ACLS Precourse Work for
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70
mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure
in her second month was 124/80 mm Hg. In evaluating this change, what does the
nurse know to be true?
a. This decline in blood pressure is the result of peripheral vasodilatation and is an
expected change.
b. Because of increased cardiac output, the blood pressure should be higher at this
time.
c. This change in blood pressure is not an expected finding because it means a
decrease in cardiac output.
d. This decline in blood pressure means a decrease in circulating blood volume, which
is dangerous for the fetus. - ansa. This decline in blood pressure is the result of
peripheral vasodilatation and is an expected change.
A 30-year-old woman with a history of mitral valve problems states that she has been
"very tired." She has started waking up at night and feels like her "heart is pounding."
During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal
space midclavicular line. In the same area, the nurse also auscultates a blowing,
swishing sound right after the S1. These findings would be most consistent with:
a. Heart failure.
b. Aortic stenosis.
c. Pulmonary edema.
d. Mitral regurgitation. - ansd. Mitral regurgitation.
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these
findings should the nurse expect to see during an assessment of this patient?
a. Hard and fixed cervical nodes
b. Enlarged and tender inguinal nodes
c. Bilateral enlargement of the popliteal nodes
d. Pelletlike nodes in the supraclavicular region - ansb. Enlarged and tender inguinal
nodes
A 45-year-old man is in the clinic for a routine physical examination. During the
recording of his health history, the patient states that he has been having difficulty
sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath."
The nurse's best response to this would be:
a. "When was your last electrocardiogram?"
b. "It's probably because it's been so hot at night."
c. "Do you have any history of problems with your heart?"
d. "Have you had a recent sinus infection or upper respiratory infection?" - ansc. "Do
you have any history of problems with your heart?"
A 65-year-old patient is experiencing pain in his left calf when he exercises that
disappears after resting for a few minutes. The nurse recognizes that this description is
most consistent with _______ the left leg.
a. Venous obstruction of
,ACLS Precourse Work for
b. Claudication due to venous abnormalities in
c. Ischemia caused by a partial blockage of an artery supplying
d. Ischemia caused by the complete blockage of an artery supplying - ansc. Ischemia
caused by a partial blockage of an artery supplying
A 67-year-old patient states that he recently began to have pain in his left calf when
climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately
2 minutes; then he is able to resume his activities. The nurse interprets that this patient
is most likely experiencing:
a... Claudication.
b. Sore muscles.
c. Muscle cramps.
d. Venous insufficiency. - ansa... Claudication.
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the
great saphenous vein for the coronary bypass grafts. The patient asks, "What happens
to my circulation when this vein is removed?" The nurse should reply:
a. "Venous insufficiency is a common problem after this type of surgery."
b. "Oh, you have lots of veins—you won't even notice that it has been removed."
c. "You will probably experience decreased circulation after the vein is removed."
d. "This vein can be removed without harming your circulation because the deeper veins
in your leg are in good condition." - ansd. "This vein can be removed without harming
your circulation because the deeper veins in your leg are in good condition."
A 70-year-old patient with a history of hypertension has a blood pressure of 180/100
mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound
at the apex immediately before the S1. The sound is heard only with the bell of the
stethoscope while the patient is in the left lateral position. With these findings and the
patient's history, the nurse knows that this extra heart sound is most likely a(n):
a. Split S1.
b. Atrial gallop.
c. Diastolic murmur.
d. Summation sound. - ansb. Atrial gallop.
A patient complains of leg pain that wakes him at night.. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them.. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing:
a. Pain related to lymphatic abnormalities.
b. Problems related to arterial insufficiency.
c. Problems related to venous insufficiency.
d. Pain related to musculoskeletal abnormalities. - ansb. Problems related to arterial
insufficiency.
, ACLS Precourse Work for
A patient has been admitted with chronic arterial symptoms. During the assessment, the
nurse should expect which findings? Select all that apply.
a. Patient has a history of diabetes and cigarette smoking.
b. Skin of the patient is pale and cool.
c. His ankles have two small, weeping ulcers.
d. Patient works long hours sitting at a computer desk.
e. He states that the pain gets worse when walking.
f. Patient states that the pain is worse at the end of the day. - ansANS: A, B, E
Patients with chronic arterial symptoms often have a history of smoking and diabetes
(among other risk factors). The pain has a gradual onset with exertion and is relieved
with rest or dangling. The skin appears cool and pale (see Table 20-3). The other
responses reflect chronic venous problems.
A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe?
a. Unilateral cool foot
b. Thin, shiny, atrophic skin
c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg - ansd. Brownish discoloration to
the skin of the lower leg
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has
no edema. Based on these findings, the nurse recalls that:
a. Nonpitting, hard edema occurs with lymphatic obstruction.
b. Alterations in arterial function will cause edema.
c. Phlebitis of a superficial vein will cause bilateral edema.
d. Long-standing arterial obstruction will cause pitting edema. - ansa. Nonpitting, hard
edema occurs with lymphatic obstruction.
A patient is recovering from several hours of orthopedic surgery. During an assessment
of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms.
Signs of acute venous symptoms include which of the following? Select all that apply.
a. Intense, sharp pain, with the deep muscle tender to the touch
b. Aching, tired pain, with a feeling of fullness
c. Pain that is worse at the end of the day
d... Sudden onset
e. Warm, red, and swollen calf
f. Pain that is relieved with elevation of the leg - ansANS: A, D, E
Signs and symptoms of acute venous problems include pain in the calf that has a
sudden onset and that is intense and sharp with tenderness in the deep muscle when
touched. The calf is warm, red, and swollen. The other options are symptoms of chronic
venous problems.
During a cardiac assessment on a 38-year-old patient in the hospital for "chest pain,"
the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when
the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70
mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure
in her second month was 124/80 mm Hg. In evaluating this change, what does the
nurse know to be true?
a. This decline in blood pressure is the result of peripheral vasodilatation and is an
expected change.
b. Because of increased cardiac output, the blood pressure should be higher at this
time.
c. This change in blood pressure is not an expected finding because it means a
decrease in cardiac output.
d. This decline in blood pressure means a decrease in circulating blood volume, which
is dangerous for the fetus. - ansa. This decline in blood pressure is the result of
peripheral vasodilatation and is an expected change.
A 30-year-old woman with a history of mitral valve problems states that she has been
"very tired." She has started waking up at night and feels like her "heart is pounding."
During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal
space midclavicular line. In the same area, the nurse also auscultates a blowing,
swishing sound right after the S1. These findings would be most consistent with:
a. Heart failure.
b. Aortic stenosis.
c. Pulmonary edema.
d. Mitral regurgitation. - ansd. Mitral regurgitation.
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these
findings should the nurse expect to see during an assessment of this patient?
a. Hard and fixed cervical nodes
b. Enlarged and tender inguinal nodes
c. Bilateral enlargement of the popliteal nodes
d. Pelletlike nodes in the supraclavicular region - ansb. Enlarged and tender inguinal
nodes
A 45-year-old man is in the clinic for a routine physical examination. During the
recording of his health history, the patient states that he has been having difficulty
sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath."
The nurse's best response to this would be:
a. "When was your last electrocardiogram?"
b. "It's probably because it's been so hot at night."
c. "Do you have any history of problems with your heart?"
d. "Have you had a recent sinus infection or upper respiratory infection?" - ansc. "Do
you have any history of problems with your heart?"
A 65-year-old patient is experiencing pain in his left calf when he exercises that
disappears after resting for a few minutes. The nurse recognizes that this description is
most consistent with _______ the left leg.
a. Venous obstruction of
,ACLS Precourse Work for
b. Claudication due to venous abnormalities in
c. Ischemia caused by a partial blockage of an artery supplying
d. Ischemia caused by the complete blockage of an artery supplying - ansc. Ischemia
caused by a partial blockage of an artery supplying
A 67-year-old patient states that he recently began to have pain in his left calf when
climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately
2 minutes; then he is able to resume his activities. The nurse interprets that this patient
is most likely experiencing:
a... Claudication.
b. Sore muscles.
c. Muscle cramps.
d. Venous insufficiency. - ansa... Claudication.
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the
great saphenous vein for the coronary bypass grafts. The patient asks, "What happens
to my circulation when this vein is removed?" The nurse should reply:
a. "Venous insufficiency is a common problem after this type of surgery."
b. "Oh, you have lots of veins—you won't even notice that it has been removed."
c. "You will probably experience decreased circulation after the vein is removed."
d. "This vein can be removed without harming your circulation because the deeper veins
in your leg are in good condition." - ansd. "This vein can be removed without harming
your circulation because the deeper veins in your leg are in good condition."
A 70-year-old patient with a history of hypertension has a blood pressure of 180/100
mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound
at the apex immediately before the S1. The sound is heard only with the bell of the
stethoscope while the patient is in the left lateral position. With these findings and the
patient's history, the nurse knows that this extra heart sound is most likely a(n):
a. Split S1.
b. Atrial gallop.
c. Diastolic murmur.
d. Summation sound. - ansb. Atrial gallop.
A patient complains of leg pain that wakes him at night.. He states that he "has been
having problems" with his legs. He has pain in his legs when they are elevated that
disappears when he dangles them.. He recently noticed "a sore" on the inner aspect of
the right ankle. On the basis of this health history information, the nurse interprets that
the patient is most likely experiencing:
a. Pain related to lymphatic abnormalities.
b. Problems related to arterial insufficiency.
c. Problems related to venous insufficiency.
d. Pain related to musculoskeletal abnormalities. - ansb. Problems related to arterial
insufficiency.
, ACLS Precourse Work for
A patient has been admitted with chronic arterial symptoms. During the assessment, the
nurse should expect which findings? Select all that apply.
a. Patient has a history of diabetes and cigarette smoking.
b. Skin of the patient is pale and cool.
c. His ankles have two small, weeping ulcers.
d. Patient works long hours sitting at a computer desk.
e. He states that the pain gets worse when walking.
f. Patient states that the pain is worse at the end of the day. - ansANS: A, B, E
Patients with chronic arterial symptoms often have a history of smoking and diabetes
(among other risk factors). The pain has a gradual onset with exertion and is relieved
with rest or dangling. The skin appears cool and pale (see Table 20-3). The other
responses reflect chronic venous problems.
A patient has been diagnosed with venous stasis. Which of these findings would the
nurse most likely observe?
a. Unilateral cool foot
b. Thin, shiny, atrophic skin
c. Pallor of the toes and cyanosis of the nail beds
d. Brownish discoloration to the skin of the lower leg - ansd. Brownish discoloration to
the skin of the lower leg
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has
no edema. Based on these findings, the nurse recalls that:
a. Nonpitting, hard edema occurs with lymphatic obstruction.
b. Alterations in arterial function will cause edema.
c. Phlebitis of a superficial vein will cause bilateral edema.
d. Long-standing arterial obstruction will cause pitting edema. - ansa. Nonpitting, hard
edema occurs with lymphatic obstruction.
A patient is recovering from several hours of orthopedic surgery. During an assessment
of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms.
Signs of acute venous symptoms include which of the following? Select all that apply.
a. Intense, sharp pain, with the deep muscle tender to the touch
b. Aching, tired pain, with a feeling of fullness
c. Pain that is worse at the end of the day
d... Sudden onset
e. Warm, red, and swollen calf
f. Pain that is relieved with elevation of the leg - ansANS: A, D, E
Signs and symptoms of acute venous problems include pain in the calf that has a
sudden onset and that is intense and sharp with tenderness in the deep muscle when
touched. The calf is warm, red, and swollen. The other options are symptoms of chronic
venous problems.
During a cardiac assessment on a 38-year-old patient in the hospital for "chest pain,"
the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when
the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130
