Advanced med surg quiz 2 - notes
NSG 400: Advanced Med Surg Quiz 2
Week 5: ch 30, 31, 32, 33, 34, 35
Chapter 30: Assessment of the Cardiovascular System
MULTIPLE CHOICE
1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional
assessment finding would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The
parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and
respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart
rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not
be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later
2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.
ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and
decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does
not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow
for better filling and better cardiac output
3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for
cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.
ANS: C Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease.
Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk
for cardiovascular disease
4. A nurse assesses an older adult client who has multiple chronic diseases. The client‟s heart rate is 48 beats/min. What
action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client‟s medications.
d. Administer 1 mg of atropine.
,ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However,
the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would
inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for
atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent
5. An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse
to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
ANS: A Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other
findings are not specific to early occurrence of heart failure
6. A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client
would alert the nurse to the presence of edema?
a. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”
ANS: B Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether
the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks
end. The other answers do not describe edema.
7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse
expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Fatigue and shortness of breath
d. Numbness and tingling of the arm
ANS: C In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor
cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be
related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not
known to be specific symptoms for women having and MI.
8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal
pulse is weak. What action would the nurse take next?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as “left pedal pulse of +1/4.”
ANS: C Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be
compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color
(pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data
are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be
positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not
,address the client’s problem.
9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires
immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status
needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may
not be significant.
10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as
the priority prior to this procedure?
a. Client‟s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents
ANS: D Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as
seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening
reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take
priority for client safety
11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client‟s health history
includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the primary health care provider before scheduling the MRI.
c. Request lab for cardiac enzymes from the primary health care provider.
d. Instruct the client to increase fluid intake the day before the MRI.
ANS: B The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report
that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram,
cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but
the nurse needs to notify the primary health care provider.
12. A nurse assesses a client who is recovering from a myocardial infarction. The client‟s blood pressure is 140/88 mm Hg.
What action would the nurse take first?
a. Compare the results with previous blood pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the primary health care provider of the elevated blood pressure.
d. Document the finding in the client‟s chart as the only action.
ANS: A The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This
client’s blood pressure is at the upper range of acceptable, so the nurse would compare the client’s current reading with those
previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse
necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.
13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass
, surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery?
a. Administration of IV furosemide
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
ANS: B The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also
supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would
go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not
address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.
14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery
disease. Which statement related to nutrition would the nurse include in this client‟s teaching?
a. “The best way to lose weight is a high-protein, low-carbohydrate diet.”
b. “You should balance weight loss with consuming necessary nutrients.”
c. “A nutritionist will provide you with information about your new diet.”
d. “If you exercise more frequently, you won‟t need to change your diet.”
ANS: B Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and
improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free
dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with
client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating
nutrient-rich foods are both important components in reducing cardiovascular risk.
15. A nurse cares for a client who has advanced cardiac disease and states, “I am having trouble breathing while I‟m sleeping
at night.” What is the nurse‟s best response?
a. “I will consult your primary health care provider to prescribe a sleep study.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”
ANS: D The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head
and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a
client with orthopnea
16. A nurse cares for a client who is recovering from a myocardial infarction. The client states, “I will need to stop eating so
much chili to keep that indigestion pain from returning.” What is the nurse‟s best response?
a. “Chili is high in fat and calories; it would be a good idea to stop eating it.”
b. “The primary health care provider has prescribed an antacid every morning.”
c. “What do you understand about what happened to you?”
d. “When did you start experiencing this indigestion?”
ANS: C Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask
the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client’s
misconception about recent pain and the cause of that pain
17. A nurse prepares a client for cardiac catheterization. The client states, “I am afraid I might die.” What is the nurse‟s best
response?
NSG 400: Advanced Med Surg Quiz 2
Week 5: ch 30, 31, 32, 33, 34, 35
Chapter 30: Assessment of the Cardiovascular System
MULTIPLE CHOICE
1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional
assessment finding would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
ANS: A When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure decrease in the vessels. The
parasympathetic system responds by lessening the inhibitory effect on the sinoatrial node. This results in an increase in heart rate and
respiratory rate. This tachycardia is an early response and is seen even when blood pressure is not critically low. An increased heart
rate and respiratory rate will compensate for the low blood pressure and maintain oxygen saturation and perfusion. The client may not
be able to compensate for long and decreased oxygenation and cool, clammy skin will occur later
2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.
ANS: D Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic (fight-or-flight) response and
decrease the heart rate (HR). The beta blocker will decrease HR and blood pressure, increasing ventricular filling time. It usually does
not have effects on beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but slowing the rate may allow
for better filling and better cardiac output
3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for
cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.
ANS: C Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to cardiovascular disease.
Advancing age also increases risk, but not as much. Asthma, colorectal cancer, and bisphosphonate therapy do not increase the risk
for cardiovascular disease
4. A nurse assesses an older adult client who has multiple chronic diseases. The client‟s heart rate is 48 beats/min. What
action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client‟s medications.
d. Administer 1 mg of atropine.
,ANS: C Pacemaker cells in the conduction system decrease in number as a person ages, potentially resulting in bradycardia. However,
the nurse would first check the medication reconciliation for medications that might cause such a drop in heart rate, and then would
inform the primary health care provider. Documentation is important, but it is not the first action. The heart rate is not low enough for
atropine or an external pacemaker to be needed unless the client is symptomatic, which is not apparent
5. An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse
to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
ANS: A Dyspnea on exertion is an early manifestation of heart failure and is associated with an activity such as stair climbing. The other
findings are not specific to early occurrence of heart failure
6. A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client
would alert the nurse to the presence of edema?
a. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”
ANS: B Weight gain can result from fluid accumulation in the interstitial spaces. This is known as edema. The nurse would note whether
the client feels that his or her shoes or rings are tight, and would observe, when present, an indentation around the leg where the socks
end. The other answers do not describe edema.
7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse
expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Fatigue and shortness of breath
d. Numbness and tingling of the arm
ANS: C In women, fatigue, shortness of breath, and indigestion may be the major symptoms of myocardial infarction caused by poor
cardiac output. Chest pain is the classic symptom of myocardial infarction and can be present in women. Pain on inspiration may be
related to a pleuropulmonary cause. Numbness and tingling of the arm could also be related to the myocardial infarction, but are not
known to be specific symptoms for women having and MI.
8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal
pulse is weak. What action would the nurse take next?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as “left pedal pulse of +1/4.”
ANS: C Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial obstruction. The left pulse would be
compared with the right, and pulses would be compared with previous assessments, especially before the procedure. Assessing color
(pale, cyanosis) and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and vascular assessment data
are acquired, the primary health care provider would be notified. Simply documenting the findings is inappropriate. The leg would be
positioned below the level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous fluids will not
,address the client’s problem.
9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires
immediate intervention?
a. Urinary output less than intake
b. Bruising at the insertion site
c. Slurred speech and confusion
d. Discomfort in the left leg
ANS: C A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular accident. A change in neurologic status
needs to be acted on immediately. Discomfort and bruising are not unexpected at the site. Urinary output less than intake may or may
not be significant.
10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as
the priority prior to this procedure?
a. Client‟s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents
ANS: D Before the procedure, the nurse would ascertain whether the client has an allergy to iodine-containing preparations, such as
seafood or local anesthetics. The contrast medium used during the procedure is iodine based. This allergy can cause a life-threatening
reaction, so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline cardiac status, but allergies take
priority for client safety
11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client‟s health history
includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the primary health care provider before scheduling the MRI.
c. Request lab for cardiac enzymes from the primary health care provider.
d. Instruct the client to increase fluid intake the day before the MRI.
ANS: B The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the primary health care provider and report
that the client has a pacemaker so that he or she can order other diagnostic tests. The client does not need an electrocardiogram,
cardiac enzymes, or increased fluids. Some newer MRI scanners have eliminated the possibility of complications due to implants, but
the nurse needs to notify the primary health care provider.
12. A nurse assesses a client who is recovering from a myocardial infarction. The client‟s blood pressure is 140/88 mm Hg.
What action would the nurse take first?
a. Compare the results with previous blood pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the primary health care provider of the elevated blood pressure.
d. Document the finding in the client‟s chart as the only action.
ANS: A The most recent range for normal blood pressure is less than 140 mm Hg systolic and less than 90mm Hg diastolic. This
client’s blood pressure is at the upper range of acceptable, so the nurse would compare the client’s current reading with those
previously recorded before doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor would the nurse
necessarily notify the primary health care provider. Documentation is important, but the nurse first checks previous readings.
13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass
, surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery?
a. Administration of IV furosemide
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
ANS: B The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and atrioventricular (AV) node. It also
supplies the sinoatrial node in 50% of people. If the client totally occludes the RCA, the AV node would not function and the client would
go into heart block, so emergency pacing would be available for the client. Furosemide, intubation, and central venous access will not
address the primary complication of RCA occlusion, which is AV node (and possibly SA node) malfunction.
14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery
disease. Which statement related to nutrition would the nurse include in this client‟s teaching?
a. “The best way to lose weight is a high-protein, low-carbohydrate diet.”
b. “You should balance weight loss with consuming necessary nutrients.”
c. “A nutritionist will provide you with information about your new diet.”
d. “If you exercise more frequently, you won‟t need to change your diet.”
ANS: B Clients at risk for cardiovascular diseases should follow the American Heart Association guidelines to combat obesity and
improve cardiac health. The nurse would encourage the client to eat vegetables, fruits, unrefined whole-grain products, and fat-free
dairy products while losing weight. High-protein food items are often high in fat and calories. Although the nutritionist can assist with
client education, the nurse would include nutrition education and assist the client to make healthy decisions. Exercising and eating
nutrient-rich foods are both important components in reducing cardiovascular risk.
15. A nurse cares for a client who has advanced cardiac disease and states, “I am having trouble breathing while I‟m sleeping
at night.” What is the nurse‟s best response?
a. “I will consult your primary health care provider to prescribe a sleep study.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”
ANS: D The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would teach the client to elevate the head
and chest with pillows or sleep in a recliner. A sleep study is not necessary to diagnose this client. Oxygen and CPAP will not help a
client with orthopnea
16. A nurse cares for a client who is recovering from a myocardial infarction. The client states, “I will need to stop eating so
much chili to keep that indigestion pain from returning.” What is the nurse‟s best response?
a. “Chili is high in fat and calories; it would be a good idea to stop eating it.”
b. “The primary health care provider has prescribed an antacid every morning.”
c. “What do you understand about what happened to you?”
d. “When did you start experiencing this indigestion?”
ANS: C Clients who experience myocardial infarction often respond with denial, which is a defense mechanism. The nurse would ask
the client what he or she thinks happened, or what the illness means to him or her. The other responses do not address the client’s
misconception about recent pain and the cause of that pain
17. A nurse prepares a client for cardiac catheterization. The client states, “I am afraid I might die.” What is the nurse‟s best
response?
