NUR 213 TEST #2 (PERFUSION) 128
QUESTIONS WITH COMPLETE SOLUTIONS.
1 of 128
Term
A nurse teaches a client with heart failure about energy
conservation. Which statement should the nurse include in
this client's teaching?
a. "Walk until you become short of breath, and then walk
back home."
b. "Gather everything you need for a chore before you begin."
c. "Pull rather than push or carry items heavier than 5 pounds."
d. "Take a walk after dinner every day to build up your strength."
Give this one a try later!
,b. "Avoid straining while having a bowel movement."
Bearing down strenuously during a bowel movement is one type of Valsalva
maneuver, which stimulates the vagus nerve and results in slowing of the heart
rate. Such a response is not desirable in a person who has bradycardia. The
other instructions are not appropriate for this condition.
b. "Avoid large crowds and people who are sick."
These agents cause immune suppression, leaving the client more vulnerable to
infection. The medication does not place the client at risk for bleeding,
orthostatic hypotension, or a change in heart rate.
b. "Gather everything you need for a chore before you begin."
A client who has heart failure should be taught to conserve energy.
Gathering all supplies needed for a chore at one time decreases the
amount of energy needed. The client should not walk until becoming short
of breath because he or she may not make it back home. Pushing a cart
takes less energy than pulling or lifting. Although walking after dinner may
help the client, the nurse should teach the client to complete activities
when he or she has the most energy. This is usually in the morning.
b. Assess vital signs and level of consciousness.
In temporary pacing, the wires are threaded onto the epicardial surface of the
heart and exit through the chest wall. The pacemaker spike should be followed
immediately by a QRS complex. Pacing spikes seen without subsequent QRS
complexes imply loss of capture. If there is no capture, then there is no
ventricular depolarization and contraction. The nurse should assess for
cardiac output via vital signs and level of consciousness. The other
interventions would not determine if the client is tolerating the loss of
capture.
Don't know?
, 2 of 128
Term
A nurse assesses a client who is recovering from a heart transplant.
Which assessment findings should alert the nurse to the possibility of
heart transplant rejection? (Select all that apply.)
a.Shortness of breath
b.Abdominal bloating
c. New-onset bradycardia
d. Increased ejection fraction
e. Hypertension
Give this one a try later!
A,B,C
Clinical manifestations of heart transplant rejection include shortness of
breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia,
hypotension, atrial fibrillation or flutter, decreased activity tolerance, and
decreased ejection fraction.
B,C,E
Women may not have chest pain with myocardial infarction, but may feel
discomfort or indigestion. They often present with a triad of symptoms—
indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite
adequate rest, and feeling unable to catch their breath. Frequently, women are
not diagnosed and therefore are not treated adequately. Hypertension and
abdominal pain are not associated with acute coronary syndrome.
, A,C,E
Complications from a right-sided heart catheterization include thrombophlebitis,
pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both
right- and left-sided heart catheterizations. Stroke and myocardial infarction are
complications of left-sided heart catheterizations.
A,C,E
A lipid panel is often used to screen for cardiovascular risk. Total
cholesterol, triglycerides, and low-density lipoprotein cholesterol levels
are all high,
indicating higher risk for cardiovascular disease. High-density lipoprotein
cholesterol is within the normal range for both males and females.
Serum albumin is not assessed for atherosclerosis.
Don't know?
3 of 128
Term
A nurse assesses a client who had a myocardial infarction and is
hypotensive. Which additional assessment finding should the nurse
expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
Give this one a try later!
QUESTIONS WITH COMPLETE SOLUTIONS.
1 of 128
Term
A nurse teaches a client with heart failure about energy
conservation. Which statement should the nurse include in
this client's teaching?
a. "Walk until you become short of breath, and then walk
back home."
b. "Gather everything you need for a chore before you begin."
c. "Pull rather than push or carry items heavier than 5 pounds."
d. "Take a walk after dinner every day to build up your strength."
Give this one a try later!
,b. "Avoid straining while having a bowel movement."
Bearing down strenuously during a bowel movement is one type of Valsalva
maneuver, which stimulates the vagus nerve and results in slowing of the heart
rate. Such a response is not desirable in a person who has bradycardia. The
other instructions are not appropriate for this condition.
b. "Avoid large crowds and people who are sick."
These agents cause immune suppression, leaving the client more vulnerable to
infection. The medication does not place the client at risk for bleeding,
orthostatic hypotension, or a change in heart rate.
b. "Gather everything you need for a chore before you begin."
A client who has heart failure should be taught to conserve energy.
Gathering all supplies needed for a chore at one time decreases the
amount of energy needed. The client should not walk until becoming short
of breath because he or she may not make it back home. Pushing a cart
takes less energy than pulling or lifting. Although walking after dinner may
help the client, the nurse should teach the client to complete activities
when he or she has the most energy. This is usually in the morning.
b. Assess vital signs and level of consciousness.
In temporary pacing, the wires are threaded onto the epicardial surface of the
heart and exit through the chest wall. The pacemaker spike should be followed
immediately by a QRS complex. Pacing spikes seen without subsequent QRS
complexes imply loss of capture. If there is no capture, then there is no
ventricular depolarization and contraction. The nurse should assess for
cardiac output via vital signs and level of consciousness. The other
interventions would not determine if the client is tolerating the loss of
capture.
Don't know?
, 2 of 128
Term
A nurse assesses a client who is recovering from a heart transplant.
Which assessment findings should alert the nurse to the possibility of
heart transplant rejection? (Select all that apply.)
a.Shortness of breath
b.Abdominal bloating
c. New-onset bradycardia
d. Increased ejection fraction
e. Hypertension
Give this one a try later!
A,B,C
Clinical manifestations of heart transplant rejection include shortness of
breath, fatigue, fluid gain, abdominal bloating, new-onset bradycardia,
hypotension, atrial fibrillation or flutter, decreased activity tolerance, and
decreased ejection fraction.
B,C,E
Women may not have chest pain with myocardial infarction, but may feel
discomfort or indigestion. They often present with a triad of symptoms—
indigestion or feeling of abdominal fullness, feeling of chronic fatigue despite
adequate rest, and feeling unable to catch their breath. Frequently, women are
not diagnosed and therefore are not treated adequately. Hypertension and
abdominal pain are not associated with acute coronary syndrome.
, A,C,E
Complications from a right-sided heart catheterization include thrombophlebitis,
pulmonary embolism, and vagal response. Cardiac tamponade is a risk of both
right- and left-sided heart catheterizations. Stroke and myocardial infarction are
complications of left-sided heart catheterizations.
A,C,E
A lipid panel is often used to screen for cardiovascular risk. Total
cholesterol, triglycerides, and low-density lipoprotein cholesterol levels
are all high,
indicating higher risk for cardiovascular disease. High-density lipoprotein
cholesterol is within the normal range for both males and females.
Serum albumin is not assessed for atherosclerosis.
Don't know?
3 of 128
Term
A nurse assesses a client who had a myocardial infarction and is
hypotensive. Which additional assessment finding should the nurse
expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
Give this one a try later!
