©Themoon EXAM SOLUTIONS
06/11/2024 14:32PM
Cardiac Exam Questions and Revised Answers
A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for
an aneurysm in the left femoral artery. Click the site of the pulse that should be assessed to
determine maximum arterial perfusion distal to the operative site. - answers✓✓The pedal pulse is
located on the top of the foot and is the most distal peripheral pulse
The health care provider prescribes a progressive exercise program that includes walking for a
client with a history of diminished arterial perfusion to the lower extremities. The nurse explains
to the client that if leg cramps occur while walking, the client should:
1. Take one aspirin (ASA) twice a day
2. Stop to rest until the pain resolves
3. Walk more slowly while pain is present
4. Take one nitroglycerin tablet sublingually - answers✓✓Answer
2. Stop to rest until the pain resolves
Decreasing the demand for oxygen by resting will relieve the pain. Pain will not resolve as long
as exercise, thus muscle hypoxia, is continued, regardless of whether ASA is taken. Walking
more slowly while pain is present is appropriate for venous insufficiency, not arterial
insufficiency. Sublingual nitroglycerin is not indicated for leg cramps
When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse
expects that the body initially attempts to compensate by:
1. Producing less antidiuretic hormone (ADH)
2. Producing more red blood cells
3. Maintaining peripheral vasoconstriction
4. Decreasing mineralocorticoid production - answers✓✓Answer
, ©Themoon EXAM SOLUTIONS
06/11/2024 14:32PM
3. Maintaining peripheral vasoconstriction
With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and
shifting blood to the major organs. With shock, more ADH is produced to promote fluid
retention, which will elevate the blood pressure. Although producing more red blood cells is a
response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism.
With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood
pressure
A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding
indicates adequate tissue perfusion to vital organs?
1. Urinary output of 30 mL in an hour
2. Central venous pressure reading of 2 mm Hg
3. Baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period
4. Baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period -
answers✓✓Answer
1. Urinary output of 30 mL in an hour
A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart,
and brain. A central venous pressure reading of 2 mm Hg indicates hypovolemia. A baseline
pulse rate of 120 that decreases to 110 beats/min within a 15-minute period and a baseline blood
pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period indicate
improvement but not necessarily adequate tissue perfusion
The results of a biopsy indicate that a client has a malignant sarcoma of the liver and
chemotherapy via regional perfusion is the treatment of choice. The nurse teaches the client that
this method of drug administration probably was selected because:
1. Drug therapy can be continued at home with little difficulty.
2. Larger doses of drugs can be delivered to the actual site of the tumor.
3. Toxic effects of the chemotherapeutic drugs are confined to the area of the tumor.
, ©Themoon EXAM SOLUTIONS
06/11/2024 14:32PM
4. Combinations of drugs are used to attack neoplastic cells at various stages of the cell cycle. -
answers✓✓2. Larger doses of drugs can be delivered to the actual site of the tumor.
Regional perfusion therapy permits relative isolation of the tumor area and saturation with the
drug(s) selected. This method of drug administration requires medical and nursing supervision.
Although toxic effects are confined mainly to the treated area, some migration may still occur.
Combinations of chemotherapeutic drugs are administered via intravenous or oral routes, not via
regional perfusion.
The nurse caring for a client admitted for chest pain and a myocardial infarction (MI) is
preparing to apply nitroglycerin ointment. Before applying, the nurse should:
1. Assess the client's pulse rate.
2. Prepare the site with an alcohol swab.
3. Remove ointment previously applied.
4. Expect the client to be relieved of pain within 20 minutes. - answers✓✓Answer
3. Remove ointment previously applied.
Before applying the nitroglycerin ointment, the nurse should remove the previous ointment. If
the previously applied ointment is not removed, the client could receive too much medication.
The nurse should assess blood pressure reading, not pulse rate. There is no need to clean the site
with alcohol before administration. Nitroglycerin ointment is not used to treat acute pain.
A client presenting to the emergency room with chest pain and dizziness was found to be having
a myocardial infarction and subsequently suffered cardiac arrest. The emergency room health
care team was able to successfully resuscitate the client. Lab work shows that the client now is
acidotic. The nurse understands that the acidic serum pH most likely is caused from :
1. Fat-forming ketoacids that are broken down.
2.The client receiving too much sodium bicarbonate during resuscitation efforts.
3. The decreased tissue perfusion that subsequently caused lactic acid production.
4. An irregular heartbeat the client experienced during cardiac arrest. - answers✓✓Answer
06/11/2024 14:32PM
Cardiac Exam Questions and Revised Answers
A nurse is assessing arterial perfusion in a client who had surgery with placement of a graft for
an aneurysm in the left femoral artery. Click the site of the pulse that should be assessed to
determine maximum arterial perfusion distal to the operative site. - answers✓✓The pedal pulse is
located on the top of the foot and is the most distal peripheral pulse
The health care provider prescribes a progressive exercise program that includes walking for a
client with a history of diminished arterial perfusion to the lower extremities. The nurse explains
to the client that if leg cramps occur while walking, the client should:
1. Take one aspirin (ASA) twice a day
2. Stop to rest until the pain resolves
3. Walk more slowly while pain is present
4. Take one nitroglycerin tablet sublingually - answers✓✓Answer
2. Stop to rest until the pain resolves
Decreasing the demand for oxygen by resting will relieve the pain. Pain will not resolve as long
as exercise, thus muscle hypoxia, is continued, regardless of whether ASA is taken. Walking
more slowly while pain is present is appropriate for venous insufficiency, not arterial
insufficiency. Sublingual nitroglycerin is not indicated for leg cramps
When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse
expects that the body initially attempts to compensate by:
1. Producing less antidiuretic hormone (ADH)
2. Producing more red blood cells
3. Maintaining peripheral vasoconstriction
4. Decreasing mineralocorticoid production - answers✓✓Answer
, ©Themoon EXAM SOLUTIONS
06/11/2024 14:32PM
3. Maintaining peripheral vasoconstriction
With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and
shifting blood to the major organs. With shock, more ADH is produced to promote fluid
retention, which will elevate the blood pressure. Although producing more red blood cells is a
response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism.
With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood
pressure
A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding
indicates adequate tissue perfusion to vital organs?
1. Urinary output of 30 mL in an hour
2. Central venous pressure reading of 2 mm Hg
3. Baseline pulse rate of 120 that decreases to 110 beats/min within a 15-minute period
4. Baseline blood pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period -
answers✓✓Answer
1. Urinary output of 30 mL in an hour
A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart,
and brain. A central venous pressure reading of 2 mm Hg indicates hypovolemia. A baseline
pulse rate of 120 that decreases to 110 beats/min within a 15-minute period and a baseline blood
pressure of 50/30 that increases to 70/40 mm Hg within a 30-minute period indicate
improvement but not necessarily adequate tissue perfusion
The results of a biopsy indicate that a client has a malignant sarcoma of the liver and
chemotherapy via regional perfusion is the treatment of choice. The nurse teaches the client that
this method of drug administration probably was selected because:
1. Drug therapy can be continued at home with little difficulty.
2. Larger doses of drugs can be delivered to the actual site of the tumor.
3. Toxic effects of the chemotherapeutic drugs are confined to the area of the tumor.
, ©Themoon EXAM SOLUTIONS
06/11/2024 14:32PM
4. Combinations of drugs are used to attack neoplastic cells at various stages of the cell cycle. -
answers✓✓2. Larger doses of drugs can be delivered to the actual site of the tumor.
Regional perfusion therapy permits relative isolation of the tumor area and saturation with the
drug(s) selected. This method of drug administration requires medical and nursing supervision.
Although toxic effects are confined mainly to the treated area, some migration may still occur.
Combinations of chemotherapeutic drugs are administered via intravenous or oral routes, not via
regional perfusion.
The nurse caring for a client admitted for chest pain and a myocardial infarction (MI) is
preparing to apply nitroglycerin ointment. Before applying, the nurse should:
1. Assess the client's pulse rate.
2. Prepare the site with an alcohol swab.
3. Remove ointment previously applied.
4. Expect the client to be relieved of pain within 20 minutes. - answers✓✓Answer
3. Remove ointment previously applied.
Before applying the nitroglycerin ointment, the nurse should remove the previous ointment. If
the previously applied ointment is not removed, the client could receive too much medication.
The nurse should assess blood pressure reading, not pulse rate. There is no need to clean the site
with alcohol before administration. Nitroglycerin ointment is not used to treat acute pain.
A client presenting to the emergency room with chest pain and dizziness was found to be having
a myocardial infarction and subsequently suffered cardiac arrest. The emergency room health
care team was able to successfully resuscitate the client. Lab work shows that the client now is
acidotic. The nurse understands that the acidic serum pH most likely is caused from :
1. Fat-forming ketoacids that are broken down.
2.The client receiving too much sodium bicarbonate during resuscitation efforts.
3. The decreased tissue perfusion that subsequently caused lactic acid production.
4. An irregular heartbeat the client experienced during cardiac arrest. - answers✓✓Answer
