1 / pn2 exam 2
1.A nurse assesses a client who had a myocardial infarction and is hy- potensive. 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 ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen
saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.
2.A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?: a. Blood pressure in- creased from 98/42 mm Hg to 132/60 mmHg
b.Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c.Oxygen saturation increased from 88% to 96%
d.*Pulse decreased from 100 beats/min to 80 beats/min* ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart 2 / rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.
3.3. A nurse assesses clients on a medical-surgical unit. Which client
should the nurse identify as having the greatest risk for cardiovascular
disease?: a. An 86-year-old man with a history of asthma pn2 exam 2
Study online at https://quizlet.com/_5kst0x
3 / b.A 32-year-old Asian-American man with colorectal cancer
c.*A 45-year-old American Indian woman with diabetes mellitus*
d.A 53-year-old postmenopausal woman who is on hormone
therapy ANS: C
The incidence of coronary artery disease and hypertension is higher in
American Indians than in whites or Asian Americans. Diabetes mellitus
increases the risk for hypertension and coronary artery disease in
people of any race or ethnicity. Asth- ma, colorectal cancer, and
hormone therapy do not increase risk for cardiovascular disease.
4.A nurse assesses an older adult client who has multiple chronic diseases. The clients heartrate is 48 beats/min. Which action should the nurse take first?: a. Document the finding in the chart.
b. Initiate external pacing.
c. *Assess the clients medications.* d.Administer 1 mg of atropine.
ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause
such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.
5.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.
1.A nurse assesses a client who had a myocardial infarction and is hy- potensive. 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 ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart rate and respiratory rate will compensate for the low blood pressure and maintain oxygen
saturations and perfusion. The client may not be able to compensate for long, and decreased oxygenation and cool, clammy skin will occur later.
2.A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find?: a. Blood pressure in- creased from 98/42 mm Hg to 132/60 mmHg
b.Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c.Oxygen saturation increased from 88% to 96%
d.*Pulse decreased from 100 beats/min to 80 beats/min* ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart 2 / rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does not have effects on beta2-adrenergic receptor sites. Cardiac output will drop because of decreased HR.
3.3. A nurse assesses clients on a medical-surgical unit. Which client
should the nurse identify as having the greatest risk for cardiovascular
disease?: a. An 86-year-old man with a history of asthma pn2 exam 2
Study online at https://quizlet.com/_5kst0x
3 / b.A 32-year-old Asian-American man with colorectal cancer
c.*A 45-year-old American Indian woman with diabetes mellitus*
d.A 53-year-old postmenopausal woman who is on hormone
therapy ANS: C
The incidence of coronary artery disease and hypertension is higher in
American Indians than in whites or Asian Americans. Diabetes mellitus
increases the risk for hypertension and coronary artery disease in
people of any race or ethnicity. Asth- ma, colorectal cancer, and
hormone therapy do not increase risk for cardiovascular disease.
4.A nurse assesses an older adult client who has multiple chronic diseases. The clients heartrate is 48 beats/min. Which action should the nurse take first?: a. Document the finding in the chart.
b. Initiate external pacing.
c. *Assess the clients medications.* d.Administer 1 mg of atropine.
ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, resulting in bradycardia. The nurse should check the medication reconciliation for medications that might cause
such a drop in heart rate, then should inform the health care provider. Documentation is important, but it is not the priority action. The heart rate is not low enough for atropine or an external pacemaker to be needed.
5.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.
