EXAM 1 NUR 202 EXAM QUIZZES WITH
UPDATED DETAILED SOLUTIONS.GRADE
A+
ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into
the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not
accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such
PHARMOCOLOGICAL AND PARENTAL THERAPIES - answer ✔✔-A client received tissue plasminogen
activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The
client's spouse asks why the client needs this medication. What response by the nurse is best?
a. "The t-PA didn't dissolve the entire coronary clot."
b. "The heparin keeps that artery from getting blocked again."
c. "Heparin keeps the blood as thin as possible for a longer time."
d. "The heparin prevents a stroke from occurring as the t-PA wears off."
ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe
for the client to continue using the bathroom. There is no indication that the client needs oxygen, a
commode, or a bedpan.
REDUCTION OF RISK - answer ✔✔-A client is in the hospital after suffering a myocardial infarction and
has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2
saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed.
What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan
ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is
compliant with treatment may be using a healthy form of coping that allows time to process the event
and start to use problem-focused coping. The nurse would not discourage this type of denial and coping,
but rather continue providing education in a positive manner. Emphasizing complications may make the
,client defensive and more anxious. Telling the client that denial is normal is placing too much attention
on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening
to the client.
PSYCHOSOCIAL INTEGRITY - answer ✔✔-A nurse is caring for a client who had a myocardial infarction.
The nurse is confused because the client states that nothing is wrong and yet listens attentively while
the nurse provides education on lifestyle changes and healthy menu choices. What response by the
charge nurse is best?
a. "Continue to educate the client on possible healthy changes."
b. "Emphasize complications that can occur with noncompliance."
c. "Tell the client that denial is normal and will soon go away."
d. "You need to make sure the client understands this illness."
ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure
that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing
trends are important nursing actions related to
hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO
while undergoing
hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring
SAFTEY INFECTION CONTROL - answer ✔✔-A client has hemodynamic monitoring after a myocardial
infarction. What safety precaution does the nurse implement for this client?
a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends.
b. Ensure that the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler position.
ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the
insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with
blood loss, the nurse would assess the client for any bleeding associated with the arterial line. The nurse
would document the findings after a full assessment. The client may or may not need pain medication
and rest; the nurse first needs to rule out any emergent bleeding.
, REDUCTION OF RISK - answer ✔✔-A client has intra-arterial blood pressure monitoring after a
myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110
beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is
most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent
situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is common
and offer to help. The other actions will not reduce the client's anxiety
PSYCHOSOCIAL INTEGRITY - answer ✔✔-A client is in the preoperative holding area prior to an
emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the
doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is
best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client's stress levels.
d. Tell the client that anxiety is common and that you can help
ANS: A
Concerns about resuming sexual activity are common after cardiac events. The nurse would gently
inquire if this is the issue. While
it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other
two responses are likely to cause the client to be defensive
PSYCHOSOCIAL INTEGRITY - answer ✔✔-A client is in the clinic a month after having a myocardial
infarction. The client reports sleeping well since moving into the guest bedroom. What response by the
nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
c. "Sleep near your spouse in case of emergency."
d. "Why would you move into the guest room?"
UPDATED DETAILED SOLUTIONS.GRADE
A+
ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into
the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not
accurate. Heparin is not a "blood thinner," although laypeople may refer to it as such
PHARMOCOLOGICAL AND PARENTAL THERAPIES - answer ✔✔-A client received tissue plasminogen
activator (tPA) after a myocardial infarction and now is on an intravenous infusion of heparin. The
client's spouse asks why the client needs this medication. What response by the nurse is best?
a. "The t-PA didn't dissolve the entire coronary clot."
b. "The heparin keeps that artery from getting blocked again."
c. "Heparin keeps the blood as thin as possible for a longer time."
d. "The heparin prevents a stroke from occurring as the t-PA wears off."
ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe
for the client to continue using the bathroom. There is no indication that the client needs oxygen, a
commode, or a bedpan.
REDUCTION OF RISK - answer ✔✔-A client is in the hospital after suffering a myocardial infarction and
has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2
saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed.
What action by the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan
ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is
compliant with treatment may be using a healthy form of coping that allows time to process the event
and start to use problem-focused coping. The nurse would not discourage this type of denial and coping,
but rather continue providing education in a positive manner. Emphasizing complications may make the
,client defensive and more anxious. Telling the client that denial is normal is placing too much attention
on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening
to the client.
PSYCHOSOCIAL INTEGRITY - answer ✔✔-A nurse is caring for a client who had a myocardial infarction.
The nurse is confused because the client states that nothing is wrong and yet listens attentively while
the nurse provides education on lifestyle changes and healthy menu choices. What response by the
charge nurse is best?
a. "Continue to educate the client on possible healthy changes."
b. "Emphasize complications that can occur with noncompliance."
c. "Tell the client that denial is normal and will soon go away."
d. "You need to make sure the client understands this illness."
ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would ensure
that the balloon remains deflated between PAOP readings. Documenting PAOP readings and assessing
trends are important nursing actions related to
hemodynamic monitoring, but are not specifically related to safety. The client does not have to be NPO
while undergoing
hemodynamic monitoring. Positioning is not related to safety with hemodynamic monitoring
SAFTEY INFECTION CONTROL - answer ✔✔-A client has hemodynamic monitoring after a myocardial
infarction. What safety precaution does the nurse implement for this client?
a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends.
b. Ensure that the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler position.
ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the
insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with
blood loss, the nurse would assess the client for any bleeding associated with the arterial line. The nurse
would document the findings after a full assessment. The client may or may not need pain medication
and rest; the nurse first needs to rule out any emergent bleeding.
, REDUCTION OF RISK - answer ✔✔-A client has intra-arterial blood pressure monitoring after a
myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110
beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is
most appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent
situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is common
and offer to help. The other actions will not reduce the client's anxiety
PSYCHOSOCIAL INTEGRITY - answer ✔✔-A client is in the preoperative holding area prior to an
emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the
doctor to "just get this over with" when asked to sign the consent form. What action by the nurse is
best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client's stress levels.
d. Tell the client that anxiety is common and that you can help
ANS: A
Concerns about resuming sexual activity are common after cardiac events. The nurse would gently
inquire if this is the issue. While
it is good that the client is sleeping well, the nurse would investigate the reason for the move. The other
two responses are likely to cause the client to be defensive
PSYCHOSOCIAL INTEGRITY - answer ✔✔-A client is in the clinic a month after having a myocardial
infarction. The client reports sleeping well since moving into the guest bedroom. What response by the
nurse is best?
a. "Do you have any concerns about sexuality?"
b. "I'm glad to hear you are sleeping well now."
c. "Sleep near your spouse in case of emergency."
d. "Why would you move into the guest room?"
