NURSING Med Surg 2
SAUNDERS COMPREHENSIVE
REVIEW TEST BANK.
A client is admitted to the emergency department
with chest pain that is consistent with myocardial
infarction based on elevated troponin levels.
Heart sounds are normal and vital signs are noted
on the client's chart. The nurse should alert the
health care provider because these changes are
most consistent with which complication? Refer
to chart.
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm - answer- 1
Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle.
Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine
output; and cool, clammy skin. Respiratory rate increases as the body develops
metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled
heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with
severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are
accompanied by back pain.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus
is scheduled for cardiac catheterization. Which medication would need to be withheld
for 24 hours before the procedure and for 48 hours after the procedure?
1. Glipizide
2. Metformin
3. Repaglinide
4. Regular insulin - answer- 2
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac
catheterization because of the injection of contrast medium during the procedure. If the
contrast medium affects kidney function, with metformin in the system the client would
be at increased risk for lactic acidosis. The medications in the remaining options do not
need to be withheld 24 hours before and 48 hours after cardiac catheterization.
,A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of
dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the
nurse anticipate will be prescribed?
1. Administer digoxin.
2. Defibrillate the client.
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing - answer- 4
Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm
becomes a concern when the client becomes symptomatic. Hypotension and dizziness
are signs of decreased cardiac output. Transcutaneous pacing provides a temporary
measure to increase the heart rate and thus perfusion in the symptomatic client.
Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular
fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the
client delays necessary intervention.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects
pulmonary edema. The nurse immediately asks another nurse to contact the health care
provider and prepares to implement which priority interventions? (SELECT ALL THAT
APPLY.)
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position - answer- 1, 2, 3, 4
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure
increases in the lungs because of the accumulated blood. Oxygen is always prescribed,
and the client is placed in a high Fowler's position to ease the work of breathing.
Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is
inserted to measure output accurately. Intravenously administered morphine sulfate
reduces venous return (preload), decreases anxiety, and also reduces the work of
breathing. Transporting the client to the coronary care unit is not a priority intervention.
In fact, this may not be necessary at all if the client's response to treatment is
successful.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air
hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse
anticipate when auscultating the client's breath sounds?
1. Stridor
,2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds - answer- 2
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.
A client with myocardial infarction is developing cardiogenic shock. Because of the risk
of myocardial ischemia, what condition should the nurse carefully assess the client for?
1. Bradycardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure - answer- 2
Classic signs of cardiogenic shock as they relate to myocardial ischemia 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.
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20
mL/hour 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(16 mmol/L) and the serum creatinine level is
2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that
the client is at risk for which problem?
1. Hypovolemia
2. Acute kidney injury
3. Glomerulonephritis
4. Urinary tract infection - answer- 2
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion,
hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is
signaled by decreased urine output and increased blood urea nitrogen (BUN) and
creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L),
and creatinine: male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97
mcmol/L). 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, glomerulonephritis, or urinary tract infection.
, The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS
complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure
0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse
take?
1. Check vital signs.
2. Check laboratory test results.
3. Notify the health care provider.
4. Continue to monitor for any rhythm change. - answer- 4
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100
beats/minute. The PR and QRS measurements are normal, measuring between 0.12
and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities
in this rhythm currently, so there is no immediate need to check vital signs or laboratory
results, or to notify the health care provider. Therefore, the nurse would continue to
monitor the client for any rhythm change.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The
nurse sees no electrocardiographic complexes on the screen. Which is the priority
nursing action?
1. Call a code.
2. Call the health care provider.
3. Check the client's status and lead placement.
4. Press the recorder button on the electrocardiogram console. - answer- 3
: Sudden loss of electrocardiographic complexes indicates ventricular asystole or
possibly electrode displacement. Accurate assessment of the client and equipment is
necessary to determine the cause and identify the appropriate intervention. The
remaining options are secondary to client assessment.
The 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 more than 140 beats/minute. The nurse determines that the client is
experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions - answer- 3
Ventricular tachycardia is characterized by the absence of P waves, wide QRS
complexes (longer than 0.12 seconds), and typically a rate between 140 and 180
impulses/minute. The rhythm is regular.
SAUNDERS COMPREHENSIVE
REVIEW TEST BANK.
A client is admitted to the emergency department
with chest pain that is consistent with myocardial
infarction based on elevated troponin levels.
Heart sounds are normal and vital signs are noted
on the client's chart. The nurse should alert the
health care provider because these changes are
most consistent with which complication? Refer
to chart.
1. Cardiogenic shock
2. Cardiac tamponade
3. Pulmonary embolism
4. Dissecting thoracic aortic aneurysm - answer- 1
Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle.
Classic signs include hypotension; a rapid pulse that becomes weaker; decreased urine
output; and cool, clammy skin. Respiratory rate increases as the body develops
metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled
heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with
severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are
accompanied by back pain.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus
is scheduled for cardiac catheterization. Which medication would need to be withheld
for 24 hours before the procedure and for 48 hours after the procedure?
1. Glipizide
2. Metformin
3. Repaglinide
4. Regular insulin - answer- 2
Metformin needs to be withheld 24 hours before and for 48 hours after cardiac
catheterization because of the injection of contrast medium during the procedure. If the
contrast medium affects kidney function, with metformin in the system the client would
be at increased risk for lactic acidosis. The medications in the remaining options do not
need to be withheld 24 hours before and 48 hours after cardiac catheterization.
,A client in sinus bradycardia, with a heart rate of 45 beats/minute, complains of
dizziness and has a blood pressure of 82/60 mm Hg. Which prescription should the
nurse anticipate will be prescribed?
1. Administer digoxin.
2. Defibrillate the client.
3. Continue to monitor the client.
4. Prepare for transcutaneous pacing - answer- 4
Sinus bradycardia is noted with a heart rate less than 60 beats per minute. This rhythm
becomes a concern when the client becomes symptomatic. Hypotension and dizziness
are signs of decreased cardiac output. Transcutaneous pacing provides a temporary
measure to increase the heart rate and thus perfusion in the symptomatic client.
Defibrillation is used for treatment of pulseless ventricular tachycardia and ventricular
fibrillation. Digoxin will further decrease the client's heart rate. Continuing to monitor the
client delays necessary intervention.
The nurse in a medical unit is caring for a client with heart failure. The client suddenly
develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects
pulmonary edema. The nurse immediately asks another nurse to contact the health care
provider and prepares to implement which priority interventions? (SELECT ALL THAT
APPLY.)
1. Administering oxygen
2. Inserting a Foley catheter
3. Administering furosemide
4. Administering morphine sulfate intravenously
5. Transporting the client to the coronary care unit
6. Placing the client in a low Fowler's side-lying position - answer- 1, 2, 3, 4
Pulmonary edema is a life-threatening event that can result from severe heart failure. In
pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure
increases in the lungs because of the accumulated blood. Oxygen is always prescribed,
and the client is placed in a high Fowler's position to ease the work of breathing.
Furosemide, a rapid-acting diuretic, will eliminate accumulated fluid. A Foley catheter is
inserted to measure output accurately. Intravenously administered morphine sulfate
reduces venous return (preload), decreases anxiety, and also reduces the work of
breathing. Transporting the client to the coronary care unit is not a priority intervention.
In fact, this may not be necessary at all if the client's response to treatment is
successful.
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air
hunger, and begins coughing frothy, pink-tinged sputum. Which finding would the nurse
anticipate when auscultating the client's breath sounds?
1. Stridor
,2. Crackles
3. Scattered rhonchi
4. Diminished breath sounds - answer- 2
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.
A client with myocardial infarction is developing cardiogenic shock. Because of the risk
of myocardial ischemia, what condition should the nurse carefully assess the client for?
1. Bradycardia
2. Ventricular dysrhythmias
3. Rising diastolic blood pressure
4. Falling central venous pressure - answer- 2
Classic signs of cardiogenic shock as they relate to myocardial ischemia 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.
A client who had cardiac surgery 24 hours ago has had a urine output averaging 20
mL/hour 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(16 mmol/L) and the serum creatinine level is
2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that
the client is at risk for which problem?
1. Hypovolemia
2. Acute kidney injury
3. Glomerulonephritis
4. Urinary tract infection - answer- 2
The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion,
hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is
signaled by decreased urine output and increased blood urea nitrogen (BUN) and
creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L),
and creatinine: male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97
mcmol/L). 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, glomerulonephritis, or urinary tract infection.
, The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS
complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure
0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse
take?
1. Check vital signs.
2. Check laboratory test results.
3. Notify the health care provider.
4. Continue to monitor for any rhythm change. - answer- 4
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100
beats/minute. The PR and QRS measurements are normal, measuring between 0.12
and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities
in this rhythm currently, so there is no immediate need to check vital signs or laboratory
results, or to notify the health care provider. Therefore, the nurse would continue to
monitor the client for any rhythm change.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The
nurse sees no electrocardiographic complexes on the screen. Which is the priority
nursing action?
1. Call a code.
2. Call the health care provider.
3. Check the client's status and lead placement.
4. Press the recorder button on the electrocardiogram console. - answer- 3
: Sudden loss of electrocardiographic complexes indicates ventricular asystole or
possibly electrode displacement. Accurate assessment of the client and equipment is
necessary to determine the cause and identify the appropriate intervention. The
remaining options are secondary to client assessment.
The 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 more than 140 beats/minute. The nurse determines that the client is
experiencing which dysrhythmia?
1. Sinus tachycardia
2. Ventricular fibrillation
3. Ventricular tachycardia
4. Premature ventricular contractions - answer- 3
Ventricular tachycardia is characterized by the absence of P waves, wide QRS
complexes (longer than 0.12 seconds), and typically a rate between 140 and 180
impulses/minute. The rhythm is regular.
