NUR361 EXAM 2 NURSELABS
CARDIOVACULAR QUESTIONS
COMPLETE WITH 100% CORRECT
ANSWERS WITH DETAILED
RATIONALES
\.A client is scheduled for a cardiac catheterization using a radiopaque dye. Which
of the following assessments is most critical before the procedure?
A. Intake and output
B. Baseline peripheral pulse rates
C. Height and weight
D. Allergy to iodine or shellfish - ANSWERS✔-D. Allergy to iodine or shellfish
This procedure requires an informed consent because it involves injection of a
radiopaque dye into the blood vessel. The risk of allergic reaction and possible
anaphylaxis is serious and must be assessed before the procedure. Allergic
reactions can be related to the use of local anesthetic, contrast agents, heparin or
other medications used during the procedure. Reactions to the contrast agents
can occur in up to 1% of the patients, and people with prior reactions are
pretreated with corticosteroids and antihistamines.
,\.A client with no history of cardiovascular disease comes into the ambulatory
clinic with flu-like symptoms. The client suddenly complains of chest pain. Which
of the following questions would best help a nurse to discriminate pain caused by
a non-cardiac problem?
A. "Have you ever had this pain before?"
B. "Can you describe the pain to me?"
C. "Does the pain get worse when you breathe in?"
D. "Can you rate the pain on a scale of 1-10, with ten (10) being the worst?" -
ANSWERS✔-C. "Does the pain get worse when you breathe in?"
Chest pain is assessed by using the standard pain assessment parameters. It is
very important to find out what makes the pain worse. Is there an exertional
component, is it associated with eating or breathing? Is there a positional
component? Don't forget to ask about new workout routines, sports, and lifting.
Ask what medications they have tried.
\.A client with myocardial infarction has been transferred from a coronary care
unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans
to allow for which of the following client activities?
A. Strict bed rest for 24 hours after transfer.
B. Bathroom privileges and self-care activities.
C. Unsupervised hallway ambulation with distances under 200 feet.
,D. Ad lib activities because the client is monitored. - ANSWERS✔-B. Bathroom
privileges and self-care activities
On transfer from the CCU, the client is allowed self-care activities and bathroom
privileges. Supervised ambulation for brief distances is encouraged, with distances
gradually increased (50, 100, 200 feet). A patient on telemetry should be
visualized hourly. With every ECG alarm, the patient should be visualized and
assessed (refer to Nursing Assessment Clinical Guideline). It is the responsibility of
nursing staff to know the whereabouts of their patient at all times - toilet doors
should not be locked - however, laminated signs may be used on doors instead
\.A nurse notes 2+ bilateral edema in the lower extremities of a client with
myocardial infarction who was admitted two (2) days ago. The nurse would plan to
do which of the following next?
A. Review the intake and output records for the last two (2) days.
B. Change the time of diuretic administration from morning to evening.
C. Request a sodium restriction of one (1) g/day from the physician.
D. Order daily weight starting the following morning. - ANSWERS✔-A. Review the
intake and output records for the last 2 days.
Edema, the accumulation of excess fluid in the interstitial spaces, can be
measured by intake greater than output and by a sudden increase in weight.
Monitor intake and output. Note decreased urinary output and positive fluid
balance on 24-hour calculations. Decreased renal perfusion, cardiac insufficiency,
and fluid shifts may cause decreased urinary output and edema formation.
, \.A nurse is assessing the blood pressure of a client diagnosed with primary
hypertension. The nurse ensures accurate measurement by avoiding which of the
following?
A. Seating the client with arm bared, supported, and at heart level.
B. Measuring the blood pressure after the client has been seated quietly for 5
minutes.
C. Using a cuff with a rubber bladder that encircles at least 80% of the limb.
D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. -
ANSWERS✔-D. Taking a blood pressure within 15 minutes after nicotine or
caffeine ingestion.
BP should be taken with the client seated with the arm bared, positioned with
support, and at heart level. The client should sit with the legs on the floor, feet
uncrossed, and not speak during the recording. The client should not have smoked
tobacco or taken in caffeine in the 30 minutes preceding the measurement. First,
the patient should be questioned regarding recent caffeine consumption, exercise,
or smoking. If any of these activities have occurred within the last 30 minutes,
blood pressure measurement should be postponed until this period has passed.
\.IV heparin therapy is ordered for a client. While implementing this order, a nurse
ensures that which of the following medications is available in the nursing unit?
A. Vitamin K
B. Aminocaproic acid
C. Potassium chloride
D. Protamine sulfate - ANSWERS✔-D. Protamine sulfate
CARDIOVACULAR QUESTIONS
COMPLETE WITH 100% CORRECT
ANSWERS WITH DETAILED
RATIONALES
\.A client is scheduled for a cardiac catheterization using a radiopaque dye. Which
of the following assessments is most critical before the procedure?
A. Intake and output
B. Baseline peripheral pulse rates
C. Height and weight
D. Allergy to iodine or shellfish - ANSWERS✔-D. Allergy to iodine or shellfish
This procedure requires an informed consent because it involves injection of a
radiopaque dye into the blood vessel. The risk of allergic reaction and possible
anaphylaxis is serious and must be assessed before the procedure. Allergic
reactions can be related to the use of local anesthetic, contrast agents, heparin or
other medications used during the procedure. Reactions to the contrast agents
can occur in up to 1% of the patients, and people with prior reactions are
pretreated with corticosteroids and antihistamines.
,\.A client with no history of cardiovascular disease comes into the ambulatory
clinic with flu-like symptoms. The client suddenly complains of chest pain. Which
of the following questions would best help a nurse to discriminate pain caused by
a non-cardiac problem?
A. "Have you ever had this pain before?"
B. "Can you describe the pain to me?"
C. "Does the pain get worse when you breathe in?"
D. "Can you rate the pain on a scale of 1-10, with ten (10) being the worst?" -
ANSWERS✔-C. "Does the pain get worse when you breathe in?"
Chest pain is assessed by using the standard pain assessment parameters. It is
very important to find out what makes the pain worse. Is there an exertional
component, is it associated with eating or breathing? Is there a positional
component? Don't forget to ask about new workout routines, sports, and lifting.
Ask what medications they have tried.
\.A client with myocardial infarction has been transferred from a coronary care
unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans
to allow for which of the following client activities?
A. Strict bed rest for 24 hours after transfer.
B. Bathroom privileges and self-care activities.
C. Unsupervised hallway ambulation with distances under 200 feet.
,D. Ad lib activities because the client is monitored. - ANSWERS✔-B. Bathroom
privileges and self-care activities
On transfer from the CCU, the client is allowed self-care activities and bathroom
privileges. Supervised ambulation for brief distances is encouraged, with distances
gradually increased (50, 100, 200 feet). A patient on telemetry should be
visualized hourly. With every ECG alarm, the patient should be visualized and
assessed (refer to Nursing Assessment Clinical Guideline). It is the responsibility of
nursing staff to know the whereabouts of their patient at all times - toilet doors
should not be locked - however, laminated signs may be used on doors instead
\.A nurse notes 2+ bilateral edema in the lower extremities of a client with
myocardial infarction who was admitted two (2) days ago. The nurse would plan to
do which of the following next?
A. Review the intake and output records for the last two (2) days.
B. Change the time of diuretic administration from morning to evening.
C. Request a sodium restriction of one (1) g/day from the physician.
D. Order daily weight starting the following morning. - ANSWERS✔-A. Review the
intake and output records for the last 2 days.
Edema, the accumulation of excess fluid in the interstitial spaces, can be
measured by intake greater than output and by a sudden increase in weight.
Monitor intake and output. Note decreased urinary output and positive fluid
balance on 24-hour calculations. Decreased renal perfusion, cardiac insufficiency,
and fluid shifts may cause decreased urinary output and edema formation.
, \.A nurse is assessing the blood pressure of a client diagnosed with primary
hypertension. The nurse ensures accurate measurement by avoiding which of the
following?
A. Seating the client with arm bared, supported, and at heart level.
B. Measuring the blood pressure after the client has been seated quietly for 5
minutes.
C. Using a cuff with a rubber bladder that encircles at least 80% of the limb.
D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion. -
ANSWERS✔-D. Taking a blood pressure within 15 minutes after nicotine or
caffeine ingestion.
BP should be taken with the client seated with the arm bared, positioned with
support, and at heart level. The client should sit with the legs on the floor, feet
uncrossed, and not speak during the recording. The client should not have smoked
tobacco or taken in caffeine in the 30 minutes preceding the measurement. First,
the patient should be questioned regarding recent caffeine consumption, exercise,
or smoking. If any of these activities have occurred within the last 30 minutes,
blood pressure measurement should be postponed until this period has passed.
\.IV heparin therapy is ordered for a client. While implementing this order, a nurse
ensures that which of the following medications is available in the nursing unit?
A. Vitamin K
B. Aminocaproic acid
C. Potassium chloride
D. Protamine sulfate - ANSWERS✔-D. Protamine sulfate
