NURS 401 Exam 1 Practice Questions with Complete
Solutions
The nurse is providing education to help reduce cardiovascular risks for
a women's book club. Which statement made by a participant indicates a
need for further teaching?
a. "We are more likely to die from cardiovascular disease than men"
b. "We need to walk or do other exercise everyday for 30 minutes"
c. "We need to stay away from people who smoke"
d. "We should take hormones for menopause to decrease the risk for
heart attack" Correct Answer-d. "We should take hormones for
menopause to decrease the risk for heart attack"
Rationale: meds used in hormone therapy can cause an increased
incidence of MI or stroke in women
A client is admitted to the telemetry unit after a right-sided cardiac
catheterization. What is the nurse's priority when caring for this client?
a. Assess the intensity and quality of the client's pain
b. Position the client in a sitting position to improve breathing
c. Check the client's arterial insertion site
d. Apply oxygen at 2 L/min via nasal cannula Correct Answer-c. Check
the client's arterial insertion site
Rationale: Pts who have had a cardiac catheterization should be
restricted to short-term bedrest, and the insertion site extremity should
be kept straight. The nurse should assess the site for bloody drainage or
hematoma formation because complications with vascular closure
devices are not common but can be very serious.
,A middle-aged man is admitted to the cardiac unit after reports of a
severe headache and flushing of the face. He is diagnosed with severe
hypertension. The patient is alert and oriented. BP = 192/104, HR = 88.
You are the RN assigned to his care. There is an unlicensed nurse
technician working with you.
1. What assessment data will you perform upon his arrival to the unit?
why?
2. The cardiologist prescribes IV fluids, hourly BP checks, BP
medication, and oxygen at 2 L/min via nasal cannula. What part of the
patient's care will you delegate to the unlicensed nurse technician? What
information will you communicate upon delegation?
3. What interventions will you implement to ensure this patient's safety?
4. The patient's wife is very concerned about her husband returning to
work as owner of a roofing company. What education will you provide
the patient and his wife at this time? With what health care team
members w Correct Answer-1. Assess all VS, specifically BP, and
conduct a head to toe assessment. VS should be taken to continue
observing the pt's condition (specifically HTN) and trended to determine
if treatment and interventions are working. During the physical
assessment, you will specifically need to listen to the heart for the
presence or absence of murmurs or other abnormal heart sounds and
perform a basic neurological assessment to determine the pt's baseline
orientation.
2. Can delegate: hourly BP checks, with understanding that you must
follow all Nurse Practice Acts related to appropriate delegation.
Communicate: task that is to be performed and the method by which it
should be (manual vs automated). Also clarify that you need the findings
reported back to you hourly.
, Follow up hourly to obtain report of the vitals so you can make
appropriate nursing decisions
3. Safety precautions; if need for invasive diagnostic testing, determine
if there is iodine-based contrast media allergies; report dysrhythmias
immediately; continually assess pt's report of pain, especially when pt's
report is descriptive of angina or MI; teach pt safety precautions
regarding calling for assistance if pt needs to ambulate to the bathroom
b/c syncope can be related to severe HTN
4. Teach methods for decreasing cardiovascular disease risk such as
control of HTN with meds, moderate physical exercise, smoking
cessation, decrease psychological stressors, and diet modification.
Collaborate with dietician for nutrition planning, primary care provider
for meds that may assist with smoking cessation, and community
support systems that may assist with psychological stressors
A client who had open abdominal surgery 4 hours ago reports feeling
weak and dizzy. The client's current BP has decreased to 98/50 and pulse
is 108. What is nurse's best action at this time?
a. Document VS and continue to monitor the client.
b. Remind the client to stay in bed if feeling weak and dizzy.
c. Call the health care provider immediately.
d. Increase the client's IV rate to restore fluid volume. Correct Answer-c.
Call the health care provider immediately.
Rationale: Surgery or trauma may cause ventricular fibrillation.
Symptoms include faintness, loss of consciousness, and apnea with
pulselessness; nurse should contact health care provider immediately.
Solutions
The nurse is providing education to help reduce cardiovascular risks for
a women's book club. Which statement made by a participant indicates a
need for further teaching?
a. "We are more likely to die from cardiovascular disease than men"
b. "We need to walk or do other exercise everyday for 30 minutes"
c. "We need to stay away from people who smoke"
d. "We should take hormones for menopause to decrease the risk for
heart attack" Correct Answer-d. "We should take hormones for
menopause to decrease the risk for heart attack"
Rationale: meds used in hormone therapy can cause an increased
incidence of MI or stroke in women
A client is admitted to the telemetry unit after a right-sided cardiac
catheterization. What is the nurse's priority when caring for this client?
a. Assess the intensity and quality of the client's pain
b. Position the client in a sitting position to improve breathing
c. Check the client's arterial insertion site
d. Apply oxygen at 2 L/min via nasal cannula Correct Answer-c. Check
the client's arterial insertion site
Rationale: Pts who have had a cardiac catheterization should be
restricted to short-term bedrest, and the insertion site extremity should
be kept straight. The nurse should assess the site for bloody drainage or
hematoma formation because complications with vascular closure
devices are not common but can be very serious.
,A middle-aged man is admitted to the cardiac unit after reports of a
severe headache and flushing of the face. He is diagnosed with severe
hypertension. The patient is alert and oriented. BP = 192/104, HR = 88.
You are the RN assigned to his care. There is an unlicensed nurse
technician working with you.
1. What assessment data will you perform upon his arrival to the unit?
why?
2. The cardiologist prescribes IV fluids, hourly BP checks, BP
medication, and oxygen at 2 L/min via nasal cannula. What part of the
patient's care will you delegate to the unlicensed nurse technician? What
information will you communicate upon delegation?
3. What interventions will you implement to ensure this patient's safety?
4. The patient's wife is very concerned about her husband returning to
work as owner of a roofing company. What education will you provide
the patient and his wife at this time? With what health care team
members w Correct Answer-1. Assess all VS, specifically BP, and
conduct a head to toe assessment. VS should be taken to continue
observing the pt's condition (specifically HTN) and trended to determine
if treatment and interventions are working. During the physical
assessment, you will specifically need to listen to the heart for the
presence or absence of murmurs or other abnormal heart sounds and
perform a basic neurological assessment to determine the pt's baseline
orientation.
2. Can delegate: hourly BP checks, with understanding that you must
follow all Nurse Practice Acts related to appropriate delegation.
Communicate: task that is to be performed and the method by which it
should be (manual vs automated). Also clarify that you need the findings
reported back to you hourly.
, Follow up hourly to obtain report of the vitals so you can make
appropriate nursing decisions
3. Safety precautions; if need for invasive diagnostic testing, determine
if there is iodine-based contrast media allergies; report dysrhythmias
immediately; continually assess pt's report of pain, especially when pt's
report is descriptive of angina or MI; teach pt safety precautions
regarding calling for assistance if pt needs to ambulate to the bathroom
b/c syncope can be related to severe HTN
4. Teach methods for decreasing cardiovascular disease risk such as
control of HTN with meds, moderate physical exercise, smoking
cessation, decrease psychological stressors, and diet modification.
Collaborate with dietician for nutrition planning, primary care provider
for meds that may assist with smoking cessation, and community
support systems that may assist with psychological stressors
A client who had open abdominal surgery 4 hours ago reports feeling
weak and dizzy. The client's current BP has decreased to 98/50 and pulse
is 108. What is nurse's best action at this time?
a. Document VS and continue to monitor the client.
b. Remind the client to stay in bed if feeling weak and dizzy.
c. Call the health care provider immediately.
d. Increase the client's IV rate to restore fluid volume. Correct Answer-c.
Call the health care provider immediately.
Rationale: Surgery or trauma may cause ventricular fibrillation.
Symptoms include faintness, loss of consciousness, and apnea with
pulselessness; nurse should contact health care provider immediately.
