NUR257 Exam 2 UPDATED ACTUAL
Exam Questions and CORRECT Answers
A client with a confirmed DVT is being discharged from the ED. Which client statement
indicates that the client has received proper nursing instruction and understands how to manage
this condition?
"I should try not to drink too much during the daytime."
"I should lie on my side with my knees bent when sleeping."
"I need to ice my leg every 2 hours for about 20 minutes."
"I need to do my leg exercises five times or more every hour." - CORRECT ANSWER -
"I need to do my leg exercises five times or more every hour."
A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect
the surgical insertion site closely for which complication(s)?
Bleeding and infection
Bleeding and wound dehiscence
Thrombosis and infection
Evisceration - CORRECT ANSWER - Bleeding and infection
A client who recently had a myocardial infarction develops pericarditis and complains of chest
pain rated 6 (on a scale of 0-10) with deep breathing. Which ordered pro re nata medications is
most appropriate for the nurse to administer?
Morphine sulfate 6 mg IVP every 2-4 hours
Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours
Acetaminophen 650 mg PO every 4 hours
Ibuprofen 800 mg PO every 8 hours - CORRECT ANSWER - Ibuprofen 800 mg PO
every 8 hours
The nurse instructs a client recovering from mechanical valve replacement surgery. Which client
statement indicates that teaching has been effective?
"I can play soccer in a week or two."
,"I will not drive until informed by my health care provider."
"I have a low risk of developing an infection in my heart."
"I will not need to take anticoagulant medication every day." - CORRECT ANSWER - "I
will not drive until informed by my health care provider."
A nurse is caring for a client receiving warfarin therapy following a mechanical valve
replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn
before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's
first priority ?
Assess the client for bleeding and notify the health care provider of the results.
Notify the next nurse on afternoon shift to hold the evening dose of warfarin.
Notify the health care provider to request an increase in the warfarin dose.
Be prepared to administer an I.M. vitamin K injection and notify the healthcare provider of the
results. - CORRECT ANSWER - Assess the client for bleeding and notify the health care
provider of the results.
The nurse suspects a client has developed pericarditis after a week of cold-like symptoms. Which
of the client's signs and symptoms indicate pericarditis?
low urine output secondary to left ventricular dysfunction
fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
pitting edema, chest discomfort, and nonspecific ST-segment elevation
lethargy, anorexia, and heart failure - CORRECT ANSWER - fever, chest discomfort, and
elevated erythrocyte sedimentation rate (ESR)
A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate
the development of left ventricular failure?
Orthopnea, nausea, pedal edema
Distended jugular veins, pedal edema, nausea
Dyspnea, orthopnea, pulmonary edema
Dyspnea, distended jugular veins, orthopnea - CORRECT ANSWER - Dyspnea,
orthopnea, pulmonary edema
,Which would the nurse stress as a periodic lifelong necessity for a client managing infective
endocarditis?
Exercise regimen
Antihypertensive medication
Potassium replacement
Antibiotic therapy - CORRECT ANSWER - Antibiotic therapy
The nurse is caring for a client who has been diagnosed with aortic stenosis. The client is
prescribed digoxin. What is the rationale for the medication?
left ventricular dysfunction
angina
dyspnea
edema - CORRECT ANSWER - left ventricular dysfunction
A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The
nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?
Computed tomography
Echocardiography
Chest x-ray
Cardiac catheterization - CORRECT ANSWER - Echocardiography
A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed with
streptococcal pharyngitis. A nurse knows that early diagnosis and effective treatment is essential
to avoid which preventable disease?
Rheumatic fever
Cardiomyopathy
Pericarditis
Mitral stenosis - CORRECT ANSWER - Rheumatic fever
, The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse.
What statement made by the client demonstrates understanding of the teaching?
"I will take antibiotics before getting my teeth cleaned."
"I can get my tongue pierced at a store in the shopping mall."
"I will avoid caffeine, alcohol, and smoking."
"I can get a tattoo at a local parlor." - CORRECT ANSWER - "I will avoid caffeine,
alcohol, and smoking."
A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart
have begun to fail. The nurse will monitor the client carefully for which initial symptoms?
Dizziness, nausea, diarrhea
Exertional dyspnea, orthopnea, pulmonary edema
Syncope, fever, vomiting
Nausea, vomiting, exertional fatigue - CORRECT ANSWER - Exertional dyspnea,
orthopnea, pulmonary edema
The nurse is assessing a client admitted with infective endocarditis. Which manifestation would
the nurse expect to find?
Bruising on the palms of the hands and soles of the feet
Raised red rash on the trunk and face
Involuntary muscle movements of the extremities
Small painful lesions on the pads of the fingers and toes - CORRECT ANSWER - Small
painful lesions on the pads of the fingers and toes
During assessment of a client admitted for cardiomyopathy, the nurse notes the following
symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate
nursing diagnosis is which of the following?
Ineffective airway clearance
Disturbed sensory perception
Decreased cardiac output
Autonomic dysreflexia - CORRECT ANSWER - Decreased cardiac output
Exam Questions and CORRECT Answers
A client with a confirmed DVT is being discharged from the ED. Which client statement
indicates that the client has received proper nursing instruction and understands how to manage
this condition?
"I should try not to drink too much during the daytime."
"I should lie on my side with my knees bent when sleeping."
"I need to ice my leg every 2 hours for about 20 minutes."
"I need to do my leg exercises five times or more every hour." - CORRECT ANSWER -
"I need to do my leg exercises five times or more every hour."
A nurse is caring for a client who had an aortic balloon valvuloplasty. The nurse should inspect
the surgical insertion site closely for which complication(s)?
Bleeding and infection
Bleeding and wound dehiscence
Thrombosis and infection
Evisceration - CORRECT ANSWER - Bleeding and infection
A client who recently had a myocardial infarction develops pericarditis and complains of chest
pain rated 6 (on a scale of 0-10) with deep breathing. Which ordered pro re nata medications is
most appropriate for the nurse to administer?
Morphine sulfate 6 mg IVP every 2-4 hours
Fentanyl 2 mg intravenous pyelogram (IVP) every 2-4 hours
Acetaminophen 650 mg PO every 4 hours
Ibuprofen 800 mg PO every 8 hours - CORRECT ANSWER - Ibuprofen 800 mg PO
every 8 hours
The nurse instructs a client recovering from mechanical valve replacement surgery. Which client
statement indicates that teaching has been effective?
"I can play soccer in a week or two."
,"I will not drive until informed by my health care provider."
"I have a low risk of developing an infection in my heart."
"I will not need to take anticoagulant medication every day." - CORRECT ANSWER - "I
will not drive until informed by my health care provider."
A nurse is caring for a client receiving warfarin therapy following a mechanical valve
replacement. The client had a prothrombin time and International Normalized Ratio (INR) drawn
before breakfast. The laboratory report shows the client's INR reading was 4. What is the nurse's
first priority ?
Assess the client for bleeding and notify the health care provider of the results.
Notify the next nurse on afternoon shift to hold the evening dose of warfarin.
Notify the health care provider to request an increase in the warfarin dose.
Be prepared to administer an I.M. vitamin K injection and notify the healthcare provider of the
results. - CORRECT ANSWER - Assess the client for bleeding and notify the health care
provider of the results.
The nurse suspects a client has developed pericarditis after a week of cold-like symptoms. Which
of the client's signs and symptoms indicate pericarditis?
low urine output secondary to left ventricular dysfunction
fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
pitting edema, chest discomfort, and nonspecific ST-segment elevation
lethargy, anorexia, and heart failure - CORRECT ANSWER - fever, chest discomfort, and
elevated erythrocyte sedimentation rate (ESR)
A client is admitted to the hospital with aortic stenosis. What assessment findings would indicate
the development of left ventricular failure?
Orthopnea, nausea, pedal edema
Distended jugular veins, pedal edema, nausea
Dyspnea, orthopnea, pulmonary edema
Dyspnea, distended jugular veins, orthopnea - CORRECT ANSWER - Dyspnea,
orthopnea, pulmonary edema
,Which would the nurse stress as a periodic lifelong necessity for a client managing infective
endocarditis?
Exercise regimen
Antihypertensive medication
Potassium replacement
Antibiotic therapy - CORRECT ANSWER - Antibiotic therapy
The nurse is caring for a client who has been diagnosed with aortic stenosis. The client is
prescribed digoxin. What is the rationale for the medication?
left ventricular dysfunction
angina
dyspnea
edema - CORRECT ANSWER - left ventricular dysfunction
A client is admitted to the hospital with possible acute pericarditis and pericardial effusion. The
nurse knows to prepare the client for which diagnostic test to confirm the client's diagnosis?
Computed tomography
Echocardiography
Chest x-ray
Cardiac catheterization - CORRECT ANSWER - Echocardiography
A client comes to the clinic reporting fever, chills, and sore throat and is diagnosed with
streptococcal pharyngitis. A nurse knows that early diagnosis and effective treatment is essential
to avoid which preventable disease?
Rheumatic fever
Cardiomyopathy
Pericarditis
Mitral stenosis - CORRECT ANSWER - Rheumatic fever
, The nurse is educating a client about the care related to a new diagnosis of mitral valve prolapse.
What statement made by the client demonstrates understanding of the teaching?
"I will take antibiotics before getting my teeth cleaned."
"I can get my tongue pierced at a store in the shopping mall."
"I will avoid caffeine, alcohol, and smoking."
"I can get a tattoo at a local parlor." - CORRECT ANSWER - "I will avoid caffeine,
alcohol, and smoking."
A nurse is caring for a client with aortic stenosis whose compensatory mechanisms of the heart
have begun to fail. The nurse will monitor the client carefully for which initial symptoms?
Dizziness, nausea, diarrhea
Exertional dyspnea, orthopnea, pulmonary edema
Syncope, fever, vomiting
Nausea, vomiting, exertional fatigue - CORRECT ANSWER - Exertional dyspnea,
orthopnea, pulmonary edema
The nurse is assessing a client admitted with infective endocarditis. Which manifestation would
the nurse expect to find?
Bruising on the palms of the hands and soles of the feet
Raised red rash on the trunk and face
Involuntary muscle movements of the extremities
Small painful lesions on the pads of the fingers and toes - CORRECT ANSWER - Small
painful lesions on the pads of the fingers and toes
During assessment of a client admitted for cardiomyopathy, the nurse notes the following
symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate
nursing diagnosis is which of the following?
Ineffective airway clearance
Disturbed sensory perception
Decreased cardiac output
Autonomic dysreflexia - CORRECT ANSWER - Decreased cardiac output
