HCAL III (Exam One)
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse expect?
- Pitting peripheral edema
- Crackles in the lung bases
- Jugular vein distention
- Hepatomegaly - Answer-- Crackles in the lung bases
A nurse is assessing a client who has coronary artery bypass grafts for cardiac tamponade. Which of the
following actions should the nurse take?
- Check for hypertension
- Auscultate for loud, bounding heart sounds
- Auscultate blood pressure for pulsus paradoxus
- Check for a pulse deficit - Answer-- Auscultate blood pressure for pulsus paradoxus
A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In
what order should the nurse complete the following steps? - Answer-- Palpate the blood pressure and
inflate the cuff above the systolic pressure
,- Deflate the cuff slowly and listen for the first audible sounds
- Identify the BP sounds audible on expiration and then on inspiration
- Subtract the inspiratory pressure from the expiratory pressure
- Inspect for jugular distention and notify the HCP
A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker.
Which of the following instructions should the nurse include in the teaching?
- "Request a provider's prescription when traveling to alert airport security."
- "Stand at least 3 feet away while using a microwave."
- "Keep your cell phone 6 inches away from your pacemaker when making a call."
- "Avoid showering for the first 2 weeks following surgery." - Answer-- "Keep your cell phone 6 inches
away from your pacemaker when making a call."
While participating in a community health fair, a nurse is providing information to a client who has a
blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take?
- Give the client a written record of his BP to bring to his provider
- Encourage the client to go to the nearest emergency department
- Instruct the client to follow-up with a provider within 6 months
- Explain to the client that he is not at risk unless he has manifestations of hypertension - Answer-- Give
the client a written record of his BP to bring to his provider
A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial
infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion?
- Ventricular dysrhythmias
, - Appearance of Q waves
- Elevated ST segment
- Recurrence of chest pain - Answer-- Ventricular dysrhythmias
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset
of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly
sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?
- Coarse crackles
- Wheezes
- Rhonchi
- Friction rub - Answer-- Coarse crackles
A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage
hypertension. Which of the following statements by the client indicates an understanding of the
teaching?
- "I can snack on fresh fruit."
- "I can continue to eat lunch meat sandwiches."
- "I can have cottage cheese with my meals."
- "Canned soup is a good lunch option." - Answer-- "I can snack on fresh fruit."
A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and high-
pitched inspiratory sounds. The nurse should identify these findings as manifestations of which of the
following complications?
- Pulmonary edema
- Tension pneumothorax
- Flail chest
- Respiratory obstruction - Answer-- Respiratory obstruction
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse expect?
- Pitting peripheral edema
- Crackles in the lung bases
- Jugular vein distention
- Hepatomegaly - Answer-- Crackles in the lung bases
A nurse is assessing a client who has coronary artery bypass grafts for cardiac tamponade. Which of the
following actions should the nurse take?
- Check for hypertension
- Auscultate for loud, bounding heart sounds
- Auscultate blood pressure for pulsus paradoxus
- Check for a pulse deficit - Answer-- Auscultate blood pressure for pulsus paradoxus
A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In
what order should the nurse complete the following steps? - Answer-- Palpate the blood pressure and
inflate the cuff above the systolic pressure
,- Deflate the cuff slowly and listen for the first audible sounds
- Identify the BP sounds audible on expiration and then on inspiration
- Subtract the inspiratory pressure from the expiratory pressure
- Inspect for jugular distention and notify the HCP
A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker.
Which of the following instructions should the nurse include in the teaching?
- "Request a provider's prescription when traveling to alert airport security."
- "Stand at least 3 feet away while using a microwave."
- "Keep your cell phone 6 inches away from your pacemaker when making a call."
- "Avoid showering for the first 2 weeks following surgery." - Answer-- "Keep your cell phone 6 inches
away from your pacemaker when making a call."
While participating in a community health fair, a nurse is providing information to a client who has a
blood pressure of 150/90 mmHg during screening. Which of the following actions should the nurse take?
- Give the client a written record of his BP to bring to his provider
- Encourage the client to go to the nearest emergency department
- Instruct the client to follow-up with a provider within 6 months
- Explain to the client that he is not at risk unless he has manifestations of hypertension - Answer-- Give
the client a written record of his BP to bring to his provider
A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial
infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion?
- Ventricular dysrhythmias
, - Appearance of Q waves
- Elevated ST segment
- Recurrence of chest pain - Answer-- Ventricular dysrhythmias
A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset
of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly
sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?
- Coarse crackles
- Wheezes
- Rhonchi
- Friction rub - Answer-- Coarse crackles
A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage
hypertension. Which of the following statements by the client indicates an understanding of the
teaching?
- "I can snack on fresh fruit."
- "I can continue to eat lunch meat sandwiches."
- "I can have cottage cheese with my meals."
- "Canned soup is a good lunch option." - Answer-- "I can snack on fresh fruit."
A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and high-
pitched inspiratory sounds. The nurse should identify these findings as manifestations of which of the
following complications?
- Pulmonary edema
- Tension pneumothorax
- Flail chest
- Respiratory obstruction - Answer-- Respiratory obstruction
