NURS 441 Concepts: Exam 2 Practice Q's & A's With
Complete Solutions
ANS: D
Clients who are hyperkalemic (those with an elevated serum
potassium level) may also be in renal failure. The client's serum
creatinine should be reviewed to determine if it is greater than
1.8 mg/dL, at which time the health care provider should be
notified before administering any supplemental potassium.
A client has been taking furosemide (Lasix) and valsartan
(Diovan) for the past year. The hospital laboratory notifies the
nurse that the client's serum potassium level is 6.2 mEq/L. What
is the nurse's best action at this time?
a. Assess the client's oxygen saturation level
b. Ask the laboratory to retest the potassium level
c. Give potassium as an IV infusion
d. Check the client's serum creatinine
ANS: B
The clinical manifestations of digoxin toxicity are often vague
and nonspecific and include anorexia, fatigue, blurred vision,
and changes in mental status, especially in older adults. Older
adults are more likely than other patients to become toxic
because of decreased renal excretion.
An older adult taking digoxin and hydrochlorothiazide (HCTZ)
for chronic heart failure is admitted to the emergency
department (ED) with an apical pulse of 48. A family member
states that the client has reported blurred vision and loss of
,appetite for 2 weeks. What is the nurse's first action?
a. Call the ED physician immediately
b. Draw a serum digoxin level
c. Assess for signs of hypokalemia
d. Establish the client's airway
ANS: D
When the patient is lying flat, the jugular veins are at the level of
the right atrium, so JVD is a common (but not a clinically
significant) finding. Obtaining vital signs and oxygen saturation
is not warranted at this point. JVD is an expected finding when a
patient performs the Valsalva maneuver because right atrial
pressure increases. JVD that persists when the patient is sitting
at a 30- to 45-degree angle or greater is significant. The nurse
will document the JVD in the medical record if it persists when
the head is elevated.
While assessing a patient who was admitted with heart failure,
the nurse notes that the patient has jugular venous distention
(JVD) when lying flat in bed. Which action should the nurse
take next?
a. Document this finding in the patient's record.
b. Obtain vital signs, including oxygen saturation.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: A
Dyspnea on exertion is an early manifestation of heart failure
and is associated with an activity such as stair climbing. The
,other findings are not specific to early occurrence of heart
failure.
An emergency room nurse obtains the health history of a client.
Which statement by the client should alert the nurse to the
occurrence of heart failure?
a. "I get short of breath when I climb stairs."
b. "I see halos floating around my head."
c. "I have trouble remembering things."
d. "I have lost weight over the past month."
ANS: B
Weight gain can result from fluid accumulation in the interstitial
spaces. This is known as edema. The nurse should note whether
the client feels that his or her shoes or rings are tight, and should
observe, when present, an indentation around the leg where the
socks end. The other answers do not describe edema.
A nurse obtains the health history of a client who is newly
admitted to the medical unit. Which statement by the client
should alert the nurse to the presence of edema?
a. "I wake up to go to the bathroom at night."
b. "My shoes fit tighter by the end of the day."
c. "I seem to be feeling more anxious lately."
d. "I drink at least eight glasses of water a day."
ANS: B
Increased myocardial contractility -- thus increasing CO
A nurse is administering a dopamine infusion at a moderate dose
to a client who has severe HF. Which of the following is an
expected effect?
, a. Lowered heart rate
b. Increased myocardial contractility
c. Decreased conduction through the AV node
d. Vasoconstriction of the renal blood vessels
ANS: A
The incidence of congenital heart disease is approximately 50%
in children with trisomy 21 (Down syndrome). A family history
of congenital heart disease, not acquired heart disease, increases
the risk of giving birth to a child with CHD. Infants born to
mothers who are insulin dependent have an increased risk of
CHD. Infants identified as having certain genetic defects, such
as Turner syndrome, have a higher incidence of CHD. A family
history is not a risk factor.
In which situation is there a risk that a newborn infant will have
a congenital heart defect
(CHD)?
a. Trisomy 21 detected on amniocentesis
b. Family history of myocardial infarction
c. Father has type 1 diabetes mellitus
d. Older sibling born with Turner syndrome
ANS: A
The infant's heart rate is above the lower limit for which the
medication is held. A dose of Lanoxin is withheld for a heart
rate less than 100 bpm in an infant. The infant's heart rate is
acceptable for administering Lanoxin. It is unnecessary to
recheck the heart rate at a later time.
Complete Solutions
ANS: D
Clients who are hyperkalemic (those with an elevated serum
potassium level) may also be in renal failure. The client's serum
creatinine should be reviewed to determine if it is greater than
1.8 mg/dL, at which time the health care provider should be
notified before administering any supplemental potassium.
A client has been taking furosemide (Lasix) and valsartan
(Diovan) for the past year. The hospital laboratory notifies the
nurse that the client's serum potassium level is 6.2 mEq/L. What
is the nurse's best action at this time?
a. Assess the client's oxygen saturation level
b. Ask the laboratory to retest the potassium level
c. Give potassium as an IV infusion
d. Check the client's serum creatinine
ANS: B
The clinical manifestations of digoxin toxicity are often vague
and nonspecific and include anorexia, fatigue, blurred vision,
and changes in mental status, especially in older adults. Older
adults are more likely than other patients to become toxic
because of decreased renal excretion.
An older adult taking digoxin and hydrochlorothiazide (HCTZ)
for chronic heart failure is admitted to the emergency
department (ED) with an apical pulse of 48. A family member
states that the client has reported blurred vision and loss of
,appetite for 2 weeks. What is the nurse's first action?
a. Call the ED physician immediately
b. Draw a serum digoxin level
c. Assess for signs of hypokalemia
d. Establish the client's airway
ANS: D
When the patient is lying flat, the jugular veins are at the level of
the right atrium, so JVD is a common (but not a clinically
significant) finding. Obtaining vital signs and oxygen saturation
is not warranted at this point. JVD is an expected finding when a
patient performs the Valsalva maneuver because right atrial
pressure increases. JVD that persists when the patient is sitting
at a 30- to 45-degree angle or greater is significant. The nurse
will document the JVD in the medical record if it persists when
the head is elevated.
While assessing a patient who was admitted with heart failure,
the nurse notes that the patient has jugular venous distention
(JVD) when lying flat in bed. Which action should the nurse
take next?
a. Document this finding in the patient's record.
b. Obtain vital signs, including oxygen saturation.
c. Have the patient perform the Valsalva maneuver.
d. Observe for JVD with the patient upright at 45 degrees.
ANS: A
Dyspnea on exertion is an early manifestation of heart failure
and is associated with an activity such as stair climbing. The
,other findings are not specific to early occurrence of heart
failure.
An emergency room nurse obtains the health history of a client.
Which statement by the client should alert the nurse to the
occurrence of heart failure?
a. "I get short of breath when I climb stairs."
b. "I see halos floating around my head."
c. "I have trouble remembering things."
d. "I have lost weight over the past month."
ANS: B
Weight gain can result from fluid accumulation in the interstitial
spaces. This is known as edema. The nurse should note whether
the client feels that his or her shoes or rings are tight, and should
observe, when present, an indentation around the leg where the
socks end. The other answers do not describe edema.
A nurse obtains the health history of a client who is newly
admitted to the medical unit. Which statement by the client
should alert the nurse to the presence of edema?
a. "I wake up to go to the bathroom at night."
b. "My shoes fit tighter by the end of the day."
c. "I seem to be feeling more anxious lately."
d. "I drink at least eight glasses of water a day."
ANS: B
Increased myocardial contractility -- thus increasing CO
A nurse is administering a dopamine infusion at a moderate dose
to a client who has severe HF. Which of the following is an
expected effect?
, a. Lowered heart rate
b. Increased myocardial contractility
c. Decreased conduction through the AV node
d. Vasoconstriction of the renal blood vessels
ANS: A
The incidence of congenital heart disease is approximately 50%
in children with trisomy 21 (Down syndrome). A family history
of congenital heart disease, not acquired heart disease, increases
the risk of giving birth to a child with CHD. Infants born to
mothers who are insulin dependent have an increased risk of
CHD. Infants identified as having certain genetic defects, such
as Turner syndrome, have a higher incidence of CHD. A family
history is not a risk factor.
In which situation is there a risk that a newborn infant will have
a congenital heart defect
(CHD)?
a. Trisomy 21 detected on amniocentesis
b. Family history of myocardial infarction
c. Father has type 1 diabetes mellitus
d. Older sibling born with Turner syndrome
ANS: A
The infant's heart rate is above the lower limit for which the
medication is held. A dose of Lanoxin is withheld for a heart
rate less than 100 bpm in an infant. The infant's heart rate is
acceptable for administering Lanoxin. It is unnecessary to
recheck the heart rate at a later time.
