RNSG 1341 Med surge Group members: CV PV Worksheet questions and answers solution

RNSG 1341 Med surge Group members: CV PV Worksheet questions and answers solution Medsurge Group members: RNSG 1341 CV PV Worksheet Congestive Heart Failure 1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing this client? 1. Apical pulse rate of 110 and 4+ pitting edema of feet. 2. Thick white sputum and crackles that clear with cough. 3. The client sleeping with no pillow and eupaea. 4. Radial pulse rate of 90 and capillary refill time d seconds. 2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart failure. A nursing diagnosis of "decreased cardiac output related to inability of the heart to pump effectively" is written. Which short-term goal would be best for the client? The client will: 1. Be able to ambulate in the hall by date of discharge. 2. Have an audible S1 and S2 with no S3 heard by the end of shift. 3. Turn, cough, and deep breathe every two (2) hours. 4. Have a pulse oximeter reading of 98% by day two (2) of care. 3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive heart failure. Which interventions should be included in the plan? Select all that apply. 1. Notify the health-care provider of a weight gain of more than one (1) pound in a week. 2. Teach clients how to count the radial pulse when taking digoxin, cardiac glycoside. 3. Instruct the client to remove the salt shaker from the dinner table. 4. Encourage clients to monitor urine output for change in color to become dark. 5. Discuss the importance of taking the loop diuretic furosemide at bedtime. 4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which intervention would the nurse implement first? 1. Sponge the client's forehead. 2. Obtain a pulse oximetry reading. 3. Take the client's vital signs. 4. Assist the client to a sitting position. 5. The nurse is assessing the client diagnosed with congestive heart failure. Which signs/symptoms would indicate that the medical treatment has been effective? 1. The client's peripheral pitting edema has gone from 3+ to 4+. 2. The client is able to take the radial pulse accurately. 3. The client is able to perform ADLs without dyspnea. 4. The client has minimal jugular vein distention. 6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure? 1. An elevated B-type natriuretic peptide (BNP). 2. An elevated creatine kinase (CK-MB). 3. A positive D-dimer. 4. A positive ventilation/perfusion (V/Q) scan. 7. The health-care provider has ordered an angiotensin-converting enzyme (1CE) inhibitor for the client diagnosed with congestive heart failure. 'Which discharge instructions should the nurse include? 1. Instruct the client to take a cough suppressant if a cough develops. 2. Teach the client how to prevent orthostatic hypotension. 3. Encourage the client to eat bananas to increase potassium level. 4. Explain the importance of taking the medication with food. 8. The nurse on the telemetry unit has just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with myocardial infarction who has an audible S3 heart sound. 2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%. 4. The client with chronic renal failure who has an elevated creatinine level. 9. The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP? 1. Assist the client to go down to the smoking area for a cigarette. 2. Transport the client to the intensive care unit via a stretcher. 3. Provide the client going home discharge-teaching instructions. 4. Help position the client who is having a portable x-ray done. 10. The charge nurse is making shift assignments for the medical floor. Which client should be assigned to the most experienced registered nurse? 1. The client diagnosed with congestive heart failure who is being discharged in the morning. 2. The client who is having frequent incontinent liquid bowel movements and vomiting. 3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure of 94/62. 4. The client who is complaining of chest pain with inspiration and a nonproductive cough. 11. The client diagnosed with congestive heart failure is complaining of leg cramps at night. Which nursing interventions should be implemented? 1. Check the client for peripheral edema and make sure the client takes a diuretic early in the day. 2. Monitor the client's potassium level and assess the client's intake of bananas and orange juice. 3. Determine if the client has gained weight and instruct the client to keep the legs elevated. 4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises daily. 12. The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome? 1. Measure intake and output. 2. Provide two (2)-g sodium diet. 3. Weigh client daily. 4. Plan for frequent rest periods. Angina/Myocardial Infarction 13. Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LOH). 3. Troponin. 4. White blood cells (vVBCs). 14. Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema. 15. The client diagnosed with rule-out myocardial infarction is experiencing chest pajn while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram. 3. Have the client sit down immediately. 4. Assess the client's vital signs. 16. The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula 4. Place the client in a supine position 5. Administer nitroglycerin subcutaneously 17. The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy. 18. The client is one (I) day postoperative coronary arte111 bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side 4. Check the client's telemetry monitor. 19. The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding. 20. The intensive care department nurse is assessing the client who is 12 hours postmyocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously. 21. The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering· this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/62. 22. The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move legs. 4. Take no action concerning the UAP's behavior. 23. The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and rake it easy? My chest doesn't hurt anymore.Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger." 24. The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling Coronary Artery Disease 25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "l should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "[ should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER." 26. The client with coronary artery disease asks the nurse, "V,'hy do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia in the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood." 27.The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client. 28. The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 1 I 0/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client'.s potassium level is 4.5 mF.q/L. 29. Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading 30.Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet. 31.The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teachings? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays?" 3. "Are you sexually active?" 4. "Have you had any weight change?" 32. The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40°F. 4. Wear open-toed shoes when ambulating. 33. The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately. 34. The client with coronary artery disease is prescribed a Holter monitor. vThich intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor. 35. Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products." 36. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain. Valvular Heart Disease 37. A client is being seen in the clinic to RIO mitral valve stenosis. Mich assessment data would be most significant? 1. The client complains of shortness of breath when walking. 2. The client has jugular vein distention and 3+ pedal edema. 3. The client complains of chest pain after eating a large meal. 4. The client's liver is enlarged and the abdomen is edematous. 38. Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency? 1. A loud S1 , S2 split, and a micral opening snap. 2. A holosystolic murmur heard best at the cardiac apex. 3. A midsystolic ejection click or murmur heard at the base. 4. A high-pitched sound heard at the third left intercostal space. 39. The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity. 40. The nurse is teaching a class on valve replacements. Mich statement identifies a disadvantage of having a biological tissue valve replacement? 1. The client must take lifetime anticoagulant therapy. 2. The client's infections are easier to treat. 3. There is a low incidence of thromboembolism. 4. The valve has to be replaced frequently. 41. The nurse is preparing to administer warfarin (Coumadin), an oral anticoagulant, to a client with a mechanical valve replacement. The client's international normalized ratio (INR) is 2.7. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Prepare to administer vitamin K (Aquamephyton). 3. Hold the medication and notify the HCP. 4. Assess the client for abnormal bleeding. 42. Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. 4. Pericardia! friction rub. 5. Pulsus paradoxus. 43. The client is being evaluated for valvular heart disease. Which information would be most significant? 1. The client has a history of coronary artery disease. 2. There is a family history of valvular heart disease. 3. The client has a history of smoking for 10 years. 4. The client has a history of rheumatic heart disease. 44. The client who has just had a percutaneous balloon valvuloplasty is in the recovery room. Which intervention should the recovery room nurse implement? 1. Assess the client's chest tube output. 2. Monitor the client's chest dressing. 3. Evaluate the client's endotracheal (ET) lip line. 4. Keep the client's affected leg straight. 45. The client with a mechanical valve replacement asks the nurse, "why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is most appropriate? 1. "You are at risk of developing an infection 111 your heart." 2. "Your teeth will not bleed as much if you have antibiotics." 3. "This procedure may cause your valve to malfunction." 4. "Antibiotics will prevent vegetative growth on your valves." 46. The client had open-heart c;urger,• to replace the mitral valve. Which intervention should the intensive care unit nurse implement? 1. Restrict the client's fluids as ordered. 2. Keep the client in the supine position. 3. Maintain 0xy'gen saturation of 90%. 4. Monitor the total parenteral nutrition. 47. Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60 year-old female with congestive heart failure. 2. A 23-year-old male with ,1larfon's S}111drome. 3. An 80-year-old male with atrial fibrillation. 4. A 33-year-old female with Down syndrome. 48. The charge nurse is making shift assignments. Which client would be most appropriate for the charge nurse co· assign to a new graduate who just completed orientation to the medical floor? 1. The client was admitted for diagnostic tests to rule out valvular heart disease. 2. The client three (3) da}s post-myocardial infarction being discharged tomorrow. 3. The client exhibiting supraventricular tachycardia (SVT) on telemetry. 4. The client diagnosed with atrial fibrillation who has an INR of five (5). Dysrhythmias and Conduction Problems (Do Not Do This Section) 49. The telemetry nurse is unable to read the telemetry monitor at the nurse's station. What intervention should the telemetry nurse implement first? 1. Go the client's room to check the client. 2. Instruct primary nurse to assess the client. 3. Contact the · nt on the client call system. 4. Request the nurse assistant to take the crash cart to the client's room. 50. The client shows ventricular fibrillation on the telemetry at the nurse's station.Which ,action should the telecry nurse implement first? 1. Administer epinephrine IVP. 2. Prepare to defibrillate the client. 3.Call a STAT code. 4. Start cardiopulmonary resuscitation. 51. The client is experiencing multifocal premature v ricular contractions. Which antidysrhythmic medication would the nurse expect the health care provider to order for this client? 1. Lidocaine. 2. Atropine. 3. Digoxin. 4. Adenosine. 52. The client is exhibiting sinus bradycardia, is complaining of syncope and weakness, and has a BP of 98/60. Which collaborative treatment should the nurse anticip being implemented? 1. Administer a thrombolytic medication. 2. Assess the client's cardiovascular scams. 3. Prepare for insertion of a pacemaker. 4. Obtain a permit for synchronized cardioversion. 53. which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation? 1. Defibrillate the client at 50, 100, and 200 joules. 2. Do not remove the oxygen source during defibrillation. 3. Place petroleum jelly on the defibrillator pads. 4. Shout "all clear" prior to defibrillation the client. 54. The client has chronic atrial fibrillation. which discharge teaching should the nurse use with the client? 1. instruct the client to use a soft-bristle toothbrush. 2. discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Te h the client about signs of pacemaker malfunction. 4. Exp! · to the client the procedure for synchronized cardioversion. 55. The client exhibiting ventricular tachycardia. Mich intervention should the nurse implement first? 1. Administer lidocaine, an antidysrhythmic, IV 2. Prepare to de rill ace the client. 3. Assess the client pica! pulse and blood pressure. 4. Start basic cardio nonary resuscitation. 56i The client is in complete heart block. which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an anti srhytbmic. 3. Obtain a STAT electrocardiog m (ECG). 4. Notify the health-care provider. 57l The client is in ventricular fibrillation. Which interventions should cl1e nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amioda IVP 58. The client who is out day postoperative coronary arte bypass surgery is exhibiting sinus tachycardia. Which intervention should the nurse implement? 1. Assess the apical heart rate for one (1) full minute. 2. Notify the client's cardiac surgeon. 3. Prepare the client for synchronized cardioversion. 4. Determine if the client is having pain. 59. The client's telemetry reading shows a P wave before each QRS complex 1d the rate is 78. Which action should the nurse implement? 1. Document this as normal sinus rhythm. 2. Request a 12-lead electrocardiogram. 3. Prepare to administer the cardiotonic digoxin PO. 4. Assess the client's cardiac enzymes. 60. Which client problem has priority for the client with cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance. Inflammatory Cardiac Disorders 61. The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration. 62. The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bow1ding peripheral pulses. 4. Pericardia! friction rub. 63. The client is admitted to the medical unit to rule out carditis. Which question should the nurse ask the client during the admission interview to support this diagnosis? 1. "Have you had a sore throat in the last month?" 2. "Did you have rheumatic fever as a child?" 3. "Do you have a family hist0ry of carditis?" 4. "What over-the-counter (OTC) medications do you take?" 64. The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAJD). vThicb teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8." 65. The client diagnosed with pericarditis is complaining of increased pain. Which intervention should the nurse implement first? 1. Administer oxygen via nasal cannula. 2. Evaluate the client's urinary output. 3. Assess the client for cardiac complications. 4. Encourage the client to use the incentive spirometer. 66. The client diagnosed with pericarditis is experiencing cardiac tamponade. ·which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds. 67. The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "T may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection." 68. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus. 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis. 69. Which nursing diagnosis would be priority for the client diagnosed with myocarditis? 1. Anxiety related to possible long-term complications. 2. High risk for injury related to antibiotic therapy. 3. Increased cardiac output related to valve regurgitation. 4. Activity intolerance related to impaired cardiac muscle fonction. 70. The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching? 1. Be sure to allow for uninterrupted rest and sleep. 2. Refer client co outpatient occupational therapy. 3. Maintain oxygen via the nasal cannula at two (2) Umin. 4. Discuss upcoming valve replacement surgery. 71. The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position. 72. The client with infective endoc,irditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges. Arterial Hypertension 1. The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first? 1. Recommend that the client have his blood pressure checked in one (1) month. 2. Instruct the client to see his health-care provider as soon as possible. 3. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet. 4. Explain that this BP is within the normal range for an elderly person. 2. The nurse is teaching the client recently diagnosed with essential hypertension. vThich instruction should the nurse provide when discussing exercise? 1. Walk at least 30 minutes a day on flat surfaces. 2. Perform light weight lifting three (3) times a week. 3. Recommend high-level aerobics daily. 4. Encourage the client to swim laps once a week. 3. The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication? 1. ACE inhibitors prevent beta receptor stimulation in the heart. 2. This medication blocks the alpha receptors in the vascular smooth muscle. 3. ACE inhibitors prevent vasoconstriction and sodium and water retention. 4. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle. 4. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? 1. Notify the health-care provider if the potassium level is 3.8 mEq. 2. Question administering the medication if the BP is 90/60 mm Hg. 3. Do not administer the medication if the client's radial pulse is 100. 4. Monitor the client's BP while he or she is lying, standing, and sitting. 5. The male client diagnosed with essential hypertension has been prescribed an alpha adrenergic blocker. vThich intervention should the nurse discuss with the client? 1. Eat at least one ()) banana a day to help increase the potassium level. 2. Explain that impotence is an expected side effect of the medication. 3. Take the medication on an empty stomach to increase absorption. 4. Change position slowly when going from lying to sitting position. 6. The nurse just received the a.m. shift report. vThich client should the nurse assess first? 1. The client was diagnosed with coronary artery disease who has a BP of 170/100. 2. The client diagnosed with deep vein thrombosis who is complaining of chest pain. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%. 4. The client diagnosed with ulcerative colitis who has nonbloody diarrhea. 7. The client diagnosed with essential hypertension asks the nurse, "vThy do I have high blood pressure? Which response by the nurse would be most appropriate? 1. "You probably have some type of kidney disease that causes the high BP." 2. "More than likely you have had a diet high in salt, fat, and cholesterol." 3. "There is no specific cause for hypertension, but there are many known risk factors." 4. "You are concerned that you have high blood pressure. Let's sit down and talk." 8. The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands teaching concerning the DASH diet? 1. "I should eat at least four (4) to five (5) servings of vegetables a day." 2. "I should eat meat that has a lot of white streaks in it." 3. "I should drink no more than two (2) glasses of whole milk a day." 4. "I should decrease my grain intake to no more than twice a week." 9. The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse? 1. The telemetry reads normal sinus rhythm. 2. The client has a weight gain of 2 kg within I to 2 days. 3. The client's blood pressure is 148/92. 4. The client's serum potassium level is 4.5 mEq. 10. The client diagnosed with essential hypertension asks the nurse, "I don't know why the doctor is worried about my blood pressure. I feel just great. Which statement by the nurse would be the most appropriate response? 1. "Damage can be occurring to your heart and kidneys even if you feel great." 2. "Unless you have a headache, your blood pressure is probably within normal limits." 3. "vlhen is the last time you saw your doctor? Does he know you are feeling great?" 4. "Your blood pressure reflects how well your heart is working." 11. The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5vV, IVPD of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1,480 mL. What is the total intake for this client? 1520 ml 12. The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation? 1. Include information on retinopathy and nephropathy. 2. Discuss sedentary lifestyle and smoking cessation. 3. Include discussions on family history and gender. 4. Provide information on a low-fiber and high-salt diet. Arterial Occlusive Disease 13. The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record? 1. Peripheral vascular disease. 2. Intermittent claudication. 3. Deep vein thrombosis. 4. Dependent rubor. 14. Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease? 1. Encourage the client to use a heating pad on the lower extremities. 2. Demonstrate to the client the correct way to apply elastic support hose. 3. Instruct the client to walk daily for at least 30 minutes. 4. Tell the client to check both feet for red areas at least once a week. 15. The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should tht: nurse include in the teaching? Select all that apply. 1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 3. Buy shoes in the morning hours only. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks. 16. Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease? 1. The client has 2+ pedal pulses. 2. The client is able to move the toes. 3. The client has numbness and tingling. 4. The client's feet are red when standing. 17. Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer? 1. Impaired skin integrity. 2. Activity intolerance. 3. Ineffective health maintenance. 4. Risk for peripheral neuropathy. 18. The client diagnosed with arterial occlusive disease is one (I) day postoperative right femoral-popliteal bypass. Which intervention should the nurse implement? 1. Keep the right leg in the dependent position. 2. Apply sequential compression devices to lower extremities. 3. Monitor the client's pedal pulses every shift. 4. Assess the client's leg dressing every four (4) hours. 19. The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first? 1. Complete a neurovascular assessment. 2. Use the Doppler device. 3. Instruct the client to hang the feet off the side of the bed. 4. Wrap the legs in a blanket. 20. The wife of a client with arterial occlusive disease tells the nurse, "My husband says he is having rest pain. What does that mean?” Which statement by the nurse would be most appropriate? 1. "It describes the type of pain he has when he stops walking." 2. "His legs are deprived of oxygen during periods of inactivity." 3. "You are concerned that your husband is having rest pain." 4. "This term is used to support that his condition is getting better." 21. The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis? 1. Hairless skin on the legs. 2. Brittle, flaky toenails. 3. Petechiae on the soles of feet. 4. Nonpitting ankle edema. 22. The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement? 1. Explain that this procedure will be done at the bedside. 2. Discuss with the client that he or she will be on bedrest with bathroom privileges. 3. Inform the client Lhat no intravenous access will be needed. 4. Inform the client that fluids will be increased after the procedure. 23. Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease? 1. An anticoagulant medication. 2. An antihypertensive medication. 3. An antiplatelet medication. 4. A muscle relaxant. 24. The nurse and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client who is four (4) hours postoperative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the UAP? 1. Monitor the continuous passive motion machine. 2. Assist the client to the bedside commode. 3. Feed the client the evening meal. 4. Elevate the foot of the client's bed. Atherosclerosis 25. The nurse is teaching a class on coronary artery disease. Which modifiable risk factor should the nurse discuss when teaching about atherosclerosis? 1. Stress. 2. Age. 3. Gender. 4. Family history. 26. The client asks the nurse, "My doctor just told me that atherosclerosis is why my legs hurt when I walk. v1hat does that mean?" Which response by the nurse would be the best response? 1. "The muscle fibers and endothelial lining of your arteries have become thickened." 2. "The next time you sec your HCP, ask what atherosclerosis means." 3. "The valves in the veins of your legs are incompetent so your legs hurt." 4. "You have a hardening of your arteries that decreases the oxygen to your legs." 27. The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. 'hat is the strongest factor in the development of atherosclerotic lesions? 1. Being overweight. 2. Sedentary lifestyle. 3. High-fat, high-cholesterol diet. 4. Smoking cigarettes. 28. The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement? 1. Praise the client for having a normal cholesterol level. 2. Explain that the client needs to lower the cholesterol level. 3. Discuss dietary changes that could help increase the level. 4. Allow the client to ventilate feelings about the blood test result. 29. The nurse is discussing the pathophysiology of atherosclerosis with a client who has a normal high-density lipoprotein (HDL) level. Which information should the nurse discuss with the client concerning IIDL? 1. A normal HDL is good because it has a protective action in the body. 2. HDL lipoprotein level measures the free fatty acids and glycerol in the blood. 3. HDLs are the primary transporters of cholesterol into the cell. 4. The client needs to decrease the amount of cholesterol and fat in the diet. 30. Which assessment data would cause the nurse to suspect the client has atherosclerosis? 1. Change in bowel movements. 2. Complaints of a headache. 3. Intermittent claudication. 4. Venous stasis ulcers. 31. The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis? 1. Glucose combines with carbon monoxide, instead of with oxygen, and leads to oxygen deprivation of tissues. 2. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis. 3. Diabetes speeds The atherosclerotic process by thickening the basement membrane of both large and small vessels. 4. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels. 32. The nurse is discussing the importance of exercising with a client who is diagnosed with CAD. Which statement best describes the scientific rationale for encouraging 30 minutes of walking daily to help prevent complications of atherosclerosis? 1. Exercise promotes the development of collateral circulation. 2. Isometric exercises help develop the client's muscle mass. 3. Daily exercise helps prevent plaque from developing in the vessel. 4. Isotonic exercises promote the transport of glucose into the cell. 33. The HCP prescribes an HivlG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication? 1. Take this medication on an empty stomach. 2. This medication should be taken in the evening. 3. Do not be concerned if muscle pain occurs. 4. Check your cholesterol level daily. 34. The nurse knows the client understands the teaching concerning a low-fat, low cholesterol diet when the client selects which meal? 1. Fried fish, garlic mashed potatoes, and iced tea. 2. Ham and cheese on white bread and whole milk. 3. Baked chicken, baked potato, and skim milk. 4. A hamburger, French fries, and carbonated beverage. 35. Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply. 1. Include the significant other in the discussion. 2. Stop smoking or using any type of tobacco products. 3. Maintain a sedentary lifestyle as much as possible. 4. Avoid stressful situations. 5. Daily isometric exercises are important. 36. The nurse is caring for clients on a telemetry floor. 'Nhich nursing task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)? 1. Teach the client how to perform a glucometer check. 2. Assist feeding the client diagnosed with congestive heart failure. 3. Check the cholesterol level for the client diagnosed with atherosclerosis. 4. Assist the nurse to check the unit of blood at the client's bedside. Abdominal Aortic Aneurysm 37. Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)? 1. Shortness of breath. 2. Abdominal bruit. 3. Ripping abdominal pain. 4. Decreased urinary output. 38. Which medical treatment would be prescribed for the client with an AAA less than 3 cm? 1. Ultrasound every six (6) months 2. intravenous pyelogram yearly 3. Assessment of abdominal girth monthly. 4. Repair of abdominal aortic aneurysm. 39. Which client would be most likely to develop an abdominal aortic aneurysm? 1. A 45-year-old female with a history of osteoporosis. 2. An 80-year-old female with congestive heart failure. 3. A 69-year-old male with peripheral vascular disease. 4. A 30-year-old male with a genetic predisposition to AAA 40. The client is diagnosed with an ahlominal aortic ancur5m. Which statement would the nurse expect the client to make during the admission assessment? 1. "have stomach pain every time I eat a big, heavy meal." 2. "I don't have any abdominal pain or any type of problems." 3. "I have periodic episodes of constipation and then diarrhea." 4. "I belch a lot, especially when I lay down after eating." 41. The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm. Which sign/symptom "would make the nurse suspect the client has an expanding AAA? 1. Complaints of low back pain. 2. Weakened radial pulses. 3. Decreased urine output. 4. Increased abdominal girth. 42. The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed personnel (UAP) would require immediate intervention from the nurse? 1. The client refuses to run from the back to the side. 2. The client's urinary output is 90 mL in six (6) hours. 3. The client wants to sit on the side of the bed. 4. The client's vital signs are T 98, P 90, R 18, and BP 130/70. 43. The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first? 1. Assess the client's bowel sounds. 2. Administer an IV prophylactic antibiotic. 3. Encourage the client to splint the incision. 4. Ambulate the client in the room with assistance. 44. Which health-care provider's order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning? 1. Type and crossmatch for two (2) units of blood. 2. Tap water enema until clear fecal return. 3. Bedrest with bathroom privileges. 4. Keep NPO after midnight. 45. The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply. 1. Tell the client to exercise three (3) times a week for 30 minutes. 2. Encourage the client to eat a low-fat, low-cholesterol diet. 3. Instruct the client to decrease tobacco use. 4. Discuss the importance of losing weight with the client. 5. Teach the client to wear a truss at all times. 46. Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair? 1. Absent bilateral pedal pulses. 2. Complaints of pain at the site of the incision. 3. Distended, tender abdomen. 4. An elevated temperature of l00 47. The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client? 1. Notify HCP of any redness or irritation of the incision. 2. Do not lift anything that weighs more than 20 pounds. 3. Inform clients there may be pain not relieved with pain medication. 4. Stress the importance of bowel movements. 48. On which area would the nurse place the bell of the stethoscope when assessing the client with an abdominal aortic aneurysm? A---- ----C B---- ----D 1. A 2. B 3. C 4. D Deep Vein Thrombosis 49. The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? 1. Have the PTT levels checked weekly until therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green leafy vegetables and notify the HCP of red or brown urine. 4. Wear knee stockings with an elastic band around the top. 50. The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating 2. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine. 3. The client who is five (5) days postoperative open cholecystectomy who has a tube and is being discharged. 4. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus. 51. The male client is diagnosed with Guillain-Barre (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive rangeof-motion (ROM) exercises? 1. Passive ROM exercises will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. ROM exercises will help alleviate the pain associated with GB syndrome. 4. They help to prevent DVTs by movement of the blood through the veins. 52. The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain before undressing the client. 2. The UAP begins to massage and rub lotion into the client's calf. 3. The UAP tests the temperature of the water with the wrist before starting. 4. The UAP collects all the linens and supplies and brings them to the room. 53. The client diagnosed with a Dvr is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every 4 hours and PRN. 5. Assess Homans' sign every 24 hours. 54. The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the TV rate by 100 units/hr if the PPT is less than 50 seconds. The current PPT level is 46 seconds. The heparin come sin 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump. 20 mL/hr 55. Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client who has refused to turn for the last three (3) hours. 3. The client who had an open cholecystectomy who refuses to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge. 56. The client diagnosed with a Dvr is on a heparin (an anticoagulant) drip at 1,400 units per hour, and Coumadin (warfarin sodium; also an anticoagulant) 5 mg twice a day. Which intervention should the nurse implement first? 1. Check the PTT and PT /INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving Coumadin. 57. Which actions should the surgical scrub nurse take to prevent personally developing a DVT? 1. Keep the legs in a dependent position and stand as still as possible. 2. Flex the leg muscles and change the leg positions frequently. 3. Wear white socks and shoes that have a wedge heel. 4. Ask the surgeon to allow the nurse to take a break midway through each surgery. 58. The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVf following hip replacement surgery complains to the nurse that there are small purple hemorrhaged areas on the upper abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client’s PTT level. 3. Explain this results from the medication. 4. Assess the client's vital signs. 59. The home health nurse is admitting a client diagnosed with a DV the client warrants immediate intervention by the nurse? 1. The client takes a stool softener everyday at dinnertime. 2. The client is wearing· a Medic Alert bracelet. 3. The client takes vitamin E over-the-counter medication. 4. The client has purchased a new recliner that will elevate the legs. 60. The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity.Which laboratory data should the nurse monitor? 1. Blood urea nitrogen (BUTT) levels. 2. Bilirubin levels. 3. International normalized ratio (INR). 4. Partial thromboplastin time (PTI). Peripheral Venous Disease 61. The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins. 62. Which assessment data would support that the client has a venous stasis ulcer? 1. A superficial pink open area on the medial part of the ankle. 2. A deep pale open area over the top side of the foot. 3. A reddened blistered area on the heel of the foot. 4. A necrotic gangrenous area on the dorsal side of the foot. 63. The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 1. Wear low-heeled, comfortable shoes. 2. Wear clean white cotton socks. 3. Move the legs back and forth often. 4. Wear graduated compression hose. 64. The client with varicose veins asks the nurse, "What caused me to have these?" Which statement by the nurse would be most appropriate? 1. "You have incompetent valves in your legs." 2. "Your legs have decreased oxygen to the muscle." 3. "There is an obstruction in the saphenous vein." 4. "Your blood is thick and can't circulate properly." 65. The nurse is caring for the client with chronic venous insufficiency. which statement indicates the client understands the discharge teaching? 1. "I shouldn't cross my legs for more than 15 minutes." 2. "l need to elevate the foot of my bed while sleeping." 3. "I should take a baby aspirin every day with food." 4. "I should increase my fluid intake to 3,000 mL a day." 66. The unlicensed assistive personnel (UiP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. Removing compression stocking before assisting the client to bed. 2. Taking the client's blood pressure manually after using the machine. 3. Assisting the client by opening the milk carton on the lunch tray. 4. Calculating the client's shift intake and output with a pen and paper. 67. The 80-year-old client is being discharged home after having surgery to debride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client? 1. Occupational therapist. 2. Social worker. 3. Physical therapist. 4. Cardiac rehabilitation. 68. Which assessment data would the nurse expect co find in the client diagnosed with chronic venous insufficiency? 1. Decreased pedal pulses. 2. Cool skin temperature. 3. Intermittent claudication. 4. Brown discolored skin. 69. Which client would be most at risk for developing varicose veins? 1. A Caucasian female who is a nurse. 2. An African American male who is a bus driver. 3. An Asian female with no children. 4. An elderly male with diabetes. 70. The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first? 1. Assist the client to dangle the legs off the side of the bed. 2. Assess and maintain pressure bandages on the affected leg. 3. Apply a sequential compression device to the affected leg. 4. Administer the prescribed prophylactic intravenous antibiotic. 71. The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is complaining of pain. 2. The client with varicose veins who has dull aching muscle cramps. 3. The client with arterial occlusive disease who cannot move the foot. 4. The client with deep vein thrombosis who has a positive Homans' sign. 72. The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for polar.