NUR 114 Final Prep Review Questions And Answers
Updated Solutions
The nurse is assessing the client's cardiovascular system. The client asks the nurse why the nurse presses on the
toenails. Which is the best reply by the nurse?
"I can see how quickly the blood returns to assess blood flow."
The nurse presses on the toenail to assess peripheral blood flow. A decreased capillary refill time indicates a
slower peripheral blood flow. Pressing toenails does not indicate any respiratory or coagulation assessments.
Pain is not assessed by toenail pressing. Capillary blood flow assessments indicate blood flow.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge
teaching?
Report any numbness, tingling, or sharp pain in the extremity.
Instructions for the client and family include: Keep the extremity straight for several hours and avoid
movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in
the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no
need to eat only soft foods after a cardiac catheterization.
A client with a history of right-sided heart failure lives in a long-term care facility. In the daily assessment, the
nurse is required to record the level of this client's peripheral edema. Which would be the main area for
examination?
feet and ankles
Edema occurs when blood is not pumped efficiently or plasma protein levels are inadequate to maintain
osmotic pressure. When blood has nowhere else to go, the extra fluid enters the tissues. Particular areas for
examination are the dependent parts of the body, such as the feet and ankles. The area over, not below, the
sacrum is another area prone to edema.
We have an expert-written solution to this problem!
, The nurse is caring for a client who has just returned from the cardiac catheterization laboratory following a
coronary angioplasty. What is the nurse's priority assessment?
Check the temperature, color, and capillary refill of the affected extremity.
Nursing responsibilities after cardiac catheterization include frequent checks of the temperature, color, and
capillary refill of the affected extremity. The client is also assessed for extremity pain, numbness, or tingling
sensation. These could all indicate arterial insufficiency. The client is nonambulatory immediately
postprocedure. Bowel assessments and pupils are not a priority after a heart procedure.
Prior to reaching the target heart rate, a client develops chest pain during an exercise stress test. What is the
nurse's appropriate response?
Stop the test and monitor the client closely.
The client may be experiencing signs of myocardial ischemia would necessitate stopping the test. CPR would
only be necessary if signs of cardiac or respiratory arrest were evident. The client should not be permitted to
continue the test due to risk of MI, therefore the first option, administer nitroglycerin is incorrect. The nurse
would not administer pain medication and slow the test as this could mask the symptoms of MI and the client
should not be permitted to continue with the test. Further assessment by the nurses must be completed and
protocol for MI initiated.
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and
mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular
disorder. What other client report increases the likelihood of a cardiovascular disorder?
Shortness of breath
Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain,
palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem.
Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this
symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain
occurs with some GI disorders.
The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease
(CVD). Which symptoms correlate with the client's diagnosis?
Updated Solutions
The nurse is assessing the client's cardiovascular system. The client asks the nurse why the nurse presses on the
toenails. Which is the best reply by the nurse?
"I can see how quickly the blood returns to assess blood flow."
The nurse presses on the toenail to assess peripheral blood flow. A decreased capillary refill time indicates a
slower peripheral blood flow. Pressing toenails does not indicate any respiratory or coagulation assessments.
Pain is not assessed by toenail pressing. Capillary blood flow assessments indicate blood flow.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge
teaching?
Report any numbness, tingling, or sharp pain in the extremity.
Instructions for the client and family include: Keep the extremity straight for several hours and avoid
movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in
the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no
need to eat only soft foods after a cardiac catheterization.
A client with a history of right-sided heart failure lives in a long-term care facility. In the daily assessment, the
nurse is required to record the level of this client's peripheral edema. Which would be the main area for
examination?
feet and ankles
Edema occurs when blood is not pumped efficiently or plasma protein levels are inadequate to maintain
osmotic pressure. When blood has nowhere else to go, the extra fluid enters the tissues. Particular areas for
examination are the dependent parts of the body, such as the feet and ankles. The area over, not below, the
sacrum is another area prone to edema.
We have an expert-written solution to this problem!
, The nurse is caring for a client who has just returned from the cardiac catheterization laboratory following a
coronary angioplasty. What is the nurse's priority assessment?
Check the temperature, color, and capillary refill of the affected extremity.
Nursing responsibilities after cardiac catheterization include frequent checks of the temperature, color, and
capillary refill of the affected extremity. The client is also assessed for extremity pain, numbness, or tingling
sensation. These could all indicate arterial insufficiency. The client is nonambulatory immediately
postprocedure. Bowel assessments and pupils are not a priority after a heart procedure.
Prior to reaching the target heart rate, a client develops chest pain during an exercise stress test. What is the
nurse's appropriate response?
Stop the test and monitor the client closely.
The client may be experiencing signs of myocardial ischemia would necessitate stopping the test. CPR would
only be necessary if signs of cardiac or respiratory arrest were evident. The client should not be permitted to
continue the test due to risk of MI, therefore the first option, administer nitroglycerin is incorrect. The nurse
would not administer pain medication and slow the test as this could mask the symptoms of MI and the client
should not be permitted to continue with the test. Further assessment by the nurses must be completed and
protocol for MI initiated.
A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and
mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular
disorder. What other client report increases the likelihood of a cardiovascular disorder?
Shortness of breath
Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain,
palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem.
Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this
symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain
occurs with some GI disorders.
The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease
(CVD). Which symptoms correlate with the client's diagnosis?
