Chapter 20: Care of Patients with Cardiac Disorders My Nursing Test Banks

Chapter 20: Care of Patients with Cardiac Disorders

MULTIPLE CHOICE

1. The nurse would anticipate that the patient with right-sided heart failure would exhibit:

a.

wheezing.

b.

orthopnea.

c.

edema.

d.

pallor.

ANS: C

Edema from the systemic backup would be the most significant sign. Wheezing, orthopnea, and pallor are indicative of left-sided failure.

DIF: Cognitive Level: Comprehension REF: 428 | Table 20-2

OBJ: 1 (theory) TOP: Heart Failure: Right Side

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The nurse anticipates that, on auscultation of the chest of an older adult with left-sided congestive heart failure (CHF), the major adventitious sound will be:

a.

wheezing.

b.

crackles.

c.

rhonchi.

d.

friction rub.

ANS: A

Wheezing will be the overriding sound.

DIF: Cognitive Level: Application REF: 428 | Table 20-2

OBJ: 1 (theory) TOP: CHF: Signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse explains to the patient that the implanted cardioverter-defibrillator (ICD) will:

a.

shock the arrhythmias into sinus rhythm.

b.

enhance the heart pumping action.

c.

stimulate an extra beat if the heart rate drops.

d.

control the rate of the heart at a the present level.

ANS: A

The ICD recognizes a correctable rhythm and shocks the heart back into a sinus rhythm.

DIF: Cognitive Level: Comprehension REF: 442 OBJ: 2 (clinical)

TOP: ICD KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. The patient with severe congestive heart failure (CHF) does not want to take the morphine ordered, stating that he is not in pain and he is fearful of becoming addicted. The nurse can allay anxiety by explaining that the morphine:

a.

is given to many people with CHF.

b.

can be omitted and relief can be obtained with NSAIDs.

c.

is used to relieve anxiety and air hunger.

d.

is the only drug that can be used for CHF patients.

ANS: C

The primary purpose of morphine is its relief of air hunger and anxiety. NSAIDs do not have the same vasodilation properties as morphine. In the event the patient cannot tolerate the prescribed medication, morphine is not the only drug that can be used.

DIF: Cognitive Level: Application REF: 430 OBJ: 4 (clinical)

TOP: CHF Treatment: Morphine KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

5. The nurse caring for a patient with congestive heart failure (CHF) will include which intervention in the plan of care?

a.

Perform all care at one time to allow more time to rest.

b.

Keep the patient as flat as possible to prevent venous pooling.

c.

Encourage eating large meals at regular times.

d.

Alternate rest with activity.

ANS: D

Alternating rest with activity preserves the patients energy. Patients are more comfortable in semi-Fowlers position to ease breathing and should eat small meals that are easy to chew and use less energy.

DIF: Cognitive Level: Application REF: 433 OBJ: 1 (clinical)

TOP: CHF: Nursing Care KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

6. The patient with tachycardia who has a heart rate of 115 complains of shortness of breath. The nurse interprets this complaint as being related to which problem?

a.

Pulmonary edema

b.

Drop in cardiac output

c.

Impending pneumonia

d.

Increasing anxiety

ANS: B

When the heart is beating rapidly, the stroke volume decreases. This diminishes the cardiac output, causing reduced oxygen to tissues and tissue hypoxia.

DIF: Cognitive Level: Application REF: 435 OBJ: 2 (clinical)

TOP: Tachycardia: Complications KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

7. The nurse evaluates the need for further instruction on reduction of caffeine when the patient who has an arrhythmia says:

a.

Ive cut my coffee from 10 cups to 2 cups a day.

b.

I dont drink regular cola drinks anymore.

c.

I have given up drinking those high-energy drinks.

d.

Ive switched from 5 cups of coffee to 5 cups of tea.

ANS: D

Tea has as much caffeine as coffee does, or more. All other options will reduce the caffeine intake.

DIF: Cognitive Level: Comprehension REF: 436 | Clinical Cues

OBJ: 2 (clinical) TOP: Arrhythmias: Caffeine Reduction

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

8. If there are several tiny spikes in place of P waves on the ECG, the nurse recognizes the arrhythmia as:

a.

premature ventricular contraction (PVC).

b.

atrial flutter/fibrillation.

c.

ventricular tachycardia (VT).

d.

premature atrial contraction (PAC).

ANS: B

Atrial flutter /atrial fibrillation has many small ineffective contractions prior to the QRS complex. An abnormally shaped P wave appears on the ECG before the QRS wave in PAC. PVC is seen as an early beat without a P wave and with a wide QRS complex. VT is seen as three or more PVCs in a row with a ventricular rate of greater than 100 beats per minute.

DIF: Cognitive Level: Application REF: 437 OBJ: 2 (clinical)

TOP: Arrhythmias: Atrial Flutter KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The patient with atrial fibrillation asks why she needs to take warfarin. The most informative response by the nurse is that warfarin will:

a.

thin the blood to increase the ejection fraction.

b.

prevent clots from forming in the atria.

c.

block the arrhythmia from involving the ventricles.

d.

increase the cardiac output.

ANS: B

Warfarin keeps clots from forming in the retained blood in the atria left there by the ineffective atrial contractions.

DIF: Cognitive Level: Application REF: 437-438 OBJ: 3 (clinical)

TOP: Arrhythmias: Warfarin KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

10. The nurse caring for a patient who is taking amiodarone (Cordarone) will plan to assess the vital signs carefully for which common side effect?

a.

Sudden increase in temperature

b.

Hypotension

c.

Bradycardia

d.

Depressed ventilation

ANS: B

Hypotension with the attendant fatigue is a side effect of amiodarone (Cordarone).

DIF: Cognitive Level: Analysis REF: 439 | Table 20-4

OBJ: 4 (clinical) TOP: Amiodarone (Cordarone): Side Effects

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

11. The nurse recognizes the disorganized ECG pattern of the most fatal of all arrhythmias as:

a.

ventricular fibrillation.

b.

premature ventricular beats.

c.

atrial fibrillation.

d.

ventricular tachycardia.

ANS: A

Ventricular fibrillation is a disorganized pattern of totally ineffective contractions and no cardiac output. This is a medical emergency and, if not corrected, is fatal.

DIF: Cognitive Level: Application REF: 440 OBJ: 2 (clinical)

TOP: Arrhythmias: Ventricular Fibrillation

KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

12. The nurse explains that the calcium channel blocker verapamil assists to correct an arrhythmia by:

a.

numbing the heart to the impulse to contract.

b.

increasing the strength of the impulse from the atrioventricular (AV) node.

c.

altering the impulse from the sinoatrial (SA) node.

d.

inhibiting transmission of the impulse from the AV node.

ANS: D

Verapamil blocks calcium from the cardiac cells, inhibiting the transmission of the impulse from the AV node.

DIF: Cognitive Level: Application REF: 439 | Table 20-4

OBJ: 4 (clinical) TOP: Arrhythmias: Verapamil

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

13. The nurse will instruct a patient with an automatic implantable cardioverter-defibrillator (AICD) to avoid:

a.

static electricity from synthetic fabric.

b.

airport security detection devices.

c.

constricting clothing and belts.

d.

high altitudes.

ANS: B

Electronic wands at airport security check stations can alter the setting on the AICD. People with AICDs should have certification that they have the imbedded device. High altitudes and clothing will not alter the settings.

DIF: Cognitive Level: Comprehension REF: 442 OBJ: 6 (clinical)

TOP: AICD: Precautions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

14. The nurse caring for a patient with a temporary transvenous pacemaker will include which intervention?

a.

Informing the patient that they may experience uncomfortable muscle contractions as current passes through the chest

b.

Leaving the wires exposed for easy assessment

c.

Using an electric razor with caution

d.

Leaving the controls of the bed in easy reach

ANS: A

It is important that the patient understands the uncomfortable muscle contractions are normal. These patients should not be exposed to any electric devices, including the electric bed.

DIF: Cognitive Level: Application REF: 440-441 OBJ: 6 (clinical)

TOP: Temporary Pacemakers: Precautions

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

15. Which teaching point will the nurse include when providing discharge instructions to the patient with a new permanent pacemaker?

a.

You will be able to have an MRI for diagnostic purposes.

b.

Avoid using microwave ovens.

c.

Avoid lifting heavy objects for as long as your physician prescribes.

d.

Airport screening devices may cause your pacemaker to fire incorrectly.

ANS: C

The postoperative patient with a permanent pacemaker can assume normal activity when the physician prescribes. Using the arm for lifting and other activities may dislodge the leads from their positions. MRIs must be avoided since the large magnet can interfere with the pacemakers function. Microwaves and airport security devices do not affect the pacemaker.

DIF: Cognitive Level: Application REF: 441 | Patient Teaching

OBJ: 5 (clinical) TOP: Permanent Pacemaker: Postoperative Expectations

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The patient who is taking digitalis for his heart condition becomes extremely dehydrated and has scant urine output. The nurse will assess regularly for the complaint of:

a.

left arm pain.

b.

blurred vision.

c.

itching.

d.

increasing edema.

ANS: B

Blurred vision, halos around lights, nausea, vomiting and diarrhea, and fatigue are all indicators of toxicity to digitalis. Assessment is especially important for the dehydrated patient because of the rising potassium level.

DIF: Cognitive Level: Application REF: 447 OBJ: 4 (clinical)

TOP: Digitalis: Toxicity KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

17. The nurse is caring for several patients on a cardiac care unit. The nurse is aware that the patient who is most likely to have the disorder of aortic stenosis is which patient?

a.

35 year old with a history of mitral valve prolapsed

b.

63 year old with uncontrolled diabetes

c.

73 year old with a history of hypertension

d.

86 year old with a history of atherosclerosis

ANS: D

Aortic stenosis is the most common valve disorder in the United States. Atherosclerosis with degenerative calcification of the valve is a common factor in older adults.

DIF: Cognitive Level: Application REF: 445 OBJ: 3 (clinical)

TOP: Cardiac Valve Disorders KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. The home health nurse is assessing the home-bound patient with heart failure. Which assessment finding is of most concern to the nurse?

a.

The patient complains of moderate shortness of breath after walking 1 mile on the treadmill.

b.

The nurse notes a 3-lb weight gain over the course of a week.

c.

The patient reports an increase of heart rate of 10 beats per minute after vacuuming the floor.

d.

The patient reports an increase in urinary output.

ANS: B

A weight gain without an increase in caloric intake is indicative of fluid retention, which is an indication of worsening heart failure. Moderate shortness of breath after exercise and a mild increase in heart rate after activity are expected. A decrease in urinary output would be of concern.

DIF: Cognitive Level: Analysis REF: 428-429 OBJ: 8 (theory)

TOP: Home Care Considerations: Heart Failure

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

19. The nurse reminds the 60-year-old moderately obese African American hypertensive diabetic male who smokes that he can modify his risk for heart disease by: (Select all that apply.)

a.

smoking cessation.

b.

controlling diabetes.

c.

exercising regularly.

d.

reducing blood pressure.

e.

reducing weight.

ANS: A, B, C, D, E

All options are modifiable. By losing weight through exercise, this patient could also lower his blood pressure and better control his diabetes.

DIF: Cognitive Level: Knowledge REF: 448 OBJ: 6 (clinical)

TOP: Modifiable Risk Factors KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

20. Of all the assessments the nurse has made on the new patient, those that may indicate heart failure are: (Select all that apply.)

a.

flushed skin.

b.

jugular distention.

c.

weight gain but eating very little.

d.

diminished pedal pulses.

e.

wearing loose house shoes rather than street shoes.

ANS: B, C, D, E

All options with the exception of flushing are possible clues to congestive heart failure. Jugular distention, weight gain with little intake, diminished pedal pulses, and wearing house shoes (because of swelling) are all related to edema related to right-sided heart failure.

DIF: Cognitive Level: Application REF: 428-429 OBJ: 1 (theory)

TOP: Heart Failure Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance

21. The independent interventions the nurse may employ when the 80-year-old patient in the long-term health care facility develops acute pulmonary edema are to: (Select all that apply.)

a.

give oxygen at 2 L/min.

b.

give morphine to relieve respiratory distress.

c.

give diuretics to relieve excess fluid.

d.

position in high Fowlers position.

e.

apply compression stockings.

ANS: A, D

Giving oxygen at low levels and positioning are the only independent nursing interventions. All other options require a physicians order.

DIF: Cognitive Level: Analysis REF: 431 OBJ: 5 (clinical)

TOP: Acute Pulmonary Edema: Independent Nursing Interventions

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

22. The nurse points out the characteristics of normal sinus rhythm (NSR), which are: (Select all that apply.)

a.

one atrial contraction (P wave).

b.

one ventricular contraction (QRS complex).

c.

one T wave.

d.

heart rate 60 to 100.

e.

P wave following the QRS complex.

ANS: A, B, C, D

The P wave precedes the QRS complex. All other options are seen in NSR.

DIF: Cognitive Level: Knowledge REF: 436 | Figure 20-5

OBJ: 1 (clinical) TOP: Normal Sinus Rhythm

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nurse is aware that some arrhythmias may be the result of: (Select all that apply.)

a.

hyperkalemia.

b.

valvular prolapse.

c.

infarct damage.

d.

defective sinoatrial node.

e.

excess fluid.

ANS: A, B, C, D, E

All options are possible causes of arrhythmias.

DIF: Cognitive Level: Comprehension REF: 435 OBJ: 5 (theory)

TOP: Arrhythmias: Etiology KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. The nurse is aware that certain risk factors increase the chance of a person developing cardiomyopathy. Which of the circumstances increase the risk for cardiomyopathy? (Select all that apply.)

a.

Systemic hypertension

b.

Chronic excessive alcohol consumption

c.

Pregnancy

d.

Diabetes

e.

Systemic infection

ANS: A, B, C, E

Cardiomyopathy is a group of disorders that result in enlargement of the heart and subsequent inefficient pumping action. Diabetes is not considered a risk factor for cardiomyopathy.

DIF: Cognitive Level: Comprehension REF: 444 OBJ: 3 (clinical)

TOP: Cardiomyopathy KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

COMPLETION

25. The nurse expresses concern to the 80-year-old resident in a long-term care facility who is attempting to jog on a treadmill. The nurse is aware that the exceptional oxygen and metabolic demands brought on by the exercise might cause ____________.

ANS:

heart failure

When the body makes excessive oxygenation and metabolic demands on an aging heart with low cardiac reserve, heart failure may result.

DIF: Cognitive Level: Application REF: 432 | Elder Care Points

OBJ: 1 (clinical) TOP: CHF: Older Adult

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

26. When the nurse assesses an apical pulse of 52, the finding of this arrhythmia is known as _________.

ANS:

bradycardia

An apical pulse of less than 60 is considered to be bradycardia.

DIF: Cognitive Level: Knowledge REF: 435 OBJ: 1 (clinical)

TOP: Bradycardia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

27. The patient suffering from ventricular tachydysrhythmia may benefit from _________________ when medications are not effectively treating the disorder.

ANS:

radiofrequency catheter ablation

This procedure destroys the irritable focus in the heart via heat and subsequent scarring, thus correcting the ventricular tachydysrhythmia when medication is not effective.

DIF: Cognitive Level: Analysis REF: 442 OBJ: 8 (theory)

TOP: Home Care Considerations: Heart Failure

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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