Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders My Nursing Test Banks

Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is reinforcing discharge instructions to a patient who has a mitral valve prolapse. What information should be included?
a. Begin a home aerobic exercise program.
b. Perform hourly leg exercises if lying down.
c. Deep breathe and cough hourly when awake.
d. You may have a possible need for prophylactic anticoagulants.
____ 2. The nurse is reinforcing teaching for a patient who has had a mechanical valve replacement. What should be included regarding safety during warfarin (Coumadin) therapy?
a. Wear Medic-Alert identification.
b. Use a straight razor when shaving.
c. Keep yearly blood test appointments.
d. Increase intake of green leafy vegetables.
____ 3. The nurse is collecting data from a patient who has mitral stenosis. For which condition should the nurse assess in the patients history?
a. Meningitis
b. Scarlet fever
c. Rheumatic fever
d. Rheumatoid arthritis
____ 4. The nurse is reinforcing teaching provided to a patient with aortic stenosis. Which statement indicates that the patient correctly understands what happens in aortic stenosis?
a. There is impaired emptying of the left ventricle.
b. There is impaired emptying of the right ventricle.
c. There is backflow of blood into the left ventricle.
d. There is backflow of blood into the right ventricle.
____ 5. A patient with mitral regurgitation asks what the health problem means. What should the nurse explain to the patient?
a. There is impaired emptying of the left atrium.
b. There is backflow of blood into the left atrium.
c. There is impaired emptying of the right atrium.
d. There is backflow of blood into the right atrium.
____ 6. While collecting data on a patient with aortic stenosis the nurse monitors for signs of heart failure. What is the nurse monitoring for heart failure as a complication of aortic stenosis?
a. Cardiac workload is increased from reduced cardiac output.
b. Cardiac workload is decreased from reduced cardiac output.
c. Cardiac workload is increased from increased cardiac output.
d. Cardiac workload is decreased from increased cardiac output.
____ 7. A patient with chronic mitral regurgitation states, I am always so tired. Which factor should the nurse identify as contributing to this patients fatigue?
a. Coughing
b. Heart murmur
c. Pulmonary congestion
d. Decreased cardiac output
____ 8. The nurse is contributing to a patients plan of care. During medication administration, which medication would the nurse understand as being prescribed to treat a patient with aortic stenosis who has symptoms of heart failure?
a. Heparin
b. Bumetanide (Bumex)
c. Digitalis
d. Warfarin (Coumadin)
____ 9. The nurse is caring for a patient who has a valvular problem. The patient states the doctor is ordering something that measures the pressures in the patients heart. Which diagnostic test should the nurse anticipate scheduling for the patient?
a. Echocardiogram
b. Chest radiograph
c. Electrocardiogram
d. Cardiac catheterization
____ 10. The nurse is contributing to a patients plan of care. Which statement is a desired outcome for the nursing diagnosis of Deficient Knowledge related to a new medical diagnosis of mitral valve prolapse?
a. Exhibits less fatigue during self-care
b. Clear breathing sounds, no edema or weight gain
c. States ability to comply with therapeutic regimen
d. Verbalizes definition of disorder and manifestations
____ 11. The nurse is providing discharge teaching for a patient with mitral stenosis. What should the nurse include in this teaching?
a. The medications you will be taking make your blood thicker, so you are at risk for small clots to form.
b. It is important that you increase your fluid intake and take iron supplements so that your body can make enough blood for your heart to pump around.
c. Your blood is rushing through your heart so fast that it may not give your heart enough oxygen and you may have something called angina, or heart pain.
d. Because of your heart condition, the blood flow through your heart is slower and blood may tend to pool in certain areas, which might allow tiny clots to form.
____ 12. The nurse is caring for a patient who has aortic stenosis. During data collection, which of these manifestations should indicate to the nurse that the patient is experiencing myocardial oxygen deficiency?
a. Angina
b. Sacral edema
c. Jugular vein distention
d. Pericardial friction rub
____ 13. The nurse is reinforcing teaching provided to a patient with aortic regurgitation on how to reduce cardiac workload. Which patient statement indicates that teaching has been effective?
a. Lie flat when in bed.
b. Elevate the legs hourly.
c. Eat three large meals daily.
d. Alternate activity with rest.
____ 14. The nurse is evaluating care provided to a patient with the nursing diagnosis of activity intolerance because of aortic regurgitation. Which outcome indicates that care has been effective?
a. Stated maintained bedrest to reduce fatigue
b. Engaged in desired daily and social activities
c. Completed activities of daily living with assistance
d. Reported no longer participates in gardening hobby
____ 15. The nurse is reviewing care for a group of patients. Which patient with a heart valve disorder should the nurse identify as being susceptible to developing the complication of fluid volume excess?
a. A 27-year-old male on atenolol (Tenormin)
b. A 68-year-old female on digoxin (Lanoxin)
c. A 44-year-old male taking amoxicillin (Amoxil)
d. An 18-year-old female taking warfarin (Coumadin)
____ 16. During data collection for a patient after cardiac surgery, the nurse notes that chest tube drainage has increased and is now greater than 200 mL per hour. What should the nurse do?
a. Notify registered nurse (RN).
b. Monitor oxygen saturation.
c. Recheck vital signs in 30 minutes.
d. Recheck drainage every 30 minutes.
____ 17. A patient is diagnosed with chronic aortic regurgitation. Which procedure should the nurse anticipate being prescribed for this patient?
a. Medication therapy
b. Valvular annuloplasty
c. Valvular commissurotomy
d. Surgical valve replacement
____ 18. A patient who has aortic stenosis develops severe dyspnea and chest pain. What should the nurse do now?
a. Obtain vital signs.
b. Give nitroglycerin.
c. Raise the head of the bed.
d. Encourage the patient to sleep.
____ 19. The nurse is monitoring a patient with aortic stenosis and notes crackles in the lungs and a cough. Which complication should the nurse suspect is occurring in this patient?
a. Pneumonia
b. Heart failure
c. Hypertension
d. Rheumatic fever
____ 20. The nurse is contributing to the care plan for a patient with aortic stenosis. Which outcome supports a favorable response for the nursing diagnosis of activity intolerance?
a. Verbalizes knowledge of disorder
b. Clear breathing sounds, no edema or weight gain
c. Vital signs within normal limits during self-care
d. States willingness to comply with therapeutic regimen
____ 21. A patient with mitral stenosis is prescribed a preoperative antibiotic. Which patient statement indicates an understanding for taking this medication?
a. To prevent postoperative pneumonia.
b. To prevent an increase in body temperature.
c. To prevent a bacterial infection in the heart.
d. To prevent infection of the surgical incision.
____ 22. The nurse reinforces teaching provided to a patient with mitral stenosis. Which patient statement indicates that the teaching has been effective?
a. The right side of the heart is not pumping effectively.
b. There is a backflow of blood into the lower left chamber of the heart.
c. There is a narrowing of the blood vessel that brings blood into the heart.
d. The top chamber on the left side of the heart doesnt empty all of the way.
____ 23. The nurse reinforces teaching provided to a patient prescribed an anticoagulant for atrial fibrillation due to valvular disease. Which statement by the patient indicates that the teaching has been effective?
a. I will have monthly blood tests done.
b. I can take aspirin for my frequent headaches.
c. I feel fine, so I do not need to wear a Medic-Alert bracelet anymore.
d. I care for my teeth very well, brushing them with a hard brush and flossing daily.
____ 24. A patient with aortic stenosis is being treated for heart failure. Which medication order should the nurse question?
a. Heparin
b. Digoxin (Lanoxin)
c. Bumetanide (Bumex)
d. Warfarin (Coumadin)
____ 25. The nurse is collecting data on a patient recovering from a hysterectomy who is experiencing left calf tenderness. Data include the following: left calf 17.5 inches; right calf 14 inches; left thigh 32 inches; right thigh 28 inches; shiny, warm, and reddened left leg. Which actions should the nurse recommend for this patients plan of care?
a. Maintain bedrest.
b. Encourage ambulation daily.
c. Place anti-embolism stocking on left leg.
d. Place anti-embolism stocking on both legs.
____ 26. The nurse is caring for a patient who develops a fever and reports right calf pain with a reddened and swollen calf. Which action should the nurse take?
a. Massage the affected calf.
b. Place ice on the affected calf.
c. Place elastic stocking on right leg.
d. Measure bilateral calf circumference daily.
____ 27. The nurse is contributing to a patients plan of care. Which positioning should the nurse recommend for a patient with a left deep vein thrombosis?
a. Elevate head above level of legs.
b. Elevate left leg above heart level.
c. Elevate right leg above heart level.
d. Elevate both legs above heart level.
____ 28. The home health nurse is visiting a patient with cardiomyopathy who lives alone and is prescribed anticoagulant therapy. Which observation indicates that the patient requires more teaching?
a. The patient is wearing elastic stockings and slippers.
b. The patient has a straight razor on the bathroom sink.
c. The patient has a soft-bristle toothbrush in the bathroom.
d. The patient has a bottle of acetaminophen on the counter.
____ 29. A patient with acute pericarditis has a nursing diagnosis of Pain related to the inflammatory process. What nursing action should the nurse recommend?
a. Restrict fluids to 500 mL per day.
b. Teach the patient to take shallow, rapid breaths.
c. Provide anti-inflammatory medication as ordered.
d. Have the patient cough and deep breathe hourly while awake.
____ 30. A healthy postoperative patient who has been on bedrest for 3 days suddenly develops dyspnea, tachypnea, restlessness, and chest pain. The patient says, I feel as if something is going to happen to me. What should the nurse do?
a. Perform a bilateral Homans test.
b. Give a narcotic for pain as ordered.
c. Ensure physician is notified immediately.
d. Reassure the patient that everything is fine.
____ 31. The nurse is reviewing the prothrombin time (PT) value for a patient prescribed warfarin (Coumadin). The laboratorys prothrombin time range is 9 to 11 seconds. What would be the therapeutic time for the patient?
a. 12.5 seconds
b. 17 seconds
c. 26 seconds
d. 30 seconds
____ 32. A patient with a history of mitral valve replacement surgery is instructed to take prophylactic antibiotics before a scheduled root canal. Which patient statement indicates to the nurse that teaching has been effective?
a. I know I need to call my doctor if I notice a dry cough.
b. If I notice any ankle edema, I should lower my salt intake.
c. If I develop a fever in the next week or so, I need to call my doctor right away.
d. Endocarditis causes rapid weight gain so I need to weigh myself every day for a full week.
____ 33. The nurse is collecting data from a patient 3 days after a motor vehicle crash in which the patient hit the steering wheel. The data reveal symptoms of pericarditis. Which finding indicates the presence of pericarditis?
a. Pain on expiration
b. Pericardial friction rub
c. Jugular vein distention
d. Crackles in lung bases
____ 34. The nurse is caring for a patient with pericarditis. Which type of medication should the nurse expect to be prescribed for the patient?
a. Beta blocker
b. Antihypertensive
c. Anti-inflammatory
d. Calcium channel blocker
____ 35. A patient with a deep vein thrombosis receiving a heparin infusion and warfarin (Coumadin) therapy develops bleeding gums. What action should the nurse take?
a. Notify the registered nurse.
b. Offer the patient a saline mouth rinse.
c. Turn off the heparin infusion immediately.
d. Tell the patient to gargle with mouthwash.
____ 36. The nurse is reinforcing teaching provided to a patient with thrombophlebitis. Which diagnostic test should the nurse explain is used to confirm thrombophlebitis?
a. Chest radiograph
b. Intravenous pyelogram
c. Duplex venous scanning
d. Arterial Doppler ultrasonography
____ 37. The nurse is collecting data from a patient. Which approach should the nurse use to determine the presence of a Homans sign?
a. Observing the calf and thigh color bilaterally
b. Listening with a Doppler to posterior bilateral tibial pulses
c. Measuring the patients calf and thigh circumference bilaterally
d. Dorsiflexing the patients foot sharply and asking if calf pain occurs
____ 38. The nurse is caring for a patient with a deep vein thrombosis who is receiving intravenous heparin. The nurse should monitor which of these laboratory tests specifically for the effects of the heparin?
a. PT
b. PTT
c. Platelets
d. Bleeding time
____ 39. The nurse is reinforcing teaching provided to a patient with strep throat. Which statement indicates that the patient understands the complication that can occur 2 to 3 weeks after this health problem?
a. Pericarditis.
b. Rheumatic fever.
c. Cardiomyopathy.
d. Rheumatic heart disease.
____ 40. A patient is diagnosed with cardiomyopathy. What should the nurse identify as a potential risk for this patient?
a. Angina
b. Pericarditis
c. Heart failure
d. Myocardial infarction
____ 41. The nurse is monitoring a patient with pericarditis. What health problem is this patient at risk for developing?
a. Emboli begin to form.
b. Pericardial sac fluid increases.
c. Cardiac workload increases by 15%.
d. Cardiac output decreases more than 10%.
____ 42. A patient who is taking digoxin (Lanoxin) is diagnosed with myocarditis. For which effect should the nurse monitor the patient?
a. Increased inflammation
b. Decreased inflammation
c. Increased risk of toxicity
d. Decreased risk of toxicity
____ 43. A postoperative patient suddenly develops dyspnea, tachypnea, restlessness, and chest pain. Which complication should the nurse suspect is occurring in this patient?
a. Pulmonary edema
b. Respiratory arrest
c. Pulmonary embolus
d. Myocardial infarction
____ 44. The nurse is preparing to administer warfarin (Coumadin) to a patient. Which laboratory value should the nurse review before administering this medication?
a. Bleeding time
b. Fibrinogen level
c. Partial thromboplastin time
d. INR
____ 45. The nurse is contributing to a patients plan of care for a patient who has an elevated INR. Which nursing diagnosis should the nurse recommend receive priority in the patients care plan?
a. Acute Pain
b. Risk for Injury
c. Risk for Infection
d. Ineffective Breathing Pattern
____ 46. The nurse caring for patients on the cardiac unit reviews the standards related to deep vein thrombosis prophylaxis. Which approach should the nurse recognize as being the most effective to prevent the development of deep vein thrombosis?
a. Using bilateral thigh-high stockings throughout hospitalization
b. Using low molecular weight heparin given subcutaneously daily
c. Using bilateral leg compression devices while the patient is in bed
d. Using a combination of pharmacological and compression interventions
____ 47. A patient recovering from cardiac surgery complains of discomfort when turning and moving in bed. What should the nurse encourage the patient perform when making position changes?
a. Hold the breath
b. Splint with a pillow
c. Bend the knees to the chest
d. Lift the head off of the bed
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 48. The nurse is reviewing the medical histories for a group of patients. Which patients should receive prophylactic antibiotics to prevent infective endocarditis (IE)? (Select all that apply.)
a. A 68-year-old with a history of atrial fibrillation scheduled for a root canal
b. A 55-year-old with a history of angina scheduled for arthroscopic knee surgery
c. A 76-year-old with a history of cardiac valve repair scheduled for a colonoscopy
d. A 71-year-old with a history of infective endocarditis scheduled for a tooth extraction
e. A 69-year-old with a history of congenital heart disease who is having an abscess drained
f. A 56-year-old with a history of mitral valve prolapse scheduled for routine dental cleaning
____ 49. A patient is being admitted to the intensive care unit after cardiac surgery. Which nursing actions should the nurse include in this patients plan of care? (Select all that apply.)
a. Note any patient shivering.
b. Assess breath sounds every shift.
c. Assist in head-to-toe data collection.
d. Place the patient in a cool environment.
e. Connect the patient to a cardiac monitor.
f. Palpate chest and neck for signs of crepitus.
____ 50. A patient is scheduled for cardiac surgery for placement of a mechanical valve. Which patient statement indicates correct understanding of characteristics of mechanical valves used for cardiac valve replacement? (Select all that apply.)
a. They are durable.
b. They require donors.
c. They create turbulent blood flow.
d. They can be placed during balloon angioplasty.
e. They do not require lifelong anticoagulant therapy.
f. They may be preferred if anticoagulation is a concern.
____ 51. The nurse has been caring for a patient experiencing a reduction in cardiac output. Which findings indicate that interventions are effective, and the patient is improving? (Select all that apply.)
a. Less shivering
b. Clear lung sounds
c. Pulse oximeter reading 96%
d. Urine output greater than 30 mL/hour
e. Cool pale extremities with diminished peripheral pulses
f. Temperature 98.6F (37C), respirations 16/min, blood pressure 110/75 mm Hg, pulse 75 beats/min)
____ 52. A patient with obstructive hypertrophic cardiomyopathy is being released from the hospital and is to continue treatment with atenolol (Tenormin) and disopyramide (Norpace) at home. Which information should be included in the patients teaching plan? (Select all that apply.)
a. Eat small meals.
b. Drink fluids to remain hydrated.
c. Plan activities in small amounts.
d. Have one alcoholic drink per day.
e. Participate in sports, such as tennis.
f. Check the pulse daily before taking medications.
____ 53. A patient is admitted for treatment of aortic stenosis. What findings should the nurse expect when collecting data from this patient? (Select all that apply.)
a. Chest pain
b. Orthopnea
c. Heart murmur
d. Dyspnea on exertion
e. Oxygen saturation 80%
____ 54. The nurse identifies the diagnosis of decreased cardiac output for a patient with a cardiac valve disorder. Which interventions should the nurse include in this patients plan of care? (Select all that apply.)
a. Provide oxygen as prescribed.
b. Maintain fluid restriction of 1000 mL.
c. Elevate the head of the bed 45 degrees.
d. Encourage frequent periods of bedrest.
e. Assess vital signs and oxygen saturation.
____ 55. A patient recovering from valve replacement surgery has a low cardiac output. Which laboratory tests should the nurse identify as a possible cause for this patients problem? (Select all that apply.)
a. Low serum sodium level
b. Low serum calcium level
c. Low serum magnesium level
d. Elevated serum glucose level
e. Elevated serum potassium level
____ 56. The nurse suspects that a patient recovering from valve replacement surgery is experiencing an infection. Which findings did the nurse use to come to this conclusion? (Select all that apply.)
a. Cloudy urine
b. Lung crackles
c. Incisional pain
d. Elevated temperature
e. Yellow-green sputum
Completion
Complete each statement.

57. A patient with aortic stenosis experiencing angina and syncope is prescribed 0.25 mg of digoxin (Lanoxin). The nurse has available digoxin, 0.125 mg tablet. How many tablets should the nurse administer to the patient?

Chapter 23. Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders
Answer Section

MULTIPLE CHOICE

1. ANS: D
Aspirin or anticoagulants may be ordered to help prevent formation of blood clots on the valve. A. The patient should follow the health care providers instructions for an exercise program. B. There is no evidence to support the need for the patient to perform leg exercises every hour. C. There is no evidence to support that the patient needs to perform deep breathing and coughing exercises every hour while awake.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

2. ANS: A
If the patient is on anticoagulants for mechanical valve replacement, medical identification should be used. D. A steady (rather than fluctuating) amount of green leafy vegetables should be eaten so that international normalized ratio (INR) values do not fluctuate due to the vitamin K found in these foods. C. Monthly blood tests are done. B. Avoid a straight razor to avoid cuts and bleeding.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

3. ANS: C
The major cause of mitral stenosis is rheumatic fever. A. B. D. Meningitis, scarlet fever, or rheumatoid arthritis are not associated with the development of mitral stenosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

4. ANS: A
Blood flow from the left ventricle into the aorta is obstructed through the stenosed aortic valve, and the left ventricle fails to move blood forward. B. Aortic stenosis does not impair blood flow from the right ventricle. C. D. A backflow of blood into the left or right ventricle does not occur with aortic stenosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

5. ANS: B
Mitral regurgitation is the incomplete closure of the mitral valve leaflets, which allows backflow of blood into the left atrium with each contraction of the left ventricle. A. C. D. Mitral regurgitation is not characterized by impaired emptying of the left or right atrium or a backflow of blood into the right atrium.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

6. ANS: A
Cardiac workload is increased from reduced cardiac output. With increased narrowing of the aortic valve opening, the compensatory mechanisms are unable to continue, and the left ventricle fails to move blood forward. This results in decreased cardiac output and heart failure. B. The cardiac workload in aortic stenosis is not decreased. C. In aortic stenosis, the cardiac workload is not increased because of increased cardiac output. D. In aortic stenosis, the cardiac workload is not decreased because of an increase in cardiac output.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

7. ANS: D
Decreased cardiac output causes fatigue due to less oxygen being provided to the tissues. A. B. C. The patient is not experiencing fatigue because of coughing, a heart murmur, or pulmonary congestion.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

8. ANS: B
Diuretics reduce fluid volume returning to the heart and, subsequently, cardiac workload. A. C. D. Medications that reduce the contractility of the heart and, subsequently, cardiac output are avoided to prevent further heart failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Comprehension | Integrated Processes: Clinical ProblemSolving Process | Question to Guide Your Learning: 2

9. ANS: D
Cardiac catheterization measures cardiac pressure and with dye injection shows blood flow. A. An echocardiogram evaluates muscle activity and ejection fraction. B. Chest radiography identifies location and size of the heart muscle. D. Electrocardiogram evaluates electrical activity of the heart.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

10. ANS: D
The patient should be able to verbalize a definition of the disorder and its manifestations to demonstrate understanding for promotion of health and self-care. A. B. C. These statements are outcomes to address specific issues such as fatigue, fluid imbalance, or ineffective coping.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

11. ANS: D
Emboli form from the stasis of blood in the heart caused by valvular disorders and decreased cardiac output. A. Patients are often placed on blood thinners, so this is a false statement. B. Iron supplementation is provided for iron deficiency anemia, not for valvular disorders. C. Blood flow through the heart is slowed, so this is a false statement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

12. ANS: A
Angina results if cardiac oxygen needs are not met. B. C. D. A lack of myocardial oxygen does not cause sacral edema, jugular vein distention, or pericardial friction rub.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

13. ANS: D
Cardiac workload and oxygen needs are reduced with rest. A. Lying flat may be uncomfortable for the patient with this health problem. B. The legs do not need to be elevated every hour. C. Large meals might be uncomfortable for this patient and should not be encouraged.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

14. ANS: B
The desired outcome for activity intolerance would be for the patient to be able to engage in desired daily and social activities. A. Needing bedrest to reduce fatigue indicates that interventions to address activity intolerance have not been effective. C. Needing assistance to complete activities of daily indicates that interventions to address activity intolerance have not been effective. D. No longer participating in a gardening hobby indicates that interventions to address activity intolerance have not been effective.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

15. ANS: B
Older adults generally would be more likely to experience the complication of fluid volume excess due to aging changes and less cardiac reserve. None of the listed medications are expected to cause fluid volume retention. A. C. D. These patients would be less prone to developing fluid volume excess with a heart valve disorder.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

16. ANS: A
The RN should be notified immediately so that the physician can be contacted. The patient needs immediate intervention to control possible hemorrhaging. B. Monitoring oxygen saturation can occur after the RN is notified. C. The vital signs should be assessed more frequently than every 30 minutes in this patient. D. The patient needs immediate attention. Waiting for 30 minutes to recheck the amount of drainage is inappropriate.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Application

17. ANS: D
Surgical valve replacement is the treatment of choice prior to heart failure development. Acute aortic regurgitation requires immediate surgery. A. B. C. Medications and valvular annuloplasty or commissurotomy would not be indicated for this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

18. ANS: A
Data collection is the first action the nurse should take in any situation to plan further care. B. C. These actions can be done after the vital signs are assessed. D. A patient with severe dyspnea and chest pain is not going to be able to sleep.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentManagement of Care | Cognitive Level: Application

19. ANS: B
Heart failure can occur with heart valve disorders. Lung symptoms are indicative of heart failure. A. C. D. Change in lung sounds and a cough does not necessarily indicate the development of pneumonia, hypertension, or rheumatic fever.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

20. ANS: B
The desired outcome for activity intolerance would be for vital signs to be within normal limits during self-care. A. Verbalizing knowledge of the disorder would support a nursing diagnosis of deficient knowledge. B. Clear breath sounds; no edema or weight gain would support the diagnosis of fluid imbalance. D. Willingness to comply with therapeutic regimen would support the diagnosis of enhanced self-care.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

21. ANS: C
Prophylactic antibiotic therapy helps prevent a bacterial infection in the heart, rheumatic fever, and subsequent rheumatic heart disease and is recommended to prevent valvular disease. A. B. D. This medication is not provided to prevent postoperative pneumonia, fever, or infection of the surgical incision.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

22. ANS: D
Mitral stenosis does not allow the left atrium to empty easily, so blood builds up in the left atrium. A. Mitral stenosis does not mean that the right side of the heart is not pumping effectively. B. There is not a backflow of blood into the lower left chamber of the heart with mitral stenosis. C. There is not a narrowing of the blood vessel that brings blood into the heart with mitral stenosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

23. ANS: A
Monthly blood tests are done to monitor the effects of the anticoagulant to maintain the therapeutic range and prevent complications such as bleeding. B. Aspirin should be avoided when taking anticoagulants. C. The patient should have medical information about anticoagulant therapy available at all times. D. The patient should use a soft-bristled brush when performing mouth care to prevent gum bleeding.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

24. ANS: C
Medications, such as digitalis, that reduce the contractility of the heart and, subsequently, cardiac output are avoided to prevent further heart failure. A. C. D. These medications can be safely provided to the patient with aortic stenosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

25. ANS: A
Patient has developed thrombophlebitis, and bedrest should be maintained as ordered until acute phase is resolved to prevent an emboli. B. Ambulation could lead to a pulmonary embolism and should be avoided. C. D. Anti-embolism stockings are placed on the unaffected leg only during the acute phase to prevent emboli.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

26. ANS: D
The calf should be measured bilaterally for comparison and documented daily to note changes. A. B. C. Massaging the calf is contraindicated, and anti-embolism stockings are placed on the unaffected leg only during acute phase to prevent emboli. Warm-moist heat may be used for superficial thrombophlebitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

27. ANS: B
Elevating the leg above heart level for 5 to 7 days is recommended. A. The head should not be placed higher than the legs. C. D. The unaffected limb does not need to be elevated.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

28. ANS: B
The patient should not use a straight razor due to the risk of injury and bleeding when on anticoagulant therapy. A, C, and D are appropriate when on anticoagulant therapy to prevent injury and bleeding.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

29. ANS: C
Anti-inflammatory medication as ordered reduces inflammation, which decreases pain, and should be included in the pain management plan. A. B. D. These actions will not help reduce the patients pain.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application

30. ANS: C
The patient likely has pulmonary emboli, which is a life-threatening condition and requires prompt medical intervention, so the physician must be notified immediately. A. B. These actions are not appropriate for the potential life-threatening condition. The physician will prescribe orders when notified. D. This would provide false reassurance which should never be done.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

31. ANS: B
Warfarins therapeutic range is 1.5 to 2 times the normal PT range. To monitor the patients therapeutic PT, compare the patients result with the therapeutic range. The therapeutic range is 13.5 to 22 seconds, so B is correct. A. The value of 12.5 seconds is sub-therapeutic. C. D. The values of 26 and 30 seconds are above therapeutic.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

32. ANS: C
A fever is a manifestation of acute endocarditis. A. B. D. Dry cough, ankle edema, and weight gain are not manifestations of acute endocarditis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

33. ANS: B
A pericardial friction rub due to inflammation of pericardium is the classic sign of pericarditis. A. In pericarditis, pain occurs with inspiration. C. D. Jugular vein distention and crackles in the lung bases are manifestations of heart failure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

34. ANS: C
Anti-inflammatory medication reduces pericardial inflammation, which decreases pain and should be included in the pain management plan. A. B. D. Beta blockers, antihypertensives, and calcium channel blockers do not treat inflammation or pain.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

35. ANS: A
The RN and physician should be notified so coagulation testing can be done to determine what to do with the heparin drip and warfarin, which can cause bleeding. C. Turning off the heparin infusion is not within the licensed practical nurses (LPNs) scope of practice. B. D. Offering a saline mouth rinse or gargling with mouthwash can be done later.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

36. ANS: C
Duplex venous scanning confirms thrombophlebitis. A. B. D Chest x-ray, intravenous pyelogram, or arterial Doppler ultrasound is not used to diagnose thrombophlebitis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

37. ANS: D
Homans sign is performed prior to confirmation of thrombophlebitis by dorsiflexing the patients foot sharply and asking if calf pain occurred. Pain is positive for thrombophlebitis. A. B. C. These approaches are not used to determine the presence of a Homans sign.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

38. ANS: B
Partial thromboplastin time (PTT) monitors the effects of heparin. A. C. D. These laboratory tests are not used to monitor the effectiveness of heparin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

39. ANS: D
Rheumatic heart disease is a complication of a strep infection. A. B. C. Pericarditis, rheumatic fever, and cardiomyopathy are not complications from a strep infection.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

40. ANS: C
A consequence of all types of cardiomyopathy can be heart failure. A. B. D. Cardiomyopathy is not associated with angina, pericarditis, or myocardial infarction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

41. ANS: B
Cardiac tamponade is a life-threatening compression of the heart by fluid accumulated in the pericardial sac. A. C. D. Emboli formation and changes in cardiac workload or output are not typically associated with pericarditis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

42. ANS: C
With myocarditis, the heart is sensitive to digoxin, which may be used to treat heart failure, and toxicity may occur even with small doses. A. B. D. Digoxin (Lanoxin) is not associated with inflammation. The patients at risk for increased and not decreased toxicity.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

43. ANS: C
The patient likely has a pulmonary embolus, which is a life-threatening condition and requires prompt medical intervention. A. B. D. Sudden dyspnea, tachypnea, restlessness and chest pain are not all associated with pulmonary edema, respiratory arrest, or myocardial infarction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

44. ANS: D
INR is used to monitor the effects of Coumadin. A. B. C. These laboratory tests are not used to monitor the effects of Coumadin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

45. ANS: B
The patient is at risk for injury due to a high INR, which indicates the patient is at risk for bleeding. A. C. D. An elevated INR increases the patients risk for bleeding and has no impact on pain, infection, breathing pattern.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

46. ANS: D
The evidence shows that use of combined treatments for those at high risk for venous thromboembolism is more effective than a single treatment. A. B. C. These approaches use single treatment for the prevention of deep vein thromobosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

47. ANS: B
To promote comfort with position changes, the nurse should encourage the patient to splint the chest incision with a pillow for all movement. This will stabilize the sternum and incision to increase comfort. A. C. D. Holding the breath, bending the knees, or lifting the head off of the bed will not increase the patients comfort with movement.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort| Cognitive Level: Application

MULTIPLE RESPONSE

48. ANS: C, D, E
Antibiotic prophylaxis guidelines have been updated. Before a dental procedure, the American Heart Association (2014) now recommends that only individuals with an artificial heart valve or a valve repaired with artificial material, a history of endocarditis, a heart transplant with abnormal valve function, or specific congenital heart defects receive antibiotics. Prophylaxis for procedures on the genitourinary or gastrointestinal tract or for most people who have orthopedic implants is no longer recommended.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

49. ANS: A, B, C, E, F
All actions should be performed for this patient except for D because the patient will likely be cool from surgery and need warming.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

50. ANS: A, C
Mechanical valves, which are man-made, create turbulent blood flow so they require lifelong anticoagulation, but they are the most durable. Valves can be dilated via percutaneous balloon procedures in less severe cases, but artificial valves are not placed this way.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

51. ANS: A, B, C, D, F
All findings indicate the patient is improving except for E. Cool pale extremities with diminished peripheral pulses indicate circulatory problems.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

52. ANS: A, B, C
A, C. Scheduling activities in small amounts and providing small meals that require less energy to digest than large meals reduce strain on the heart. B. Hydration is important to maintain cardiac output. D. Avoid alcohol as it decreases cardiac function. E. Strenuous exercise and athletic sports are restricted to prevent sudden death. F. Pulse does not need to be taken with these two medications.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

53. ANS: A, B, C, D
Angina pectoris (chest pain) is the primary symptom that occurs as a result of a lack of oxygen to the myocardium. Other signs and symptoms include a murmur, syncope from dysrhythmias or decreased cardiac output, and heart failure signs and symptoms. Orthopnea, dyspnea on exertion, and fatigue are indicators of left ventricular failure, resulting in pulmonary edema and right sided heart failure. E. A change in oxygen saturation level is not a manifestation of aortic stenosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential| Cognitive Level: Application

54. ANS: A, C, D, E
When planning care for the patient with decreased cardiac output because of a cardiac valve disorder the nurse should provide oxygen as prescribed, elevate the head of the bed 45 degrees, encourage frequent rest periods, and assess vital signs and oxygen saturation. B. A fluid restriction is not an appropriate intervention for this nursing diagnosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential| Cognitive Level: Application

55. ANS: B, C, E
Low calcium and magnesium and high potassium levels decrease contractility and cardiac output. A. D. Sodium and glucose levels are not identified as influencing cardiac output.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential| Cognitive Level: Application

56. ANS: A, B, D, E
Evidence of infection in the patient recovering from valve replacement surgery includes cloudy urine, lung crackles, fever, and yellow-green sputum. C. Incisional pain is not an indication of infection in this patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

COMPLETION

57. ANS:
2, two
0.25 mg 1 tablet = 2 tablets
0.125 mg
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

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