NUR 213 TEST #2 | 128 COMPLETE
QUESTIONS AND CORRECT ANSWERS |
ALREADY GRADED A+ | NEW UPDATE 2025
A nurse assesses a client who had a myocardial infarction and is hypotensive.
Which additional assessment finding should 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 - ANSWER a. Heart rate of 120 beats/min
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
saturations and perfusion. The client may not be able to compensate for long, and
decreased oxygenation and cool, clammy skin will occur later.
A nurse assesses a client after administering a prescribed beta blocker. Which
assessment should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min - ANSWER d. Pulse
decreased from 100 beats/min to 80 beats/min
,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
will drop because of decreased HR.
A nurse assesses clients on a medical-surgical unit. Which client should 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 Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy -
ANSWER c. A 45-year-old American Indian woman with diabetes mellitus
The incidence of coronary artery disease and hypertension is higher in American
Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for
hypertension and coronary artery disease in people of any race or ethnicity.
Asthma, colorectal cancer, and hormone therapy do not increase risk for
cardiovascular disease.
A nurse assesses an older adult client who has multiple chronic diseases. The
client's heart rate is 48 beats/min. Which action should 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. - ANSWER c. Assess the client's medications.
,Pacemaker cells in the conduction system decrease in number as a person ages,
resulting in bradycardia. The nurse should check the medication reconciliation for
medications that might cause such a drop in heart rate, then should inform the
health care provider. Documentation is important, but it is not the priority action.
The heart rate is not low enough for atropine or an external pacemaker to be
needed.
An emergency room nurse obtains the health history of a client. Which statement
by the client should 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." - ANSWER a. "I get short of breath
when I climb stairs."
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.
A nurse obtains the health history of a client who is newly admitted to the medical
unit. Which statement by the client should 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." - ANSWER b. "My shoes fit
tighter by the end of the day."
, Weight gain can result from fluid accumulation in the interstitial spaces. This is
known as edema. The nurse should note whether the client feels that his or her
shoes or rings are tight, and should observe, when present, an indentation around
the leg where the socks end. The other answers do not describe edema.
A nurse assesses an older adult client who is experiencing a myocardial infarction.
Which clinical manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm - ANSWER c. Disorientation and confusion
In older adults, disorientation or confusion may be the major manifestation of
myocardial infarction caused by poor cardiac output. Pain manifestations and
numbness and tingling of the arm could also be related to the myocardial
infarction. However, the nurse should be more concerned about the new onset of
disorientation or confusion caused by decreased perfusion.
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. Which action should the
nurse take?
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." - ANSWER c. Assess the
color and temperature of the left leg.
QUESTIONS AND CORRECT ANSWERS |
ALREADY GRADED A+ | NEW UPDATE 2025
A nurse assesses a client who had a myocardial infarction and is hypotensive.
Which additional assessment finding should 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 - ANSWER a. Heart rate of 120 beats/min
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
saturations and perfusion. The client may not be able to compensate for long, and
decreased oxygenation and cool, clammy skin will occur later.
A nurse assesses a client after administering a prescribed beta blocker. Which
assessment should the nurse expect to find?
a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c. Oxygen saturation increased from 88% to 96%
d. Pulse decreased from 100 beats/min to 80 beats/min - ANSWER d. Pulse
decreased from 100 beats/min to 80 beats/min
,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
will drop because of decreased HR.
A nurse assesses clients on a medical-surgical unit. Which client should 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 Asian-American man with colorectal cancer
c. A 45-year-old American Indian woman with diabetes mellitus
d. A 53-year-old postmenopausal woman who is on hormone therapy -
ANSWER c. A 45-year-old American Indian woman with diabetes mellitus
The incidence of coronary artery disease and hypertension is higher in American
Indians than in whites or Asian Americans. Diabetes mellitus increases the risk for
hypertension and coronary artery disease in people of any race or ethnicity.
Asthma, colorectal cancer, and hormone therapy do not increase risk for
cardiovascular disease.
A nurse assesses an older adult client who has multiple chronic diseases. The
client's heart rate is 48 beats/min. Which action should 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. - ANSWER c. Assess the client's medications.
,Pacemaker cells in the conduction system decrease in number as a person ages,
resulting in bradycardia. The nurse should check the medication reconciliation for
medications that might cause such a drop in heart rate, then should inform the
health care provider. Documentation is important, but it is not the priority action.
The heart rate is not low enough for atropine or an external pacemaker to be
needed.
An emergency room nurse obtains the health history of a client. Which statement
by the client should 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." - ANSWER a. "I get short of breath
when I climb stairs."
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.
A nurse obtains the health history of a client who is newly admitted to the medical
unit. Which statement by the client should 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." - ANSWER b. "My shoes fit
tighter by the end of the day."
, Weight gain can result from fluid accumulation in the interstitial spaces. This is
known as edema. The nurse should note whether the client feels that his or her
shoes or rings are tight, and should observe, when present, an indentation around
the leg where the socks end. The other answers do not describe edema.
A nurse assesses an older adult client who is experiencing a myocardial infarction.
Which clinical manifestation should the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Disorientation and confusion
d. Numbness and tingling of the arm - ANSWER c. Disorientation and confusion
In older adults, disorientation or confusion may be the major manifestation of
myocardial infarction caused by poor cardiac output. Pain manifestations and
numbness and tingling of the arm could also be related to the myocardial
infarction. However, the nurse should be more concerned about the new onset of
disorientation or confusion caused by decreased perfusion.
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. Which action should the
nurse take?
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." - ANSWER c. Assess the
color and temperature of the left leg.
