Portage Learning Pathophysiology NURS
231 BIOD 331 Final Exam & Module 1-10
Exams With Verified Solutions All
Versions Latest Update A Grade
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows
significantly. What action by the nurse is most important?
a. Increase the setting on the suction.
b. Notify the provider immediately.
c. Re-position the chest tube.
d. Take the tubing apart to assess for clots. - CORRECT ANSWER ✔✔- ANS: B
If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked
by a clot.
This could lead to cardiac tamponade. The nurse should notify the provider immediately. The
nurse should not
independently increase the suction, re-position the chest tube, or take the tubing apart.
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly.
b. Monitor the pedal pulses.
c. Monitor the clients vital signs.
d. Obtain consent for a central line. - CORRECT ANSWER ✔✔- ANS: A
Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue.
If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is
getting the central line,
ensuring informed consent is on the chart is a priority. But at this point, the client has only a
peripheral line, so
caution must be taken to preserve the integrity of the clients integumentary system. Monitoring
pedal pulses
1|Page
,and vital signs give indications as to how well the drug is working.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a
significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours - CORRECT ANSWER ✔✔- c. Poor peripheral pulses and
cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be
reported
immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is
just
slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00
PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core
Measures set, by what time should the client have a percutaneous coronary intervention performed?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM) - CORRECT ANSWER ✔✔- c. 1630 (4:30 PM)
The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention
within 90
minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous
coronary
intervention performed no later than 1630 (4:30 PM).
The provider requests the nurse start an infusion of an inotropic agent like digoxin on a client. How does
the nurse explain the action of these drugs to the client and spouse?
a. It constricts vessels, improving blood flow.
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,b. It dilates vessels, which lessens the work of the heart.
c. It increases the force of the hearts contractions.
d. It slows the heart rate down for better filling. - CORRECT ANSWER ✔✔- ANS: C
A positive inotrope is a medication that increases the strength of the hearts contractions. The other
options are not correct.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as
sinus bradycardia. What action by the nurse is most important?
a. Assess the clients blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. - CORRECT ANSWER ✔✔- ANS: A
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in
this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic
status,
including vital signs and level of consciousness. The client may or may not need the Rapid Response
Team, a
temporary pacemaker, or medication; there is no indication of this in the question.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this
include? (Select all that apply.)
a. Age
b. Hypertension
c. Obesity
d. Smoking
e. Stress - CORRECT ANSWER ✔✔- b. Hypertension
c. Obesity
d. Smoking
e. Stress
3|Page
, *Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary
artery disease. Age is a nonmodifiable risk factor.
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the
nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol. - CORRECT ANSWER ✔✔- a. Assist the
client to the chair for meals and to the bathroom.
c. Ensure the client wears TED hose or sequential compression devices.
e. Take and record a full set of vital signs per hospital protocol.
*The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom,
applying TEDs or sequential compression devices, and recording vital signs. The spirometer should
be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing
assessment, although if the client reports
pain, the UAP should inform the nurse so a more detailed assessment is done.
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI)
differs from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause - CORRECT ANSWER ✔✔- a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
4|Page
231 BIOD 331 Final Exam & Module 1-10
Exams With Verified Solutions All
Versions Latest Update A Grade
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows
significantly. What action by the nurse is most important?
a. Increase the setting on the suction.
b. Notify the provider immediately.
c. Re-position the chest tube.
d. Take the tubing apart to assess for clots. - CORRECT ANSWER ✔✔- ANS: B
If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked
by a clot.
This could lead to cardiac tamponade. The nurse should notify the provider immediately. The
nurse should not
independently increase the suction, re-position the chest tube, or take the tubing apart.
A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety?
a. Assess the IV site hourly.
b. Monitor the pedal pulses.
c. Monitor the clients vital signs.
d. Obtain consent for a central line. - CORRECT ANSWER ✔✔- ANS: A
Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue.
If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is
getting the central line,
ensuring informed consent is on the chart is a priority. But at this point, the client has only a
peripheral line, so
caution must be taken to preserve the integrity of the clients integumentary system. Monitoring
pedal pulses
1|Page
,and vital signs give indications as to how well the drug is working.
A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a
significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours - CORRECT ANSWER ✔✔- c. Poor peripheral pulses and
cool skin
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be
reported
immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is
just
slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00
PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core
Measures set, by what time should the client have a percutaneous coronary intervention performed?
a. 1530 (3:30 PM)
b. 1600 (4:00 PM)
c. 1630 (4:30 PM)
d. 1700 (5:00 PM) - CORRECT ANSWER ✔✔- c. 1630 (4:30 PM)
The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention
within 90
minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous
coronary
intervention performed no later than 1630 (4:30 PM).
The provider requests the nurse start an infusion of an inotropic agent like digoxin on a client. How does
the nurse explain the action of these drugs to the client and spouse?
a. It constricts vessels, improving blood flow.
2|Page
,b. It dilates vessels, which lessens the work of the heart.
c. It increases the force of the hearts contractions.
d. It slows the heart rate down for better filling. - CORRECT ANSWER ✔✔- ANS: C
A positive inotrope is a medication that increases the strength of the hearts contractions. The other
options are not correct.
A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as
sinus bradycardia. What action by the nurse is most important?
a. Assess the clients blood pressure and level of consciousness.
b. Call the health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication. - CORRECT ANSWER ✔✔- ANS: A
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in
this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic
status,
including vital signs and level of consciousness. The client may or may not need the Rapid Response
Team, a
temporary pacemaker, or medication; there is no indication of this in the question.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this
include? (Select all that apply.)
a. Age
b. Hypertension
c. Obesity
d. Smoking
e. Stress - CORRECT ANSWER ✔✔- b. Hypertension
c. Obesity
d. Smoking
e. Stress
3|Page
, *Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary
artery disease. Age is a nonmodifiable risk factor.
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the
nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-to-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol. - CORRECT ANSWER ✔✔- a. Assist the
client to the chair for meals and to the bathroom.
c. Ensure the client wears TED hose or sequential compression devices.
e. Take and record a full set of vital signs per hospital protocol.
*The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom,
applying TEDs or sequential compression devices, and recording vital signs. The spirometer should
be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing
assessment, although if the client reports
pain, the UAP should inform the nurse so a more detailed assessment is done.
A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI)
differs from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause - CORRECT ANSWER ✔✔- a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
4|Page
