Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder My Nursing Test Banks

Chapter 47: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.The nurse is aware that the muscle layer of the heart, which is responsible for the hearts contraction, is the:

a. endocardium.
b. pericardium.
c. mediastinum.
d. myocardium.

ANS: D

The myocardium is the specialized muscle layer that allows the heart to contract.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1533

OBJ: 2 TOP: Myocardium KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2.The nurse clarifies that the master pacemaker of the heart is the:

a. left ventricle.
b. atrioventricular (AV) node.
c. sinoatrial (SA) node.
d. bundle of His.

ANS: C

The SA node is the master pacemaker of the heart.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1533

OBJ:10TOP:Acute myocardial infarction

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

3.The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having:

a. hepatitis A.
b. indigestion.
c. urinary infection.
d. menopausal complications.

ANS: B

Indigestion, gallbladder attack, anxiety attack, and depression are frequent misdiagnoses for women having an MI.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1559

OBJ:16TOP:MIs in women

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

4.The nurse identifies the LUBB sound of the LUBB/DUBB of the cardiac cycle as the sound of the:

a. AV valves closing.
b. closure of the semilunar valves.
c. contraction of the papillary muscles.
d. contraction of the ventricles.

ANS: A

The LUBB is the first sound of a low pitch heard when the AV valves close.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1535

OBJ: 4 TOP: Lubb sound KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

5.A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patients condition as:

a. moderate heart failure.
b. severe heart failure.
c. congestive heart failure.
d. negligible heart failure.

ANS: B

Class IV: Severe; patient unable to perform any physical activity without discomfort. Angina or symptoms of cardiac inefficiency may develop at rest.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1565, Box 47-3

OBJ:9TOP:Classification of heart failure

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6.The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a:

a. stage A.
b. stage B.
c. stage C.
d. stage D.

ANS: A

The ACC/AHA staging describes stage A as a person without symptoms of heart failure, but with primary conditions associated with the development of the disease.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3

OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

7.The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says:

a. I can ambulate in the hallway with this gadget on.
b. I always take off the telemetry device when I shower.
c. My EKG is being watched by one of the nurses in CCU on the home unit.
d. I am able to sleep just fine with this device on.

ANS: B

Remote telemetry allows the patient to be on a separate unit, but be monitored in a central location. The patients can be ambulatory and can sleep with the monitor on. They should not remove the monitor to shower.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1539

OBJ:6TOP:Remote telemetry

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

8.The nurse assesses pitting edema that can be depressed approximately  inch and refills in 15 seconds. The nurse would document this assessment as:

a. +1 edema.
b. +2 edema.
c. +3 edema.
d. +4 edema.

ANS: B

A +2 edema can be documented if the skin can be depressed  inch and respond within 15 seconds.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Table 47-5

OBJ:9TOPitting edema

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9.What do dark or cold spots on a thallium scan indicate?

a. Tissue with adequate blood supply
b. Dilated vessels
c. Areas of neoplastic growth
d. Tissue that has inadequate perfusion

ANS: D

Thallium scans show adequate perfused areas by the collection of thallium. Dark spots or cold spots indicate tissues that have inadequate perfusion.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1539

OBJ:6TOP:Thallium scan

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

10.The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of:

a. normal heart action.
b. mild heart failure.
c. moderate heart failure.
d. severe heart failure.

ANS: C

An ejection factor (cardiac output) of 42% indicates moderate heart failure.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1540

OBJ: 6 TOP: Heart failure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

11.The nurse takes into consideration that age-related changes can affect the peripheral circulation because of:

a. sclerosed blood vessels.
b. hypotension.
c. inactivity.
d. poor nutrition.

ANS: A

Aging causes sclerotic changes in the blood vessels that lead to decreased elasticity and narrowing of the vessel lumen.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1542, Lifespan

OBJ: 16 TOP: Endocarditis KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

12.The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as:

a. sinus bradycardia.
b. atrial fibrillation.
c. sinus tachycardia.
d. ventricular tachycardia.

ANS: C

Sinus tachycardia has a P wave followed by the QRS and the T. All the components of the complex are present and in the correct order, but the rate is over 100 beats a minute.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1545

OBJ: 8 TOP: Arrhythmias KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

13.After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of:

a. congestive heart failure.
b. heart block.
c. aortic stenosis.
d. infective endocarditis.

ANS: D

Collection of subjective data includes noting patient complaints of influenza-like symptoms with recurrent fever, undue fatigue, chest pain, and chills. Objective data may reveal the significant signs of petechiae in the conjunctiva and mouth. Both subjective data and objective data are indicative of infective endocarditis.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1576

OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

14.The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into:

a. atrial fibrillation and possible emboli.
b. sinus tachycardia and syncope.
c. ventricular tachycardia and death.
d. sinus bradycardia and fatigue.

ANS: C

PVCs are capable of progressing into ventricular tachycardia and death.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1547

OBJ: 10 TOP: PVCs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

15.The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between:

a. 1 and 2.
b. 2 and 3.
c. 3 and 4.
d. 4 and 5.

ANS: B

The desired INR for the monitoring of anticoagulant therapy is between 2 and 3.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1546

OBJ: 8 TOP: INR KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

16.What should a person with unstable angina avoid?

a. Walking outside
b. Eating red meat
c. Swimming in warm pool
d. Shoveling snow

ANS: D

The person with angina should avoid exposure to cold, heavy exercise, eating heavy meals, and emotional stress.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1552

OBJ: 9 TOP: Angina KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

17.The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurses most helpful response would be:

a. Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.
b. If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital.
c. When nitroglycerin is not relieving the pain, lie down and rest.
d. Use oxygen at home to relieve pain when nitroglycerin is not successful.

ANS: B

Administer prescribed nitroglycerin. Repeat every 5 minutes, three times. If pain is unrelieved, notify the physician. Nitroglycerin administered sublingually usually relieves angina symptoms but does not relieve the pain from an MI. Administering nitroglycerin more than three times will probably not relieve the pain.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1545

OBJ:9TOP:Angina pectoris

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

18.The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurses immediate course of action would be to:

a. reteach him about his medications.
b. have a serious talk with him and his family about compliance.
c. arrange for home visits after discharge.
d. collect more information to identify his reasons for noncompliance.

ANS: D

Nursing interventions include measures to prevent disease progression and complications. Reteaching about medication will not identify the cause of noncompliance.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1556

OBJ:18TOP:Noncompliance

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

19.What is the major cause of cardiac valve disease?

a. Rheumatic fever
b. Long history of malnutrition
c. Drug abuse
d. Obesity

ANS: A

Rheumatic fever, a streptococcal infection, is the major cause of cardiac valve disease.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1572

OBJ:10TOP:Valvular disease

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

20.The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurses reaction is one of:

a. satisfaction. This is good cholesterol control.
b. determination. This is evidence that more instruction is necessary.
c. inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol.
d. regret. This shows very poor cholesterol control.

ANS: A

Total cholesterol of less than 200 is desirable. The higher the number of HDLs the better. A high number of LDLs puts the patient at risk for heart disease.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1541, Box 47-1

OBJ:6TOP:Lipid studies

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

21.A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include:

a. substernal pain that radiates down the left arm.
b. epigastric pain that radiates to the jaw.
c. indigestion, nausea, and eructation.
d. fatigue, shortness of breath, and dyspnea.

ANS: A

The pain often radiates down the left inner arm to the little finger and also upward to the shoulder and jaw.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1553, figure 47-1

OBJ:9TOP:Angina pectoris

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

22.A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage?

a. CK-MB
b. Elevated white count
c. Elevated sedimentation rate
d. Low level of sodium

ANS: A

The CK-MB is elevated when there is infarcted myocardial muscle. The elevated white count, low sodium, and ESR are nonspecific.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1559

OBJ: 6 TOP: CK-MB KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

23.The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young

adults who have minimal risk factors for cardiovascular disease is related to which factor(s)?

a. Cocaine use
b. Viral infections
c. Vitamin B1 deficiencies
d. Pregnancy

ANS: A

Cardiomyopathy caused by cocaine abuse is seen more frequently than ever before. Cocaine also causes high circulating levels of catecholamines, which may further damage myocardial cells, leading to ischemic or dilated cardiomyopathy. The cardiomyopathy produced is difficult to treat. Interventions deal mainly with the HF that ensues.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1578

OBJ:14TOP:Cardiomyopathy

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

24.The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?

a. Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.
b. Place patient in side-lying position to reduce the symptoms of atrial fibrillation.
c. Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.
d. Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.

ANS: C

Signs and symptoms of pulmonary edema are restlessness; vague uneasiness; agitation; disorientation; diaphoresis; severe dyspnea; tachypnea; tachycardia; pallor or cyanosis; cough producing large quantities of blood-tinged, frothy sputum; audible wheezing and crackles; and cold extremities. The legs in a dependent position will decrease venous return and ease the pulmonary edema.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1572

OBJ:12TOPulmonary edema

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

25.The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which method to avoid the Valsalva maneuver during a bowel movement?

a. Mouth breathing
b. Pursing the lips and whistling
c. Taking a deep breath and holding it
d. Breathing rapidly through the nose

ANS: A

Mouth breathing will lessen the severity of straining and will decrease the effect of the Valsalva maneuver on intrathoracic pressure.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1562

OBJ: 9 TOP: MI KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

26.The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommends a lipid study every _________ years.

a. 2
b. 3
c. 4
d. 5

ANS: D

The National Heart, Lung, and Blood Institute recommend a lipid study every 5 years for all Americans, but especially for the older adult.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1542

OBJ:6TOP:Lipid studies

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

27.During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure?

a. I have to sleep in my recliner and I have this hacking cough.
b. I have no appetite and I have lost 3 lb in the last week.
c. I have to urinate every 2 hours, even during the night.
d. I go barefoot most of the time because my feet are so hot.

ANS: A

Left ventricular failure; the first is signs and symptoms of decreased cardiac output. The second is pulmonary congestion. Signs and symptoms of this condition include dyspnea, orthopnea, pulmonary crackles, hemoptysis, and cough.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1565, Box 47-3

OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

28.The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask?

a. Do you have a toothache?
b. Have you contacted your physician about your dental appointment?
c. Is your dentist board certified?
d. Do you think you should wait that long for your tooth extraction?

ANS: B

Patients with endocarditis are put on a protocol of prophylactic antibiotics for any invasive procedure. The dentist and physician should be contacted before the extraction.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1574

OBJ: 13 TOP: Endocarditis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

29.The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can:

a. cause severe episodes of diarrhea.
b. cause a severe skin eruption if taken with Coumadin.
c. increase the action of the Coumadin.
d. cause the Coumadin to be less effective.

ANS: C

Herbal remedies such as ginkgo, garlic, angelica, and red clover can increase (potentiate) the action of the Coumadin.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1589

OBJ: 21 TOP: Coumadin KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

30.What is the difference between primary and secondary hypertension?

a. Secondary hypertension is caused by another disorder like renal disease.
b. Secondary hypertension is related to hereditary factors.
c. Secondary hypertension cannot be treated effectively.
d. Secondary hypertension is no real threat to health.

ANS: A

Secondary hypertension is a consistently elevated blood pressure that is caused by another disorder, such as renal disease, diabetes, or Cushing syndrome.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1584

OBJ:18TOP:Secondary hypertension

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

31.The nurse is treating a patient who has had a pacemaker inserted for the correction of atrial fibrillation. Which diagnostic test is no longer available to the patient because of the implanted device?

a. MRI
b. CT scan
c. Thallium scan
d. PET

ANS: A

Because of the large magnets in the MRI cabinet, the pacemaker may be reset to a fixed mode and interfere with the functioning of the pacemaker.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1551

OBJ: 10 TOP: Pacemaker KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

32.Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?

a. Cool dry lower limb
b. Edematous, red scaly skin on medial surface of the leg
c. Lack of hair and shiny appearance of the lower leg
d. Lack of a pedal pulse

ANS: B

Suggestion of a stasis ulcer in the making is an edematous, dry scaly area on the medial surface of the lower leg that has a darker pigmentation (rubor). Cool hairless limbs with absent or weak pedal pulses are indicative of arterial insufficiency.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1582

OBJ: 21 TOP: Medications KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

33.What is the patient goal of the walking exercise program designed for the rehabilitation of a post-MI patient?

a. Walk 2 miles in less than 60 minutes after 12 weeks.
b. Jog  mile in less than 30 minutes after 12 weeks.
c. Fast walk 1 mile in less than 20 minutes after 12 weeks.
d. Walk 1 mile in 15 minutes without dyspnea after 12 weeks.

ANS: A

The goal of the 12-week walking program is that the patient can walk 2 miles in less than 60 minutes.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1563, Home Care

OBJ:11TOP:Cardiac rehab

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

34.The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patients right leg and dorsiflexes the foot?

a. Pain, which would be a positive Homans sign
b. Muscular spasm, which would be a sign of hypocalcemia
c. Rigidity, which would be a sign of ankylosis
d. Crepitus, which would be a sign of a joint disorder

ANS: A

A positive Homans sign for deep vein thrombosis (DVT) is a report of pain when the affected leg is flexed and the foot is dorsiflexed.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1595

OBJ: 21 TOP: DVT KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

35.How should the nurse advise a patient with an international normalized ratio (INR) of 5.8?

a. Make arrangements to go to the emergency room immediately
b. Increase fluid intake to 2000 mL/day
c. Stop taking the anticoagulant and notify health care provider
d. Add more leafy green vegetables to patient diet

ANS: C

The INR that is desired should be maintained between 2 and 3. A reading of 5.8 puts the patient at risk for hemorrhage. The patient should stop taking the anticoagulant and contact the physician for further instruction.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1546

OBJ:6TOP:Myocardial infarction

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

36.The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for:

a. reduction of alcohol intake.
b. avoiding cold remedies.
c. cessation of smoking.
d. weight reduction.

ANS: C

The hazards of cigarette smoking and its relationship to Buerger disease are the primary focus of patient teaching. None of the palliative treatments are effective if the patient does not stop smoking. Nowhere are the cause and effect of smoking so dramatically seen as with Buerger disease.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1594

OBJ:20TOP:Buerger disease

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

37.Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)?

a. I eat a banana every morning with breakfast.
b. I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.
c. I try to eat a well-balanced, low-fat diet.
d. I dont drink alcohol or caffeine.

ANS: B

Avoid marked changes in eating habits, such as dramatically increasing foods high in vitamin K (e.g., broccoli, spinach, kale, greens). Limit alcohol intake to small amounts.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1597

OBJ: 10 TOP: Warfarin KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

38.The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause:

a. hypotension.
b. thrombophlebitis.
c. pulmonary emboli.
d. heart failure.

ANS: D

Heart failure can result from rapid infusion of intravenous fluids in older adults.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1542, Lifespan

OBJ: 9 TOP: Heart failure KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

39.The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times?

a. Late in the afternoon
b. At bedtime
c. With any meal
d. In the morning

ANS: D

Diuretics should be scheduled for morning administration to avoid causing the patient nocturia.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1567, Table 47-6

OBJ: 12 TOP: Lasix KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

40.The nurse would assess closely for signs of right-sided heart failure which include (select all that apply):

a. cough.
b. increasing abdominal girth.
c. shortness of breath.
d. edema of feet and ankles.
e. distended jugular veins.
f. orthopnea.

ANS: B, D, E

Indicators of right-sided heart failure are distended jugular veins, anorexia, abdominal distention from ascites, liver enlargement with right upper quadrant pain, and edema of feet and ankles.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1563, Box 47-4

OBJ:9TOP:Right-sided heart failure

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

41.The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.)

a. Warming hands and feet with a heating pad
b. Using mittens in cold weather
c. Practicing stress-reducing techniques
d. Complete smoking cessation
e. Using caution when cleaning the refrigerator or freezer

ANS: B, C, D, E

Nursing interventions include patient teaching in techniques for stress reduction, avoiding exposure to cold, and techniques for smoking cessation.

PTS:1DIF:Cognitive Level: Analysis

REF: Page 1595, Nursing Care Plan OBJ: 20 TOP: Raynaud disease

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

42.Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder? (Select all that apply.)

a. Increase the dose of aspirin for better therapy.
b. Take medication at the same time each day.
c. Report to physician cuts that do not stop bleeding with direct pressure.
d. No restrictions for food or drink.
e. Report for prescribed blood tests (PTT, INR, CBC, blood sugar).

ANS: B, C

Aspirin should not be used with anticoagulant therapy because it will increase bleeding. Gums, nosebleeds, excessive bruising, and cuts that do not stop bleeding with direct pressure should be reported to the physician. Alcohol and dark green and yellow vegetables should be avoided because they contain vitamin K. Normal blood tests for anticoagulant therapy are PTT, INR, and PT.

PTS:1DIF:Cognitive Level: Analysis

REF: Page 1591, Nursing Care Plan OBJ: 10 TOP: Anticoagulant therapy

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

43.What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.)

a. Detect thrombi before a cardioversion
b. Check for cardiac arrhythmias
c. Visualize vegetation on the heart valves
d. Measure effectiveness of diuretic therapy
e. Visualize abscesses on the heart valves

ANS: A, C, E

The TEE is used to check for thrombi before cardioversion, and to visualize vegetation and abscesses on the valves of the heart.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1592

OBJ: 16 TOP: TEE KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

44.Which patient teaching would help to prevent venous stasis? (Select all that apply.)

a. Dangle legs when sitting
b. Avoid crossing legs at the knee
c. Elevate legs when lying in bed or sitting
d. Massage extremities to help maintain blood flow
e. Wear elastic stockings when ambulating

ANS: B, C, E

Avoid prolonged sitting or standing. Avoid crossing the legs at the knee.

Elevate legs when sitting. Wear elastic stockings when ambulatory. Do not massage extremities because of danger of embolization of clots (thrombus breaking off and becoming an embolus).

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1597

OBJ:16TOP:Thrombophlebitis

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

45.The nurse points out which of the following as modifiable risks for coronary artery disease (CAD)? (Select all that apply.)

a. Diabetes mellitus
b. Heredity
c. Smoking
d. Hypertension
e. Hyperlipidemia
f. Age

ANS: A, C, D, E

Modifiable risks for the development of CAD include smoking, hyperlipidemia, hypertension, diabetes mellitus, obesity, sedentary lifestyle, and stress.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1544-1545

OBJ:7TOP:Modifiable risks for CAD

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

46.The nurse outlines which of the following as conditions that would disqualify a candidate for a heart transplant? (Select all that apply.)

a. Recent malignancy
b. Dilated cardiomyopathy
c. Peptic ulcer disease
d. Diabetes type 2
e. Severe obesity
f. Inoperable coronary artery disease

ANS: A, C, E

Contraindications for candidacy for cardiac transplant include recent malignancy, active peptic ulcer disease, severe obesity, diabetes type 1 with end-organ damage. Dilated cardiomyopathy and inoperable coronary artery disease are indications for transplant.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1579, Box 47-7

OBJ:15TOP:Contraindications for cardiac transplant

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

47.When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.)

a. Pain radiating to left arm and jaw
b. Hypertension
c. Pallor
d. Diaphoresis
e. Erratic behavior
f. Cardiac rhythm changes

ANS: B, C, D, E, F

Hypertension, vomiting, diaphoresis, hypotension, pallor, and cardiac rhythm changes are objective data seen in patients with an MI.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1558, Table 47-2

OBJ:10TOP:Myocardial infarction

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

48.Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.)

a. Ringing in the ears
b. Bradycardia
c. Headache
d. Visual disturbance
e. Hematuria
f. Gastrointestinal complaints

ANS: B, C, D, F

Major signs of digoxin toxicity are nausea, bradycardia (HR <60), headache, and visual disturbances, as well as fatigue and arrhythmias.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1548, Table 47-1

OBJ:10TOPigitoxin toxicity

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

49.The nurse encourages the patient who is recovering from a myocardial infarct (MI) to ask the health care provider to prescribe a cardiac rehabilitation series in order to learn to (select all that apply):

a. improve stamina.
b. strengthen muscles.
c. plan an appropriate diet.
d. select herbal remedies.
e. reduce risk of further problems.
f. understand heart condition.

ANS: A, B, E, F

Cardiac rehabilitation offers exercise programs to increase strength and increase stamina. Educational opportunities are offered on reduction of risk and understanding the disease process.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1563

OBJ:11TOP:Cardiac rehab

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance

50.Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for (select all that apply):

a. checking pedal pulses.
b. ambulating with assistance 2 hours after recovery.
c. checking color and warmth of left leg frequently.
d. sandbagging over insertion site.
e. placing patient in semi-Fowler position.

ANS: A, C, D

The pulses below the insertion site are checked to ensure patency of the vessels; the color and warmth of the left extremity is checked to ensure adequate circulation. A sandbag or other pressure device is placed over the insertion site. The patient is maintained in a supine position for several hours postprocedure.

PTS: 1 DIF: Cognitive Level: Application REF: Page 1537

OBJ: 6 TOP: Angiogram KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

51.The cardiac marker ___________ rises 3 hours after a myocardial infarct and measures myocardial contractile protein.

ANS:

troponin I

Troponin I is a serum cardiac marker that rises 3 hours after an MI and can measure myocardial contractile tissue. Troponin I is not affected by skeletal muscle injury as is troponin T.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1541

OBJ: 6 TOP: Troponin I KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

52.The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is ________.

ANS:

advanced cardiac life support (ACLS)

advanced cardiac life support

ACLS

ACLS is a life support system that uses special techniques, ventilation equipment, and therapies for emergency situations.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1550

OBJ: 9 TOP: ACLS KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

53.The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called ____________.

ANS:

automaticity

Automaticity is the special ability of the myocardium to contract in a rhythmic pattern.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1534

OBJ:2TOP:Automaticity

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

54.The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost ______ L of fluid.

ANS:

3

A liter of fluid equals 2.2 lb. A loss of 6.6 lb would mean the loss of 3 L of fluid.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1564

OBJ: 9 TOP: Fluid loss KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

55.The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is ______________ _____________.

ANS:

intermittent claudication

Intermittent claudication is a pain caused by ischemia when a person with arterial insufficiency exerts to the point that the tissues have inadequate oxygen-rich blood. The pain is relieved by rest.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1581

OBJ:9TOP:Intermittent claudication

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

56.The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a ____________.

ANS:

cardioversion

Cardioversion is the restoration of the hearts normal sinus rhythm with the delivery of synchronized electric shock.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1540

OBJ: 10 TOP: Cardioversion KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

OTHER

57.Trace the impulse pattern of conduction in sequence through the heart. (Separate letters by a comma and space as follows: A, B, C, D)

a. Atrial wall

b. Atrial-ventricular (AV) node

c. Purkinje fibers

d. Sinoatrial (SA) node

e. Bundle branches

f. Bundle of His

ANS:

B, A, D, F, E, C

The conduction begins with the impulse from the SA node that travels down the atrial wall to the AV node, to the Bundle of His, to the bundle branches, and finally to the Purkinje fibers.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1535-1534

OBJ: 3 TOP: Conduction KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

58.Arrange in sequence the path of the blood through the coronary circulation. (Separate letters by a comma and space as follows: A, B, C, D)

a. Right atrium

b. Pulmonary artery

c. Tricuspid valve

d. Right ventricle

e. Superior and inferior vena cava

f. Pulmonary vein

g. Left atrium

h. Mitral valve

i. Left ventricle

j. Lungs

ANS:

E, A, C, D, B, J, F, G, H, I

The blood travels through the vena cava to the right atrium, through the tricuspid valve to the right ventricle, through the pulmonary artery to the lungs. The pulmonary veins deliver the blood to the left atrium, then through the mitral valve to the left ventricle and out the aorta to the body.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1535, Figure 47-4

OBJ: 5 TOP: Path of blood through heart KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity

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