Adult Health Nursing 7th Edition By Cooper Gosnell -Test Bank

Chapter 2: Care of the Surgical Patient MULTIPLE CHOICE 1. The patient who had a nephrectomy yesterday has not used the patient-controlled analgesia (PCA) delivery system but admits to being in pain but fearful of addiction. What is the nurse’s best response? a. “Modern analgesic drugs do not cause addiction.” b. “Pain relief is worth a short period of addiction.” c. “Addiction rarely occurs in the brief time postsurgical analgesia is required.” d. “Addiction could be a real concern.” ANS: C Addiction rarely occurs in the short time that it is required after surgery. Postsurgical analgesia, because of its brief application, does not usually produce a physical or a psychological dependence. DIF: Cognitive Level: Application REF: Page 34 OBJ: 13 TOP: Fear of addiction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery? a. Palliative b. Diagnostic c. Reconstructive d. Ablative ANS: D Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed. DIF: Cognitive Level: Comprehension REF: Page 16, Table 2-1 OBJ: 2 TOP: Types of surgeries KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity In which situation might surgery be delayed? a. The patient has taken Dilantin today. b. An illegible signature is on the consent form.. c. The patient is still taking anticoagulants. d. The admission office is unable to confirm insurance coverage. ANS: C All medications should be cancelled before surgery, except for drugs such as phenytoin (Dilantin). Anticoagulant therapy increases the threat of hemorrhage and may be a cause for delay. DIF: Cognitive Level: Knowledge REF: Page 34, Page 36 Table 2-6 OBJ: 7 TOP: Anticoagulant therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. 3. 4. Which circumstance could prevent the patient from signing his informed consent for a cholecystectomy? a. The patient complains of pain radiating to the scapula. b. The patient received an injection of Demerol, 75 mg IM, 1 hour ago. c. The patient is 85 years of age. d. The patient is concerned over his lack of insurance coverage. ANS: B Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives. Age, illegibility, and lack of insurance coverage do not prevent signing the consent. Pain into the scapula is a symptom of colitis. DIF: Cognitive Level: Application REF: Page 23 OBJ: 7 TOP: Informed consent KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse anticipates that the patient will be given ______________anesthesia because of the extensive tissue manipulation involved in a hysterectomy. a. general b. regional c. specific d. preoperative ANS: A An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia when the procedure requires extensive tissue manipulation. DIF: Cognitive Level: Knowledge REF: Page 34 OBJ: 9 TOP: Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse caring for a patient who had an epidural block for a vaginal repair should be alert for: a. a flushing of the face and torso. b. numbness of the perineum. c. complaint of thirst. d. a sudden drop in blood pressure. ANS: D Epidural anesthesia may cause a sudden drop in blood pressure or respiratory difficulty as the anesthetic agent moves up in the spinal cord. Elevating the patient’s torso may prevent respiratory paralysis. DIF: Cognitive Level: Comprehension REF: Page 37 OBJ: 9 TOP: Epidural block KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. Why might the older adult patient not respond to surgical treatment as well as a younger adult patient? a. Poor skin turgor b. Fear of the unknown c. Response to physiological changes d. Decreased peristalsis related to anesthesia ANS: C Of specific concern in older adults is the body’s response to temperature changes, cardiovascular shifts, respiratory needs, and renal function. Fear of the unknown and decreased peristalsis are common to all ages. DIF: Cognitive Level: Application REF: Page 17 OBJ: 5 TOP: Older adult patients KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be: a. coughing every 2 hours. b. turning every 2 hours. c. monitoring intravenous therapy at 50 ml/hr. d. assessing vital signs every 2 hours. ANS: A Coughing increases ICP. DIF: Cognitive Level: Analysis REF: Page 28, Box 2-6 OBJ: 12 TOP: Postoperative complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The nurse acting as a circulating nurse has a responsibility for: a. observing for breaks in sterile technique. b. identifying and handling surgical specimens correctly. c. assisting with surgical draping of the patient. d. maintaining count of sponges, needles, and instruments during surgery. ANS: A The circulating nurse is responsible for observing breaks in sterile technique. The scrub nurse handles the surgical specimens, drapes the patient, and maintains needle and sponge count during surgery, then does a final sponge and needle check with the circulating nurse before closing. DIF: Cognitive Level: Analysis REF: Page 43, Box 2-7 OBJ: 11 TOP: Duties of circulating nurse KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 10. Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon? a. “I have been taking an herbal product of feverfew for my migraines.” b. “I exercise for 3 hours a day.” c. “I drink 2 glasses of wine a day.” d. “I use atropine eyedrops every day.” ANS: A The herbal remedy of feverfew acts as an anticoagulant and increases the possibility of hemorrhage. The drug should be stopped before surgery, and bleeding and clotting times should be evaluated. DIF: Cognitive Level: Application REF: Page 21, Table 2-3 OBJ: 14 TOP: Preoperative assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis? a. Ambulation b. An enema c. Encouraging hot liquids d. Administering a laxative ANS: A Encouraging activity (turning every 2 hours, early ambulation) assists GI activity. DIF: Cognitive Level: Comprehension REF: Page 50 OBJ: 13 TOP: Postoperative complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make? a. Check ankle dressings for hemorrhage. b. Check airway for patency. c. Check intravenous site. d. Check pedal pulse. ANS: B Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation. DIF: Cognitive Level: Application REF: Pages 42-43, Table 2-7 OBJ: 12 TOP: Nursing assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 13. Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage? a. Increasing blood pressure b. Decreasing pulse c. Restlessness d. Weakness, apathy ANS: C A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, reduced urine output, and restlessness may signal hypovolemic shock. DIF: Cognitive Level: Comprehension REF: Page 45, Box 2-8 OBJ: 12 TOP: Postoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings would include which of the following instructions? a. Disregard appearance of edema above the stocking b. Massage legs to smooth wrinkles out of stockings c. Wring stockings thoroughly before hanging to dry d. Wash stockings in warm water and mild soap ANS: D Stockings should be washed gently in warm water and mild soap and laid over a surface to dry. They should not be wrung out or hung. Massaging legs may dislodge a clot and the appearance of edema indicates the stockings are too restrictive. DIF: Cognitive Level: Comprehension REF: Page 31, Patient Teaching Box OBJ: 13 TOP: Thrombolytic deterrent stockings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F? a. Notify the charge nurse immediately b. Offer warm fluids through a straw c. Do nothing, this is a normal reaction to anesthesia d. Cover with a warm blanket ANS: D Hypothermia is a frequent assessment postsurgery. A warm blanket or a ventilated cover would be applied to bring up the temperature. Vital signs are checked every 15 minutes until stable. DIF: Cognitive Level: Analysis REF: Page 43, Page 45 Table 2-8 OBJ: 13 TOP: Hypothermia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16. In which location are guidelines for ensuring that all nursing interventions on the day of surgery completed and documented? a. In the nurse’s notes b. In the anesthesia record c. In the preoperative checklist d. In the progress notes ANS: C When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list. DIF: Cognitive Level: Knowledge REF: Page 40 OBJ: 6 TOP: Preoperative checklistKEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 17. While turning a patient who had a bowel resection yesterday, the wound eviscerated. What is the initial nursing intervention? a. Place the patient in the high Fowler’s position. b. Give the patient fluids to prevent shock. c. Replace the dressing with sterile fluffy pads. d. Apply a warm, moist normal saline sterile dressing. ANS: D Cover the wound with a sterile towel moistened with sterile physiological saline (warm). DIF: Cognitive Level: Application REF: Pages 46-47, Figure 2-13 OBJ: 13 TOP: Evisceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative? a. Only when the patient asks. b. When the onset of pain is assessed. c. Sparingly to avoid drug dependence. d. Only when severe pain is assessed. ANS: B The nurse should assess for pain frequently to medicate at the onset of pain. DIF: Cognitive Level: Application REF: Page 48 OBJ: 14 TOP: Medication administration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 19. What should the nurse do to minimize the potential for venous stasis? a. Place pillows under the knee in a position of comfort b. Assist patient to sit with feet flat on the floor c. Assist with early ambulation d. Perform gentle leg massage ANS: C Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications. DIF: Cognitive Level: Application REF: Page 49 OBJ: 13 TOP: Venous stasis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 20. The nurse clarifies that serum potassium levels are determined before surgery to: a. assess kidney function. b. determine respiratory insufficiency. c. prevent arrhythmias related to anesthesia. d. measure functional liver capability. ANS: C Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, arrhythmias can occur during anesthesia. DIF: Cognitive Level: Analysis REF: Page 23 OBJ: 4 TOP: Preoperative assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially? a. Notify the diet kitchen to omit peaches from diet tray b. Apply a medical alert band to patient’s wrist c. Tag chart with allergy alert d. Place patient in an isolation room ANS: B The initial intervention would be to place a medical alert band on the patient, then tag the chart. The charge nurse and the surgeon should be notified in the event the surgeon wants to order a preoperative prophylactic treatment. DIF: Cognitive Level: Knowledge REF: Pages 25-26, Box 2-5 OBJ: 13 TOP: Latex allergy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 22. Which of the following early postoperative observations should be reported immediately? a. “Coffee ground” emesis b. Shivering c. Scanty urine output d. Evidence of pain ANS: A Any emesis that is red or coffee ground should be reported immediately as it indicates GI bleeding. Shivering, scanty urine output, and evidence of pain are within normal expectation of a postsurgical patient. DIF: Cognitive Level: Application REF: Page 45 OBJ: 10 TOP: Postoperative assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of: a. hypovolemic shock. b. dehiscence. c. atelectasis. d. pulmonary embolus. ANS: D Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism. DIF: Cognitive Level: Analysis REF: Page 47 OBJ: 13 TOP: Assessment and postoperative complications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The removal of a nondiseased appendix during a hysterectomy is classified as: a. major, emergency, diagnostic b. major, urgent, palliative c. minor, elective, ablative d. minor, urgent, reconstructive ANS: C Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes. DIF: Cognitive Level: Comprehension REF: Page 16, Table 2-1 OBJ: 2 TOP: Types of surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 25. Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery? a. Analgesic agent b. Antihypertensive agent c. Anticoagulant agent d. Antibiotic agent ANS: C Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery. DIF: Cognitive Level: Analysis REF: Page 36, Table 2-6 OBJ: 4 TOP: Individual’s ability to tolerate surgery KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 26. The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to: a. Support the surgical site with a pillow b. Position patient in a side-lying position c. Medicate with prescribed narcotic before coughing d. Ask the patient to cross arms over the chest to increase force of cough ANS: A To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow, rolled bath blanket, or the heel of the hand. DIF: Cognitive Level: Application REF: Page 47 OBJ: 8 TOP: Postoperative nursing interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 27. The nurse would include the nursing diagnosis of deficient knowledge, postoperative, when the patient scheduled for a bowel resection tomorrow remarks: a. “I am going to have adequate pain medication after surgery.” b. “I know you all are going to make me cough and walk soon after surgery.” c. ”I am glad I will get to go home tomorrow evening.” d. “I will have to put up with dressing changes.” ANS: C The patient’s lack of understanding about the length of time in the hospital following such a serious surgery indicates a knowledge deficit that needs to be addressed. DIF: Cognitive Level: Analysis REF: Page 52, Box 2-11 OBJ: 16 TOP: Nursing process/diagnosis KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 28. What instruction should a nurse give when teaching the patient to cough effectively after surgery? a. Breathe through the nose, hold breath, and exhale slowly. b. Take three deep breaths and cough from the chest. c. Inhale while contracting the abdominal muscles and exhale while contracting the diaphragm. d. Take short, frequent panting breaths and cough from the throat to clear accumulated mucus. ANS: B Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually adequately able to remove trapped mucus and surgical gases. DIF: Cognitive Level: Application REF: Page 29, Skill 2-3 OBJ: 8 TOP: Prevention of postoperative complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 29. What is the responsibility of the nurse as a witness to informed consent? a. Explain the surgical options b. Explain the operative risks c. Verify/obtain the patient’s signature d. Verify the patient’s understanding of the procedure ANS: C A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure. DIF: Cognitive Level: Knowledge REF: Page 23 OBJ: 7 TOP: Informed consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 30. On the patient’s return to the medical-surgical unit, the nurse performing an abdominal assessment can affirm an absence of bowel sounds after listening in each quadrant for at least: a. 30 seconds. b. 1 minute. c. 2 minutes. d. 3 minutes. ANS: D Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute. Absence of bowel sounds may be recorded if the nurse has listened to each quadrant 3 to 5 minutes. DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 12 TOP: Bowel sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 31. When the patient asks the nurse to make sure no one sees her with her dentures out, the nurse recognizes the common preoperative fear of: a. anesthesia. b. loss of control. c. fear of separation from family. d. mutilation. ANS: B Fear of loss of control may be partially related to concerns about anesthesia, but this patient’s concern is about self-image. Preoperative anxiety from any cause may affect the amount of anesthesia and postoperative analgesia needed. DIF: Cognitive Level: Assessment REF: Page 20, Box 2-4 OBJ: 4 TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 32. What is the ideal time for preoperative teaching? a. Immediately before surgery to eliminate fear b. 2 months in advance so the patient can prepare c. 1 to 2 days before the surgery when anxiety is not as high d. In the surgical holding area ANS: C Preoperative teaching is provided 1 to 2 days prior to surgery when anxiety is low. DIF: Cognitive Level: Implementation REF: Page 22 OBJ: 4 TOP: Preoperative teaching KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 33. In preparation for the return of the surgical patient, the patient’s bed and equipment should be in what position? a. Lowest position with side rails elevated with oxygen and suction equipment available b. Highest position with side rails elevated with IV pole and pump at bedside c. Lowest position with side rails down on the receiving side d. Highest position with the side rails down on receiving side and up on opposite side ANS: D In preparation for the return of the surgical patient, the patient’s bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer. DIF: Cognitive Level: Implementation REF: Page 40 OBJ: 12 TOP: Postoperative preparation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 34. A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.) a. Care of the wound site and any dressings b. When he may operate a motor vehicle c. Signs and symptoms to report to the physician d. Call the physician’s office once he arrives home e. Report bowel movements to the physician f. Actions and side effects of any medications ANS: A,B,C,F As the day of discharge approaches, the nurse should be certain that the patient has vital information. DIF: Cognitive Level: Analysis REF: Page 53, Box 2-13 OBJ: 15 TOP: Discharge instructions KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment Which of the following are considerations for the older adult surgical patient? (Select all that apply.) a. The need for specific clear preoperative and postoperative teaching b. Awareness of lower morbidity and mortality rate c. Presence of coexisting conditions d. Increased risk of respiratory complications e. Expectation of normal recovery time ANS: A,C,D Surgery places greater stress on older than on younger patients. Teaching should be given at the older person’s level of understanding. Teaching should be specific and clear. Presence of coexisting conditions may delay recovery time and response to surgery. DIF: Cognitive Level: Application REF: Page 17, Life Span Considerations OBJ: 7 TOP: Older adult considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity Which of the following are preoperative conditions that may affect the patient’s response to surgery? (Select all that apply.) a. Age b. Religion c. Mental status d. Occupation e. Nutritional status ANS: A,C,E Each system of the body is affected by the patient’s age, health, nutritional status, and mental state. Religion and occupation do not affect the physiological response to the surgery. DIF: Cognitive Level: Comprehension REF: Page 17 OBJ: 4 TOP: Factors influencing toleration to surgery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 35. 36. Which interventions in preparing the patient for abdominal surgery may be delegated to unlicensed assistive personnel (UAP)? a. Vital signs b. Insertion of N/G tube c. Enema d. Height and weight e. Obtaining operative consent f. Sterile gowning ANS: A,C,D Vital signs, enema, and height and weight can be safely performed by UAP. Insertion of an N/G tube, obtaining an operative consent, and sterile gloving are interventions requiring critical thinking and knowledge unique to a nurse. DIF: Cognitive Level: Application REF: Page 18, Box 2-2 OBJ: 3 TOP: Delegation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance COMPLETION 38. ______________ therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem. ANS: Palliative Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure. DIF: Cognitive Level: Knowledge REF: Page 16, Table 2-1 OBJ: 1 TOP: Palliative therapy KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 39. Discharge planning for a surgical procedure begins in the ______________ period and continues through the _____________ period. ANS: preoperative, recuperative When discharge planning is begun in the preoperative period and all through the postoperative period, the patient can assume greater responsibility for self-care and will experience less stress about going home. DIF: Cognitive Level: Comprehension REF: Page 52 OBJ: 15 TOP: Discharge planning KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 40. The type of anesthesia that uses a combination of drugs to reduce the level of consciousness and provides amnesia is _________________ __________. ANS: 37. conscious sedation Conscious sedation uses a combination of drugs to produce a reduced level of consciousness and amnesia, as well as pain control, but allows the patient to control his or her own breathing. The recovery is more rapid than with general anesthesia. DIF: Cognitive Level: Comprehension REF: Page 48 OBJ: 10 TOP: Conscious sedation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 41. The nurse is aware that there is a loss of _________ during catabolism after severe tissue injury. ANS: potassium The injured cells loose potassium as catabolism (tissue breakdown) occurs. DIF: Cognitive Level: Knowledge REF: Page 51 OBJ: 13 TOP: Catabolism KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 42. The nurse explains that to promote deep breathing and improve lung expansion and oxygenation the patient should use the _____________ ______________ at regular intervals during the day. ANS: incentive spirometer The incentive spirometer is a device to encourage deep breathing and lung expansion. The usual rate of usage is 8 to 10 breaths hourly during waking hours. DIF: Cognitive Level: Comprehension REF: Page 26 OBJ: 13 TOP: Incentive spirometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 43. The nurse caring for a postsurgical patient is aware that the patient should void ____ to _____ hours postsurgery. ANS: 6 to 8 6, 8 Urinary output should be obvious 6 to 8 hours postsurgery. If urinary output has not begun, a catheter may be inserted. DIF: Cognitive Level: Comprehension REF: Page 48 OBJ: 13 TOP: Resumption of urinary flow KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity OTHER 44. A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU. (Separate letters by a comma and space as follows: A, B, C, D) a. System review b. Breathing c. Circulation d. Airway e. Level of consciousness ANS: D, B, E, C, A The assessment of an adequate airway is primary in the postanesthesia assessment, followed by breathing assessment, level of consciousness, circulation, and finally system review. DIF: Cognitive Level: Application REF: Page 44, Table 2-7 OBJ: 12 TOP: Nursing assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 45. Place the instructions for controlled coughing in the correct sequence. (Separate letters by a comma and space as follows: A, B, C, D) a. Inhale deeply and hold breath for a count of three b. Document exercise and patient reaction c. Cough 2 or 3 times without inhaling then relax d. Take several deep breaths e. Inhale through nose f. Exhale through pursed lips ANS: D, E, F, A, C, B The patient should be instructed to take several deep breaths, inhale through the nose, exhale through pursed lips, inhale deeply and hold for a count of three, cough two or three times without exhaling, relax. The procedure may be repeated before documentation. DIF: Cognitive Level: Application REF: Pages 29-30, Skill 2-3 OBJ: 13 TOP: Controlled coughing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity Chapter 8: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder MULTIPLE CHOICE 1. The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s contraction, is the: a. endocardium. b. pericardium. c. mediastinum. d. myocardium. ANS: D The myocardium is the specialized muscle layer that allows the heart to contract. DIF: Cognitive Level: Comprehension REF: Page 308 OBJ: 2 TOP: Myocardium KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse clarifies that the master pacemaker of the heart is the: a. left ventricle. b. atrioventricular (AV) node. c. sinoatrial (SA) node. d. bundle of His. ANS: C The SA node is the master pacemaker of the heart. DIF: Cognitive Level: Application REF: Page 308 TOP: Acute myocardial infarction KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 3. The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having: a. hepatitis A. b. indigestion. c. urinary infection. d. menopausal complications. ANS: B Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI. DIF: Cognitive Level: Application REF: Page 334 OBJ: 16 TOP: MIs in women KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 4. The nurse identifies the “LUBB” sound of the “LUBB/DUBB” of the cardiac cycle as the sound of the: a. AV valves closing. b. closure of the semilunar valves. OBJ: 10 c. contraction of the papillary muscles. d. contraction of the ventricles. ANS: A The LUBB is the first sound of a low pitch heard when the AV valves close. DIF: Cognitive Level: Application REF: Page 310 OBJ: 4 TOP: Lubb sound KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient’s condition as: a. moderate heart failure. b. severe heart failure. c. congestive heart failure. d. negligible heart failure. ANS: B Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest. DIF: Cognitive Level: Knowledge REF: Page 340, Box 8-3 OBJ: 9 TOP: Classification of heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 6. The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a: a. stage A. b. stage B. c. stage C. d. stage D. ANS: A The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease. DIF: Cognitive Level: Analysis REF: Page 340, Box 8-3 OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 7. The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says: a. “I can ambulate in the hallway with this gadget on.” b. “I always take off the telemetry device when I shower.” c. “My EKG is being watched by one of the nurses in CCU on the home unit.” d. “I am able to sleep just fine with this device on.” ANS: B Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower. DIF: Cognitive Level: Application REF: Page 314 OBJ: 6 TOP: Remote telemetry KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 8. The nurse assesses pitting edema that can be depressed approximately inch and refills in 15 seconds. The nurse would document this assessment as: a. +1 edema. b. +2 edema. c. +3 edema. d. +4 edema. ANS: B A +2 edema can be documented if the skin can be depressed inch and respond within 15 seconds. DIF: Cognitive Level: Analysis REF: Page 340, Table 8-5 OBJ: 9 TOP: Pitting edema KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 9. What do dark or “cold” spots on a thallium scan indicate? a. Tissue with adequate blood supply b. Dilated vessels c. Areas of neoplastic growth d. Tissue that has inadequate perfusion ANS: D Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or “cold spots” indicate tissues that have inadequate perfusion. DIF: Cognitive Level: Application REF: Page 314 OBJ: 6 TOP: Thallium scan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 10. The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of: a. normal heart action. b. mild heart failure. c. moderate heart failure. d. severe heart failure. ANS: C An ejection factor (cardiac output) of 42% indicates moderate heart failure. DIF: Cognitive Level: Comprehension REF: Page 315 OBJ: 6 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse takes into consideration that age-related changes can affect the peripheral circulation because of: a. sclerosed blood vessels. b. hypotension. c. inactivity. d. poor nutrition. ANS: A Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen. DIF: Cognitive Level: Comprehension REF: Page 317, Life Span Considerations OBJ: 16 TOP: Endocarditis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 12. The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as: a. sinus bradycardia. b. atrial fibrillation. c. sinus tachycardia. d. ventricular tachycardia. ANS: C Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats a minute. DIF: Cognitive Level: Application REF: Page 320 OBJ: 8 TOP: Arrhythmias KEY: Nursing Process Step: I Assessment MSC: NCLEX: Physiological Integrity 13. After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of: a. congestive heart failure. b. heart block. c. aortic stenosis. d. infective endocarditis. ANS: D Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis. DIF: Cognitive Level: Analysis REF: Page 351 OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into: a. atrial fibrillation and possible emboli. b. sinus tachycardia and syncope. c. ventricular tachycardia and death. d. sinus bradycardia and fatigue. ANS: C PVCs are capable of progressing into ventricular tachycardia and death. DIF: Cognitive Level: Application REF: Page 322 OBJ: 10 TOP: PVCs KEY: Nursing Process Step: I Assessment MSC: NCLEX: Physiological Integrity 15. The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between: a. 1 and 2. b. 2 and 3. c. 3 and 4. d. 4 and 5. ANS: B The desired INR for the monitoring of anticoagulant therapy is between 2 and 3. DIF: Cognitive Level: Knowledge REF: Page 321 OBJ: 8 TOP: INR KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What should a person with unstable angina avoid? a. Walking outside b. Eating red meat c. Swimming in warm pool d. Shoveling snow ANS: D The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress. DIF: Cognitive Level: Application REF: Page 327 OBJ: 9 TOP: Angina KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 17. The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse’s most helpful response would be: a. “Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.” b. “If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital.” c. “When nitroglycerin is not relieving the pain, lie down and rest.” d. “Use oxygen at home to relieve pain when nitroglycerin is not successful.” ANS: B Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain. DIF: Cognitive Level: Application REF: Page 320 OBJ: 9 TOP: Angina pectoris KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 18. The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse’s immediate course of action would be to: a. reteach him about his medications. b. have a serious talk with him and his family about compliance. c. arrange for home visits after discharge. d. collect more information to identify his reasons for noncompliance. ANS: D Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance. DIF: Cognitive Level: Application REF: Page 331 OBJ: 18 TOP: Noncompliance KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 19. What is the major cause of cardiac valve disease? a. Rheumatic fever b. Long history of malnutrition c. Drug abuse d. Obesity ANS: A Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease. DIF: Cognitive Level: Comprehension REF: Page 347 OBJ: 10 TOP: Valvular disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 20. The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low- density lipid (LDL) of 80. The nurse’s reaction is one of: a. satisfaction. This is good cholesterol control. b. determination. This is evidence that more instruction is necessary. c. inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol. d. regret. This shows very poor cholesterol control. ANS: A Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high number of LDLs puts the patient at risk for heart disease. DIF: Cognitive Level: Analysis REF: Page 316, Box 8-1 OBJ: 6 TOP: Lipid studies KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 21. A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include: a. substernal pain that radiates down the left arm. b. epigastric pain that radiates to the jaw. c. indigestion, nausea, and eructation. d. fatigue, shortness of breath, and dyspnea. ANS: A The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw. DIF: Cognitive Level: Comprehension REF: Page 327, Figure 8-11 OBJ: 9 TOP: Angina pectoris KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage? a. CK-MB b. Elevated white count c. Elevated sedimentation rate d. Low level of sodium ANS: A The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific. DIF: Cognitive Level: Application REF: Page 334 OBJ: 6 TOP: CK-MB KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 23. The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young adults who have minimal risk factors for cardiovascular disease is related to which factor(s)? a. Cocaine use b. Viral infections c. Vitamin B1 deficiencies d. Pregnancy ANS: A Cardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues. DIF: Cognitive Level: Analysis REF: Page 353 OBJ: 14 TOP: Cardiomyopathy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 24. The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention? a. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock. b. Place patient in side-lying position to reduce the symptoms of atrial fibrillation. c. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema. d. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock. ANS: C Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema. DIF: Cognitive Level: Analysis REF: Page 347 OBJ: 12 TOP: Pulmonary edema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 25. The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which method to avoid the Valsalva maneuver during a bowel movement? a. Mouth breathing b. Pursing the lips and whistling c. Taking a deep breath and holding it d. Breathing rapidly through the nose ANS: A Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva maneuver on intrathoracic pressure. DIF: Cognitive Level: Application REF: Page 337 OBJ: 9 TOP: MI KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 26. The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommends a lipid study every _________ years. a. 2 b. 3 c. 4 d. 5 ANS: D The National Heart, Lung, and Blood Institute recommend a lipid study every 5 years for all Americans, but especially for the older adult. DIF: Cognitive Level: Comprehension REF: Page 317 OBJ: 6 TOP: Lipid studies KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 27. During a health interview by the home health nurse, which patient complaint suggests left- sided heart failure? a. “I have to sleep in my recliner and I have this hacking cough.” b. “I have no appetite and I have lost 3 lb in the last week.” c. “I have to urinate every 2 hours, even during the night.” d. “I go barefoot most of the time because my feet are so hot.” ANS: A Left ventricular failure; the first is signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough. DIF: Cognitive Level: Analysis REF: Page 340, Box 8-3 OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 28. The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask? a. “Do you have a toothache?” b. “Have you contacted your physician about your dental appointment?” c. “Is your dentist board certified?” d. “Do you think you should wait that long for your tooth extraction?’ ANS: B Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction. DIF: Cognitive Level: Application REF: Page 349 OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 29. The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can: a. cause severe episodes of diarrhea. b. cause a severe skin eruption if taken with Coumadin. c. increase the action of the Coumadin. d. cause the Coumadin to be less effective. ANS: C Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the action of the Coumadin. DIF: Cognitive Level: Comprehension REF: Page 364 OBJ: 21 TOP: Coumadin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 30. What is the difference between primary and secondary hypertension? a. Secondary hypertension is caused by another disorder like renal disease. b. Secondary hypertension is related to hereditary factors. c. Secondary hypertension cannot be treated effectively. d. Secondary hypertension is no real threat to health. ANS: A Secondary hypertension is a consistently elevated blood pressure that is caused by another disorder, such as renal disease, diabetes, or Cushing syndrome. DIF: Cognitive Level: Analysis REF: Page 359 OBJ: 18 TOP: Secondary hypertension KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 31. The nurse is treating a patient who has had a pacemaker inserted for the correction of atrial fibrillation. Which diagnostic test is no longer available to the patient because of the implanted device? a. MRI b. CT scan c. Thallium scan d. PET ANS: A Because of the large magnets in the MRI cabinet, the pacemaker may be reset to a fixed mode and interfere with the functioning of the pacemaker. DIF: Cognitive Level: Application REF: Page 326 OBJ: 10 TOP: Pacemaker KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 32. Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer? a. Cool dry lower limb b. Edematous, red scaly skin on medial surface of the leg c. Lack of hair and shiny appearance of the lower leg d. Lack of a pedal pulse ANS: B Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency. DIF: Cognitive Level: Application REF: Page 357 OBJ: 21 TOP: Medications KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 33. What is the patient goal of the walking exercise program designed for the rehabilitation of a post-MI patient? a. Walk 2 miles in less than 60 minutes after 12 weeks. b. ANS: A The goal of the 12-week walking program is that the patient can walk 2 miles in less than 60 minutes. DIF: Cognitive Level: Knowledge REF: Page 338, Home Care Considerations OBJ: 11 TOP: Cardiac rehab KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance 34. The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient’s right leg and dorsiflexes the foot? Jog mile in less than 30 minutes after 12 weeks. c. “Fast walk” 1 mile in less than 20 minutes after 12 weeks. d. Walk 1 mile in 15 minutes without dyspnea after 12 weeks. a. Pain, which would be a positive Homans sign b. Muscular spasm, which would be a sign of hypocalcemia c. Rigidity, which would be a sign of ankylosis d. Crepitus, which would be a sign of a joint disorder ANS: A A positive Homans sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed. DIF: Cognitive Level: Application REF: Page 370 OBJ: 21 TOP: DVT KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 35. How should the nurse advise a patient with an international normalized ratio (INR) of 5.8? a. Make arrangements to go to the emergency room immediately b. Increase fluid intake to 2000 mL/day c. Stop taking the anticoagulant and notify health care provider d. Add more leafy green vegetables to patient diet ANS: C The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the physician for further instruction. DIF: Cognitive Level: Application REF: Page 321 OBJ: 6 TOP: Myocardial infarction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 36. The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for: a. reduction of alcohol intake. b. avoiding cold remedies. c. cessation of smoking. d. weight reduction. ANS: C The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease. DIF: Cognitive Level: Knowledge REF: Page 369 OBJ: 20 TOP: Buerger disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 37. Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)? a. “I eat a banana every morning with breakfast.” b. “I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.” c. “I try to eat a well-balanced, low-fat diet.” d. “I don’t drink alcohol or caffeine.” ANS: B Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts. DIF: Cognitive Level: Comprehension REF: Page 372 OBJ: 10 TOP: Warfarin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 38. The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause: a. hypotension. b. thrombophlebitis. c. pulmonary emboli. d. heart failure. ANS: D Heart failure can result from rapid infusion of intravenous fluids in older adults. DIF: Cognitive Level: Knowledge REF: Page 317, Lifespan Considerations OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 39. The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times? a. Late in the afternoon b. At bedtime c. With any meal d. In the morning ANS: D Diuretics should be scheduled for morning administration to avoid causing the patient nocturia. DIF: Cognitive Level: Analysis REF: Page 342, Table 8-6 OBJ: 12 TOP: Lasix KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 40. The nurse would assess closely for signs of right-sided heart failure which include (select all that apply): a. cough. b. increasing abdominal girth. c. shortness of breath. d. edema of feet and ankles. e. distended jugular veins. f. orthopnea. ANS: B,D,E Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles. DIF: Cognitive Level: Analysis REF: Page 341, Box 8-4 OBJ: 9 TOP: Right-sided heart failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 41. The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.) a. Warming hands and feet with a heating pad b. Using mittens in cold weather c. Practicing stress-reducing techniques d. Complete smoking cessation e. Using caution when cleaning the refrigerator or freezer ANS: B,C,D,E Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation. DIF: Cognitive Level: Analysis REF: Page 370, Nursing Care Plan OBJ: 20 TOP: Raynaud disease KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 42. Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder? (Select all that apply.) a. Increase the dose of aspirin for better therapy. b. Take medication at the same time each day. c. Report to physician cuts that do not stop bleeding with direct pressure. d. No restrictions for food or drink. e. Report for prescribed blood tests (PTT, INR, CBC, blood sugar). ANS: B,C Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the physician. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT. DIF: Cognitive Level: Analysis REF: Page 366, Nursing Care Plan OBJ: 10 TOP: Anticoagulant therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 43. What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.) a. Detect thrombi before a cardioversion b. Check for cardiac arrhythmias c. Visualize vegetation on the heart valves d. Measure effectiveness of diuretic therapy e. Visualize abscesses on the heart valves ANS: A,C,E The TEE is used to check for thrombi before cardioversion, and to visualize vegetation and abscesses on the valves of the heart. DIF: Cognitive Level: Knowledge REF: Page 367 OBJ: 16 TOP: TEE KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 44. Which patient teaching would help to prevent venous stasis? (Select all that apply.) a. Dangle legs when sitting b. Avoid crossing legs at the knee c. Elevate legs when lying in bed or sitting d. Massage extremities to help maintain blood flow e. Wear elastic stockings when ambulating ANS: B,C,E Avoid prolonged sitting or standing. Avoid crossing the legs at the knee. Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus). DIF: Cognitive Level: Analysis REF: Page 372 OBJ: 16 TOP: Thrombophlebitis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 45. The nurse points out which of the following as modifiable risks for coronary artery disease (CAD)? (Select all that apply.) a. Diabetes mellitus b. Heredity c. Smoking d. Hypertension e. Hyperlipidemia f. Age ANS: A,C,D,E Modifiable risks for the development of CAD include smoking, hyperlipidemia, hypertension, diabetes mellitus, obesity, sedentary lifestyle, and stress. DIF: Cognitive Level: Analysis REF: Pages 318-319 OBJ: 7 TOP: Modifiable risks for CAD KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 46. The nurse outlines which of the following as conditions that would disqualify a candidate for a heart transplant? (Select all that apply.) a. Recent malignancy b. Dilated cardiomyopathy c. Peptic ulcer disease d. Diabetes type 2 e. Severe obesity f. Inoperable coronary artery disease ANS: A,C,E Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant. DIF: Cognitive Level: Application REF: Page 354, Box 8-7 OBJ: 15 TOP: Contraindications for cardiac transplant KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 47. When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.) a. Pain radiating to left arm and jaw b. Hypertension c. Pallor d. Diaphoresis e. Erratic behavior f. Cardiac rhythm changes ANS: B,C,D,E,F Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI. DIF: Cognitive Level: Analysis REF: Page 333, Table 8-2 OBJ: 10 TOP: Myocardial infarction KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 48. Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.) a. Ringing in the ears b. Bradycardia c. Headache d. Visual disturbance e. Hematuria f. Gastrointestinal complaints ANS: B,C,D,F Major signs of digoxin toxicity are nausea, bradycardia (HR <60), headache, and visual disturbances, as well as fatigue and arrhythmias. DIF: Cognitive Level: Application REF: Page 323, Table 8-1 OBJ: 10 TOP: Digitoxin toxicity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 49. The nurse encourages the patient who is recovering from a myocardial infarct (MI) to ask the health care provider to prescribe a cardiac rehabilitation series in order to learn to (select all that apply): a. improve stamina. b. strengthen muscles. c. plan an appropriate diet. d. select herbal remedies. e. reduce risk of further problems. f. understand heart condition. ANS: A,B,E,F Cardiac rehabilitation offers exercise programs to increase strength and increase stamina. Educational opportunities are offered on reduction of risk and understanding the disease process. DIF: Cognitive Level: Application REF: Page 338 OBJ: 11 TOP: Cardiac rehab KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 50. Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for (select all that apply): a. checking pedal pulses. b. ambulating with assistance 2 hours after recovery. c. checking color and warmth of left leg frequently. d. sandbagging over insertion site. e. placing patient in semi-Fowler position. ANS: A,C,D The pulses below the insertion site are checked to ensure patency of the vessels; the color and warmth of the left extremity is checked to ensure adequate circulation. A sandbag or other pressure device is placed over the insertion site. The patient is maintained in a supine position for several hours postprocedure. DIF: Cognitive Level: Application REF: Page 312 OBJ: 6 TOP: Angiogram KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity COMPLETION 51. The cardiac marker ___________ rises 3 hours after a myocardial infarct and measures myocardial contractile protein. ANS: troponin I Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T. DIF: Cognitive Level: Comprehension REF: Page 316 OBJ: 6 TOP: Troponin I KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 52. The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is ________. ANS: advanced cardiac life support (ACLS) advanced cardiac life support ACLS ACLS is a life support system that uses special techniques, ventilation equipment, and therapies for emergency situations. DIF: Cognitive Level: Knowledge REF: Page 325 OBJ: 9 TOP: ACLS KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 53. The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called ____________. ANS: automaticity Automaticity is the special ability of the myocardium to contract in a rhythmic pattern. DIF: Cognitive Level: Knowledge REF: Page 309 OBJ: 2 TOP: Automaticity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 54. The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost ______ L of fluid. ANS: 3 A liter of fluid equals 2.2 lb. A loss of 6.6 lb would mean the loss of 3 L of fluid. DIF: Cognitive Level: Comprehension REF: Page 339 OBJ: 9 TOP: Fluid loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 55. The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is ______________ _____________. ANS: intermittent claudication Intermittent claudication is a pain caused by ischemia when a person with arterial insufficiency exerts to the point that the tissues have inadequate oxygen-rich blood. The pain is relieved by rest. DIF: Cognitive Level: Knowledge REF: Page 356 OBJ: 9 TOP: Intermittent claudication KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 56. The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a ____________. ANS: cardioversion Cardioversion is the restoration of the heart’s normal sinus rhythm with the delivery of synchronized electric shock. DIF: Cognitive Level: Knowledge REF: Page 315 OBJ: 10 TOP: Cardioversion KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity OTHER 57. Trace the impulse pattern of conduction in sequence through the heart. (Separate letters by a comma and space as follows: A, B, C, D) a. Atrial wall b. Atrial-ventricular (AV) node c. Purkinje fibers d. Sinoatrial (SA) node e. Bundle branches f. Bundle of His ANS: B, A, D, F, E, C The conduction begins with the impulse from the SA node that travels down the atrial wall to the AV node, to the Bundle of His, to the bundle branches, and finally to the Purkinje fibers. DIF: Cognitive Level: Analysis REF: Pages 308-309 OBJ: 3 TOP: Conduction KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 58. Arrange in sequence the path of the blood through the coronary circulation. (Separate letters by a comma and space as follows: A, B, C, D) a. Right atrium b. Pulmonary artery c. Tricuspid valve d. Right ventricle e. Superior and inferior vena cava f. Pulmonary vein g. Left atrium h. Mitral valve i. Left ventricle j. Lungs ANS: E, A, C, D, B, J, F, G, H, I The blood travels through the vena cava to the right atrium, through the tricuspid valve to the right ventricle, through the pulmonary artery to the lungs. The pulmonary veins deliver the blood to the left atrium, then through the mitral valve to the left ventricle and out the aorta to the body. DIF: Cognitive Level: Analysis REF: Page 310, Figure 8-4 OBJ: 5 TOP: Path of blood through heart KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity