Nur 504 Exam 1 TestBank Questions With Complete
Solutions
A client presents to the emergency department with a thoracic
aortic aneurysm. Which
findings are most consistent with this condition? (Select all that
apply.)
a. Abdominal tenderness
b. Difficulty swallowing
c. Changes in bowel habits
d. Shortness of breath
e. Hoarseness Correct Answers ANS: B, E
Signs of a thoracic aortic aneurysm include shortness of breath,
hoarseness, and difficulty
swallowing. Pain is often rated as a 10 on a 10-point scale.
Bowel habits are not related.
A client with a known abdominal aortic aneurysm reports
dizziness and severe abdominal
pain. The nurse assesses the client's blood pressure at 82/40 mm
Hg. What actions by the
nurse are most important? (Select all that apply.)
a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes. Correct Answers ANS: B,
D, E
This client may have a ruptured/rupturing aneurysm. The nurse
would notify the Rapid
,Response team and perform frequent client assessments. Giving
pain medication will lower
the client's blood pressure even further. The nurse cannot have
the client sign a consent until
the surgeon has explained the procedure.
A new nurse is caring for a client with an abdominal aneurysm.
What action by the new nurse
requires the nurse's mentor to intervene?
a. Assesses the client for back pain.
b. Auscultates over abdominal bruit.
c. Measures the abdominal girth.
d. Palpates the abdomen in four quadrants. Correct Answers
ANS: D
Abdominal aneurysms should never be palpated as this increases
the risk of rupture. The nurse
mentoring the new nurse would intervene when the new nurse
attempts to do this. The other
actions are appropriate.
A nurse administers prescribed adenosine to a client. Which
response would the nurse assess for as the expected therapeutic
response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis Correct Answers ANS: C
Clients usually respond to adenosine with a short period of
asystole, bradycardia with long
pauses, nausea, or vomiting. Adenosine has no impact on
intraocular pressure nor does it
,cause increased heart rate or hypertensive crisis.
A nurse admits a client who is experiencing an exacerbation of
heart failure. What action
would the nurse take first?
a. Assess the client's respiratory status.
b. Draw blood to assess the client's serum electrolytes.
c. Administer intravenous furosemide.
d. Ask the client about current medications. Correct Answers
ANS: A
Assessment of respiratory and oxygenation status is the most
important nursing intervention
for the prevention of complications. Monitoring electrolytes,
administering diuretics, and
asking about current medications are important but do not take
precedence over assessing
respiratory status.
A nurse assesses a client 2 hours after a cardiac angiography via
the left femoral artery. The
nurse notes that the left pedal pulse is weak. What action would
the nurse take next?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as "left pedal pulse of +1/4." Correct
Answers ANS: C
Loss of a pulse distal to an angiography entry site is serious,
indicating a possible arterial
obstruction. The left pulse would be compared with the right,
and pulses would be compared
, with previous assessments, especially before the procedure.
Assessing color (pale, cyanosis)
and temperature (cool, cold) will identify a decrease in
circulation. Once all peripheral and
vascular assessment data are acquired, the primary health care
provider would be notified.
Simply documenting the findings is inappropriate. The leg
would be positioned below the
level of the heart to increase blood flow to the distal portion of
the leg. Increasing intravenous
fluids will not address the client's problem.
A nurse assesses a client admitted to the cardiac unit. Which
statement by the client alerts the
nurse to the possibility of right-sided heart failure?
a. "I sleep with four pillows at night."
b. "My shoes fit really tight lately."
c. "I wake up coughing every night."
d. "I have trouble catching my breath." Correct Answers ANS:
B
Signs of systemic congestion occur with right-sided heart
failure. Fluid is retained, pressure
builds in the venous system, and peripheral edema develops.
Left-sided heart failure
symptoms include respiratory symptoms. Orthopnea, coughing,
and difficulty breathing all
could be results of left-sided heart failure.
A nurse assesses a client after administering a prescribed beta
blocker. Which assessment
would the nurse expect to find?
Solutions
A client presents to the emergency department with a thoracic
aortic aneurysm. Which
findings are most consistent with this condition? (Select all that
apply.)
a. Abdominal tenderness
b. Difficulty swallowing
c. Changes in bowel habits
d. Shortness of breath
e. Hoarseness Correct Answers ANS: B, E
Signs of a thoracic aortic aneurysm include shortness of breath,
hoarseness, and difficulty
swallowing. Pain is often rated as a 10 on a 10-point scale.
Bowel habits are not related.
A client with a known abdominal aortic aneurysm reports
dizziness and severe abdominal
pain. The nurse assesses the client's blood pressure at 82/40 mm
Hg. What actions by the
nurse are most important? (Select all that apply.)
a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes. Correct Answers ANS: B,
D, E
This client may have a ruptured/rupturing aneurysm. The nurse
would notify the Rapid
,Response team and perform frequent client assessments. Giving
pain medication will lower
the client's blood pressure even further. The nurse cannot have
the client sign a consent until
the surgeon has explained the procedure.
A new nurse is caring for a client with an abdominal aneurysm.
What action by the new nurse
requires the nurse's mentor to intervene?
a. Assesses the client for back pain.
b. Auscultates over abdominal bruit.
c. Measures the abdominal girth.
d. Palpates the abdomen in four quadrants. Correct Answers
ANS: D
Abdominal aneurysms should never be palpated as this increases
the risk of rupture. The nurse
mentoring the new nurse would intervene when the new nurse
attempts to do this. The other
actions are appropriate.
A nurse administers prescribed adenosine to a client. Which
response would the nurse assess for as the expected therapeutic
response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis Correct Answers ANS: C
Clients usually respond to adenosine with a short period of
asystole, bradycardia with long
pauses, nausea, or vomiting. Adenosine has no impact on
intraocular pressure nor does it
,cause increased heart rate or hypertensive crisis.
A nurse admits a client who is experiencing an exacerbation of
heart failure. What action
would the nurse take first?
a. Assess the client's respiratory status.
b. Draw blood to assess the client's serum electrolytes.
c. Administer intravenous furosemide.
d. Ask the client about current medications. Correct Answers
ANS: A
Assessment of respiratory and oxygenation status is the most
important nursing intervention
for the prevention of complications. Monitoring electrolytes,
administering diuretics, and
asking about current medications are important but do not take
precedence over assessing
respiratory status.
A nurse assesses a client 2 hours after a cardiac angiography via
the left femoral artery. The
nurse notes that the left pedal pulse is weak. What action would
the nurse take next?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as "left pedal pulse of +1/4." Correct
Answers ANS: C
Loss of a pulse distal to an angiography entry site is serious,
indicating a possible arterial
obstruction. The left pulse would be compared with the right,
and pulses would be compared
, with previous assessments, especially before the procedure.
Assessing color (pale, cyanosis)
and temperature (cool, cold) will identify a decrease in
circulation. Once all peripheral and
vascular assessment data are acquired, the primary health care
provider would be notified.
Simply documenting the findings is inappropriate. The leg
would be positioned below the
level of the heart to increase blood flow to the distal portion of
the leg. Increasing intravenous
fluids will not address the client's problem.
A nurse assesses a client admitted to the cardiac unit. Which
statement by the client alerts the
nurse to the possibility of right-sided heart failure?
a. "I sleep with four pillows at night."
b. "My shoes fit really tight lately."
c. "I wake up coughing every night."
d. "I have trouble catching my breath." Correct Answers ANS:
B
Signs of systemic congestion occur with right-sided heart
failure. Fluid is retained, pressure
builds in the venous system, and peripheral edema develops.
Left-sided heart failure
symptoms include respiratory symptoms. Orthopnea, coughing,
and difficulty breathing all
could be results of left-sided heart failure.
A nurse assesses a client after administering a prescribed beta
blocker. Which assessment
would the nurse expect to find?
