Nursing 308 Exam 2 with !| !| !| !| !|
verified answers & rationales !| !| !|
Which instruction by the nurse is given to a patient who is about to undergo
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Holter monitoring is most appropriate?
!| !| !| !|
A. "You may remove the monitor only to shower or bathe."
!| !| !| !| !| !| !| !| !| !|
B. "You should connect the monitor whenever you feel symptoms."
!| !| !| !| !| !| !| !| !|
C. "You should refrain from exercising while wearing this monitor."
!| !| !| !| !| !| !| !| !|
D. "You will need to keep a diary of all your activities and symptoms." -
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Correct answer ✔D. "You will need to keep a diary of all your activities and
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
symptoms." !|
A Holter monitor is worn continuously for at least 24 hours while a patient
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
continues with usual activity and keeps a diary of activities and symptoms.
!| !| !| !| !| !| !| !| !| !| !| !|
The patient should not take a bath or shower while wearing this monitor.
!| !| !| !| !| !| !| !| !| !| !| !|
The nurse is admitting a patient who is scheduled to undergo a cardiac
!| !| !| !| !| !| !| !| !| !| !| !| !|
catheterization. What allergy information is most important for the nurse to!| !| !| !| !| !| !| !| !| !| !|
assess and document before this procedure?
!| !| !| !| !|
A. Iron
!|
B. Iodine
!| !|
C. Aspirin
!|
D. Penicillin - Correct answer ✔B. Iodine
!| !| !| !| !| !| !|
,The physician will usually use an iodine-based contrast to perform this
!| !| !| !| !| !| !| !| !| !| !|
procedure. Therefore it is imperative to know whether or not the patient is
!| !| !| !| !| !| !| !| !| !| !| !| !|
allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or
!| !| !| !| !| !| !| !| !| !| !| !|
penicillin will be secondary. !| !| !|
The blood pressure of an older adult patient admitted with pneumonia is
!| !| !| !| !| !| !| !| !| !| !| !|
160/70 mm Hg. What is an age-related change that contributes to this
!| !| !| !| !| !| !| !| !| !| !| !|
finding?
A. Stenosis of the heart valves
!| !| !| !| !|
B. Decreased adrenergic sensitivity
!| !| !|
C. Increased parasympathetic activity
!| !| !|
D. Loss of elasticity in arterial vessels - Correct answer ✔D. Loss of elasticity
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
in arterial vessels Correct
!| !| !|
An age-related change that increases the risk of systolic hypertension is a
!| !| !| !| !| !| !| !| !| !| !| !|
loss of elasticity in the arterial walls. Because of the increasing resistance to
!| !| !| !| !| !| !| !| !| !| !| !| !|
flow, pressure is increased within the blood vessel, and hypertension results.
!| !| !| !| !| !| !| !| !| !| !|
Valvular rigidity of aging causes murmurs, and decreased adrenergic
!| !| !| !| !| !| !| !| !|
sensitivity slows the heart rate. Blood pressure is not raised. Increased
!| !| !| !| !| !| !| !| !| !| !|
parasympathetic activity would slow the heart rate. !| !| !| !| !| !|
The nurse is providing care for a patient who has decreased cardiac output
!| !| !| !| !| !| !| !| !| !| !| !| !|
related to heart failure. What should the nurse recognize about cardiac
!| !| !| !| !| !| !| !| !| !| !|
output?
A. It is calculated by multiplying the patient's stroke volume by the heart
!| !| !| !| !| !| !| !| !| !| !| !| !|
rate. !|
,B. It is the average amount of blood ejected during one complete cardiac
!| !| !| !| !| !| !| !| !| !| !| !| !|
cycle.
C. It is determined by measuring the electrical activity of the heart and the
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
patient's heart rate. !| !|
D. It is the patient's average resting heart rate multiplied by the patient's
!| !| !| !| !| !| !| !| !| !| !| !| !|
mean arterial blood pressure. - Correct answer ✔A. It is calculated by
!| !| !| !| !| !| !| !| !| !| !| !|
multiplying the patient's stroke volume by the heart rate. !| !| !| !| !| !| !| !| !|
Cardiac output is determined by multiplying the patient's stroke volume by
!| !| !| !| !| !| !| !| !| !| !|
heart rate, thus identifying how much blood is pumped by the heart over a 1-
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
minute period. Electrical activity of the heart and blood pressure are not
!| !| !| !| !| !| !| !| !| !| !| !|
direct components of cardiac output.
!| !| !| !|
The nurse is performing an assessment for a patient with fatigue and
!| !| !| !| !| !| !| !| !| !| !| !|
shortness of breath. Auscultation of the heart reveals the presence of a
!| !| !| !| !| !| !| !| !| !| !| !|
murmur. What is this assessment finding indicative of?
!| !| !| !| !| !| !|
A. Increased viscosity of the patient's blood
!| !| !| !| !| !|
B. Turbulent blood flow across a heart valve
!| !| !| !| !| !| !| !|
C. Friction between the heart and the myocardium
!| !| !| !| !| !| !|
D. A deficit in heart conductivity that impairs normal contractility - Correct
!| !| !| !| !| !| !| !| !| !| !| !|
answer ✔B. Turbulent blood flow across a heart valve
!| !| !| !| !| !| !| !| !|
Turbulent blood flow across the affected valve results in a murmur. A
!| !| !| !| !| !| !| !| !| !| !| !|
murmur is not a direct result of variances in blood viscosity, conductivity, or
!| !| !| !| !| !| !| !| !| !| !| !| !|
friction between the heart and myocardium.
!| !| !| !| !|
, While assessing the cardiovascular status of a patient, the nurse performs
!| !| !| !| !| !| !| !| !| !| !|
auscultation. Which intervention should the nurse implement in the !| !| !| !| !| !| !| !| !|
assessment during auscultation? !| !|
A. Position the patient supine.
!| !| !| !|
B. Ask the patient to hold his or her breath.
!| !| !| !| !| !| !| !| !| !|
C. Palpate the radial pulse while auscultating the apical pulse.
!| !| !| !| !| !| !| !| !| !|
D. Use the bell of the stethoscope when auscultating S1 and S2. - Correct
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
answer ✔C. Palpate the radial pulse while auscultating the apical pulse.
!| !| !| !| !| !| !| !| !| !| !|
To detect a pulse deficit, simultaneously palpate the radial pulse when
!| !| !| !| !| !| !| !| !| !| !|
auscultating the apical area. The diaphragm is more appropriate than the bell !| !| !| !| !| !| !| !| !| !| !| !|
when auscultating S1 and S2. A sitting or side-lying position is most
!| !| !| !| !| !| !| !| !| !| !| !|
appropriate for cardiac auscultation. It is not necessary to ask the patient to !| !| !| !| !| !| !| !| !| !| !| !| !|
hold his or her breath during cardiac auscultation.
!| !| !| !| !| !| !|
A patient presents to the emergency department with reports of chest pain
!| !| !| !| !| !| !| !| !| !| !| !|
for 3 hours. What component of his blood work is most clearly indicative of
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
a myocardial infarction (MI)?
!| !| !|
A. CK-MB !|
B. Troponin
!| !|
C. Myoglobin
!|
D. C-reactive protein - Correct answer ✔B. Troponin
!| !| !| !| !| !| !| !|
Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity
!| !| !| !| !| !| !| !| !| !| !| !| !|
and specificity that exceed those of CK-MB and myoglobin. CRP levels are
!| !| !| !| !| !| !| !| !| !| !| !|
not used to diagnose acute MI.
!| !| !| !| !|
verified answers & rationales !| !| !|
Which instruction by the nurse is given to a patient who is about to undergo
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Holter monitoring is most appropriate?
!| !| !| !|
A. "You may remove the monitor only to shower or bathe."
!| !| !| !| !| !| !| !| !| !|
B. "You should connect the monitor whenever you feel symptoms."
!| !| !| !| !| !| !| !| !|
C. "You should refrain from exercising while wearing this monitor."
!| !| !| !| !| !| !| !| !|
D. "You will need to keep a diary of all your activities and symptoms." -
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
Correct answer ✔D. "You will need to keep a diary of all your activities and
!| !| !| !| !| !| !| !| !| !| !| !| !| !| !|
symptoms." !|
A Holter monitor is worn continuously for at least 24 hours while a patient
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
continues with usual activity and keeps a diary of activities and symptoms.
!| !| !| !| !| !| !| !| !| !| !| !|
The patient should not take a bath or shower while wearing this monitor.
!| !| !| !| !| !| !| !| !| !| !| !|
The nurse is admitting a patient who is scheduled to undergo a cardiac
!| !| !| !| !| !| !| !| !| !| !| !| !|
catheterization. What allergy information is most important for the nurse to!| !| !| !| !| !| !| !| !| !| !|
assess and document before this procedure?
!| !| !| !| !|
A. Iron
!|
B. Iodine
!| !|
C. Aspirin
!|
D. Penicillin - Correct answer ✔B. Iodine
!| !| !| !| !| !| !|
,The physician will usually use an iodine-based contrast to perform this
!| !| !| !| !| !| !| !| !| !| !|
procedure. Therefore it is imperative to know whether or not the patient is
!| !| !| !| !| !| !| !| !| !| !| !| !|
allergic to iodine or shellfish. Knowledge of allergies to iron, aspirin, or
!| !| !| !| !| !| !| !| !| !| !| !|
penicillin will be secondary. !| !| !|
The blood pressure of an older adult patient admitted with pneumonia is
!| !| !| !| !| !| !| !| !| !| !| !|
160/70 mm Hg. What is an age-related change that contributes to this
!| !| !| !| !| !| !| !| !| !| !| !|
finding?
A. Stenosis of the heart valves
!| !| !| !| !|
B. Decreased adrenergic sensitivity
!| !| !|
C. Increased parasympathetic activity
!| !| !|
D. Loss of elasticity in arterial vessels - Correct answer ✔D. Loss of elasticity
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
in arterial vessels Correct
!| !| !|
An age-related change that increases the risk of systolic hypertension is a
!| !| !| !| !| !| !| !| !| !| !| !|
loss of elasticity in the arterial walls. Because of the increasing resistance to
!| !| !| !| !| !| !| !| !| !| !| !| !|
flow, pressure is increased within the blood vessel, and hypertension results.
!| !| !| !| !| !| !| !| !| !| !|
Valvular rigidity of aging causes murmurs, and decreased adrenergic
!| !| !| !| !| !| !| !| !|
sensitivity slows the heart rate. Blood pressure is not raised. Increased
!| !| !| !| !| !| !| !| !| !| !|
parasympathetic activity would slow the heart rate. !| !| !| !| !| !|
The nurse is providing care for a patient who has decreased cardiac output
!| !| !| !| !| !| !| !| !| !| !| !| !|
related to heart failure. What should the nurse recognize about cardiac
!| !| !| !| !| !| !| !| !| !| !|
output?
A. It is calculated by multiplying the patient's stroke volume by the heart
!| !| !| !| !| !| !| !| !| !| !| !| !|
rate. !|
,B. It is the average amount of blood ejected during one complete cardiac
!| !| !| !| !| !| !| !| !| !| !| !| !|
cycle.
C. It is determined by measuring the electrical activity of the heart and the
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
patient's heart rate. !| !|
D. It is the patient's average resting heart rate multiplied by the patient's
!| !| !| !| !| !| !| !| !| !| !| !| !|
mean arterial blood pressure. - Correct answer ✔A. It is calculated by
!| !| !| !| !| !| !| !| !| !| !| !|
multiplying the patient's stroke volume by the heart rate. !| !| !| !| !| !| !| !| !|
Cardiac output is determined by multiplying the patient's stroke volume by
!| !| !| !| !| !| !| !| !| !| !|
heart rate, thus identifying how much blood is pumped by the heart over a 1-
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
minute period. Electrical activity of the heart and blood pressure are not
!| !| !| !| !| !| !| !| !| !| !| !|
direct components of cardiac output.
!| !| !| !|
The nurse is performing an assessment for a patient with fatigue and
!| !| !| !| !| !| !| !| !| !| !| !|
shortness of breath. Auscultation of the heart reveals the presence of a
!| !| !| !| !| !| !| !| !| !| !| !|
murmur. What is this assessment finding indicative of?
!| !| !| !| !| !| !|
A. Increased viscosity of the patient's blood
!| !| !| !| !| !|
B. Turbulent blood flow across a heart valve
!| !| !| !| !| !| !| !|
C. Friction between the heart and the myocardium
!| !| !| !| !| !| !|
D. A deficit in heart conductivity that impairs normal contractility - Correct
!| !| !| !| !| !| !| !| !| !| !| !|
answer ✔B. Turbulent blood flow across a heart valve
!| !| !| !| !| !| !| !| !|
Turbulent blood flow across the affected valve results in a murmur. A
!| !| !| !| !| !| !| !| !| !| !| !|
murmur is not a direct result of variances in blood viscosity, conductivity, or
!| !| !| !| !| !| !| !| !| !| !| !| !|
friction between the heart and myocardium.
!| !| !| !| !|
, While assessing the cardiovascular status of a patient, the nurse performs
!| !| !| !| !| !| !| !| !| !| !|
auscultation. Which intervention should the nurse implement in the !| !| !| !| !| !| !| !| !|
assessment during auscultation? !| !|
A. Position the patient supine.
!| !| !| !|
B. Ask the patient to hold his or her breath.
!| !| !| !| !| !| !| !| !| !|
C. Palpate the radial pulse while auscultating the apical pulse.
!| !| !| !| !| !| !| !| !| !|
D. Use the bell of the stethoscope when auscultating S1 and S2. - Correct
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
answer ✔C. Palpate the radial pulse while auscultating the apical pulse.
!| !| !| !| !| !| !| !| !| !| !|
To detect a pulse deficit, simultaneously palpate the radial pulse when
!| !| !| !| !| !| !| !| !| !| !|
auscultating the apical area. The diaphragm is more appropriate than the bell !| !| !| !| !| !| !| !| !| !| !| !|
when auscultating S1 and S2. A sitting or side-lying position is most
!| !| !| !| !| !| !| !| !| !| !| !|
appropriate for cardiac auscultation. It is not necessary to ask the patient to !| !| !| !| !| !| !| !| !| !| !| !| !|
hold his or her breath during cardiac auscultation.
!| !| !| !| !| !| !|
A patient presents to the emergency department with reports of chest pain
!| !| !| !| !| !| !| !| !| !| !| !|
for 3 hours. What component of his blood work is most clearly indicative of
!| !| !| !| !| !| !| !| !| !| !| !| !| !|
a myocardial infarction (MI)?
!| !| !|
A. CK-MB !|
B. Troponin
!| !|
C. Myoglobin
!|
D. C-reactive protein - Correct answer ✔B. Troponin
!| !| !| !| !| !| !| !|
Troponin is the biomarker of choice in the diagnosis of MI, with sensitivity
!| !| !| !| !| !| !| !| !| !| !| !| !|
and specificity that exceed those of CK-MB and myoglobin. CRP levels are
!| !| !| !| !| !| !| !| !| !| !| !|
not used to diagnose acute MI.
!| !| !| !| !|
