LEWIS: MEDICAL-SURGICAL
NURSING|QUESTIONS
WITH100%CORRECT ANSWERS
Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis
should be reported immediately to the health care provider?
a. Pulsus paradoxus 8 mm Hg
b. Blood pressure (BP) of 168/94
c. Jugular venous distention (JVD) to jaw level
d. Level 6 (0 to 10 scale) chest pain with a deep breath - ✔️✔️ANS: C
The JVD indicates that the patient may have developed cardiac tamponade and may need rapid
intervention to maintain adequate cardiac output. Hypertension would not be associated with
complications of pericarditis, and the BP is not high enough to indicate that there is any
immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal.
Level 6/10 chest pain should be treated but is not unusual with pericarditis.
The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data
obtained by the nurse would be most important to report to the health care provider?
a. The patient complains of chest pressure when ambulating.
b. A loud systolic murmur is heard along the right sternal border.
c. A thrill is palpated at the second intercostal space, right sternal border.
d. The point of maximum impulse (PMI) is at the left midclavicular line. - ✔️✔️ANS: A
Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and
reporting this information would be a priority. A systolic murmur and thrill are expected in a
patient with aortic stenosis. A PMI at the left midclavicular line is normal.
Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain
that increases with a deep breath. Which action will the nurse take first?
a. Auscultate the heart sounds.
b. Check the patient's temperature.
c. Notify the patient's health care provider.
d. Give the PRN acetaminophen (Tylenol). - ✔️✔️ANS: A
The patient's clinical manifestations and history are consistent with pericarditis, and the first
action by the nurse should be to listen for a pericardial friction rub. Checking the temperature
and notifying the health care provider are also appropriate actions but would not be done before
listening for a rub. It is not stated for what symptom (e.g., headache) or finding (e.g., increased
temperature) the PRN acetaminophen (Tylenol) is ordered.
The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which
information obtained by the nurse when assessing the patient should be communicated to the
health care provider immediately?
a. The patient has bilateral crackles.
b. The patient has bilateral, 4+ peripheral edema.
, c. The patient has a loud systolic murmur across the precordium.
d. The patient has a palpable thrill felt over the left anterior chest. - ✔️✔️ANS: A
Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left
ventricular failure with pulmonary congestion and needs immediate interventions such as
diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral
regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not
need to be addressed urgently.
Which action by the nurse will determine if the therapies ordered for a patient with chronic
constrictive pericarditis are effective?
a. Assess for the presence of a paradoxical pulse.
b. Monitor for changes in the patient's sedimentation rate.
c. Assess for the presence of jugular venous distention (JVD).
d. Check the electrocardiogram (ECG) for ST segment changes. - ✔️✔️ANS: C
Because the most common finding on physical examination for a patient with chronic
constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement.
Paradoxical pulse, ST-segment ECG changes, and changes in sedimentation rates occur with
acute pericarditis but are not expected in chronic constrictive pericarditis.
Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge
teaching about self-management has been most effective?
a. "I will avoid taking aspirin or other antiinflammatory drugs."
b. "I will need to limit my intake of salt and fluids even in hot weather."
c. "I will take antibiotics when my teeth are cleaned at the dental office."
d. "I should begin an exercise program that includes things like biking or swimming." - ✔️✔️ANS:
C
Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use
prophylactic antibiotics for any procedure that may cause bacteremia. The other statements
indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair
ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt
(unless ordered), aspirin, or NSAIDs.
The nurse is assessing a patient with myocarditis before administering the scheduled dose of
digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health
care provider?
a. Leukocytosis
b. Irregular pulse
c. Generalized myalgia
d. Complaint of fatigue - ✔️✔️ANS: B
Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other
findings are common symptoms of myocarditis and there is no urgent need to report these.
After receiving report on the following patients, which patient should the nurse assess first?
a. Patient with rheumatic fever who has sharp chest pain with a deep breath
b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
c. Patient with infective endocarditis who has a murmur and splinter hemorrhages
NURSING|QUESTIONS
WITH100%CORRECT ANSWERS
Which assessment finding obtained by the nurse when assessing a patient with acute pericarditis
should be reported immediately to the health care provider?
a. Pulsus paradoxus 8 mm Hg
b. Blood pressure (BP) of 168/94
c. Jugular venous distention (JVD) to jaw level
d. Level 6 (0 to 10 scale) chest pain with a deep breath - ✔️✔️ANS: C
The JVD indicates that the patient may have developed cardiac tamponade and may need rapid
intervention to maintain adequate cardiac output. Hypertension would not be associated with
complications of pericarditis, and the BP is not high enough to indicate that there is any
immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal.
Level 6/10 chest pain should be treated but is not unusual with pericarditis.
The nurse is caring for a 78-year-old patient with aortic stenosis. Which assessment data
obtained by the nurse would be most important to report to the health care provider?
a. The patient complains of chest pressure when ambulating.
b. A loud systolic murmur is heard along the right sternal border.
c. A thrill is palpated at the second intercostal space, right sternal border.
d. The point of maximum impulse (PMI) is at the left midclavicular line. - ✔️✔️ANS: A
Chest pressure (or pain) occurring with aortic stenosis is caused by cardiac ischemia, and
reporting this information would be a priority. A systolic murmur and thrill are expected in a
patient with aortic stenosis. A PMI at the left midclavicular line is normal.
Two days after an acute myocardial infarction (MI), a patient complains of stabbing chest pain
that increases with a deep breath. Which action will the nurse take first?
a. Auscultate the heart sounds.
b. Check the patient's temperature.
c. Notify the patient's health care provider.
d. Give the PRN acetaminophen (Tylenol). - ✔️✔️ANS: A
The patient's clinical manifestations and history are consistent with pericarditis, and the first
action by the nurse should be to listen for a pericardial friction rub. Checking the temperature
and notifying the health care provider are also appropriate actions but would not be done before
listening for a rub. It is not stated for what symptom (e.g., headache) or finding (e.g., increased
temperature) the PRN acetaminophen (Tylenol) is ordered.
The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which
information obtained by the nurse when assessing the patient should be communicated to the
health care provider immediately?
a. The patient has bilateral crackles.
b. The patient has bilateral, 4+ peripheral edema.
, c. The patient has a loud systolic murmur across the precordium.
d. The patient has a palpable thrill felt over the left anterior chest. - ✔️✔️ANS: A
Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left
ventricular failure with pulmonary congestion and needs immediate interventions such as
diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral
regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not
need to be addressed urgently.
Which action by the nurse will determine if the therapies ordered for a patient with chronic
constrictive pericarditis are effective?
a. Assess for the presence of a paradoxical pulse.
b. Monitor for changes in the patient's sedimentation rate.
c. Assess for the presence of jugular venous distention (JVD).
d. Check the electrocardiogram (ECG) for ST segment changes. - ✔️✔️ANS: C
Because the most common finding on physical examination for a patient with chronic
constrictive pericarditis is jugular venous distention, a decrease in JVD indicates improvement.
Paradoxical pulse, ST-segment ECG changes, and changes in sedimentation rates occur with
acute pericarditis but are not expected in chronic constrictive pericarditis.
Which statement by a patient with restrictive cardiomyopathy indicates that the nurse's discharge
teaching about self-management has been most effective?
a. "I will avoid taking aspirin or other antiinflammatory drugs."
b. "I will need to limit my intake of salt and fluids even in hot weather."
c. "I will take antibiotics when my teeth are cleaned at the dental office."
d. "I should begin an exercise program that includes things like biking or swimming." - ✔️✔️ANS:
C
Patients with restrictive cardiomyopathy are at risk for infective endocarditis and should use
prophylactic antibiotics for any procedure that may cause bacteremia. The other statements
indicate a need for more teaching by the nurse. Dehydration and vigorous exercise impair
ventricular filling in patients with restrictive cardiomyopathy. There is no need to avoid salt
(unless ordered), aspirin, or NSAIDs.
The nurse is assessing a patient with myocarditis before administering the scheduled dose of
digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health
care provider?
a. Leukocytosis
b. Irregular pulse
c. Generalized myalgia
d. Complaint of fatigue - ✔️✔️ANS: B
Myocarditis predisposes the heart to digoxin-associated dysrhythmias and toxicity. The other
findings are common symptoms of myocarditis and there is no urgent need to report these.
After receiving report on the following patients, which patient should the nurse assess first?
a. Patient with rheumatic fever who has sharp chest pain with a deep breath
b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg
c. Patient with infective endocarditis who has a murmur and splinter hemorrhages
