationale:In the first several hours after insertion of a permanent or a temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client ’s activities of the arm on the side of the insertion site.
6.Answer: c .
Rationale:An automatic internal cardioverter-defibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes related to ventricular tachycardia.
7. Answer: b .
Rationale:The nurse or rescuer puts two large adhesive patch electrodes on the client ’s chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds . The machine then indicates if defibrillation is necessary
8.Answer: a .
Rationale:After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation.
9.Answer:c .
Rationale:The client may be defibrillated up to three times in succession . The energy levels used are 200 , 300 , and 360 J for the first , second , and third attempts , respectively .
10.Answer: c .
Rationale:Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
11.Answer:c .
Rationale:Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
12.Answer: a .
Rationale:Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm . Options b , c , and d are incorrect descriptions of this procedure .
13.Answer:a .
Rationale:Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombi formation
14.Answer: C .
Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
15.Answer: d .
Rationale:Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds . Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented . Options a, b , and c will not assist in terminating the dysrhythmia.
16.Answer: c .
Rationale:First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is contraindicated.
17.Answer:a .
Rationale:Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.
18.Answer:C .
Rationale: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second) , and typically a rate between 140 and 180 impulses/min . The rhythm is regular. Level of
19.Answer:b .
Rationale: Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are higher than 100 beats/min .
20.Answer: c .
Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Options 2 and 4 will not help in tolerating ambulation . Removal of telemetry equipment is contraindicated unless prescribed.
21.Answer:b .
Rationale: The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or glomerulonephritis.
22.Answer:b .
Rationale:Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium .
23.Answer:b .
Rationale:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway.
24.Answer:a.
Rationale: Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (β-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart.
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