Chapter 51 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 51

Question 1

Type: MCSA

After a cardiac catheterization, an infant is diagnosed with a malformation of the mitral valve. The nurse will monitor the client for the development of a problem associated with the delivery of

1. oxygenated blood to the body.

2. deoxygenated blood to the lung.

3. oxygenated blood to the right atrium.

4. deoxygenated blood to the left ventricle.

Correct Answer: 1

Rationale 1: The mitral valve separates the left ventricle from the left atrium. Problems with this valve will impede the flow of oxygenated blood from the left atrium into the left ventricle for delivery to the body.

Rationale 2: The pulmonic valve separates the right ventricle from the pulmonary artery. Problems with this valve would impede the delivery of deoxygenated blood back to the lung.

Rationale 3: The blood that returns to the right atrium is deoxygenated.

Rationale 4: The blood delivered to the left ventricle is oxygenated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe three major alterations in cardiovascular function.

MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment.

Page Number: 1287

Question 2

Type: MCSA

During assessment, the nurse notes a cardiac murmur that occurs between S1 and S2. The nurse documents this murmur as being

1. diastolic.

2. holosystolic.

3. systolic.

4. pansystolic.

Correct Answer: 3

Rationale 1: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. The period of time between S2 and the next S1 is diastole.

Rationale 2: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. Holosystolic is not a type of murmur.

Rationale 3: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. The period of time between S2 and the next S1 is diastole.

Rationale 4: The period of the cardiac cycle between S1 and S2 is ventricular systole. Any extra heart sounds heard during this period of time would be documented as systolic. Pansystolic is not a type of murmur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Outline the structure and physiology of the cardiovascular system.

MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment.

Page Number: 1289

Question 3

Type: MCMA

The nurse is planning teaching for a client that focuses on Healthy People 2020 objectives for cardiovascular health. Which modifiable risk factors should the nurse include in this teaching?

Standard Text: Select all that apply.

1. Age

2. Gender

3. Obesity

4. Smoking

5. Hypertension

Correct Answer: 3, 4, 5

Rationale 1: Age is a nonmodifiable risk factor.

Rationale 2: Gender is a nonmodifiable risk factor.

Rationale 3: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include obesity.

Rationale 4: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include smoking.

Rationale 5: Many of the Healthy People 2020 objectives for cardiovascular health relate to modifiable risk factors. Modifiable risk factors include hypertension.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Identify major risk factors for the development of cardiovascular disease and related health-promotion objectives from Healthy People 2020.

MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment.

Page Number: 1294

Question 4

Type: MCSA

The client has experienced a myocardial infarction with damage to the inferior portion of the heart. Due to this history, the nurse monitors the client for the development of rhythm disturbances that are most directly based upon which factor?

1. The resultant change in blood sugar

2. Electrolyte disturbances from tissue damage

3. The automaticity of cardiac cells

4. Decreased blood flow to the liver

Correct Answer: 3

Rationale 1: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. Although extreme changes in blood sugar can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable.

Rationale 2: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. Although electrolyte disturbances can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable.

Rationale 3: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. The most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable.

Rationale 4: Each cardiac cell can generate its own electrical impulse. Myocardial infarction interferes with the flow of blood to these cells, and the resultant ischemia makes the cells more irritable and more likely to generate an impulse. These uncontrolled impulses result in rhythm disturbances. Although extreme changes in blood flow to the liver can result in cardiac disturbances, the most likely cause of rhythm disturbance following myocardial infarction is insult to the cells causing them to be irritable.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe three major alterations in cardiovascular function.

MNL Learning Outcome: 4.10.3. Relate the factors that alter cardiac function to clinical manifestations and treatment.

Page Number: 1290

Question 5

Type: MCSA

A client has a heart rate of 170 beats per minute. For what will the nurse assess next in this client?

1. Increased cardiac output

2. Increased preload

3. Decreased afterload

4. Decreased cardiac output

Correct Answer: 4

Rationale 1: Cardiac output equals stroke volume x heart rate. Because this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease.

Rationale 2: Preload refers to the degree to which muscle fibers in the ventricle are stretched at the end of the relaxation period.

Rationale 3: Afterload is reflective of systemic vascular resistance.

Rationale 4: Cardiac output equals stroke volume x heart rate. Because this client has a sustained rapid heart rate, the ventricles are most likely not having sufficient time to relax and refill between contractions, so the stroke volume will decrease. At the rate of 170, the compensatory increase in heart rate is no longer helpful in increasing cardiac output. This leads to a decrease in cardiac output.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1290

Question 6

Type: MCSA

The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value should the nurse review first while assessing this complaint?

1. Blood urea nitrogen

2. Hemoglobin and hematocrit

3. Blood sugar

4. Serum potassium

Correct Answer: 2

Rationale 1: The clients symptoms may or may not be associated with the blood urea nitrogen level.

Rationale 2: Hemoglobin is the oxygen-carrying portion of the blood, and anemia (decrease in hemoglobin and hematocrit) is often associated with client complaints of being tired, listless, and unable to tolerate normal activities.

Rationale 3: These symptoms may or may not be seen in a client with an alteration in the blood sugar level.

Rationale 4: These symptoms may or may not be seen in a client with an altered serum potassium level.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1293

Question 7

Type: MCSA

The nurse assessing a 1-day-old infant discovers the heart rate is 140 and irregular. What action should the nurse take?

1. Immediately contact the infants physician.

2. Prepare to resuscitate the infant.

3. Note this normal finding in the infants medical record.

4. Stimulate the infant gently.

Correct Answer: 3

Rationale 1: There is no need to contact the infants physician.

Rationale 2: This infant does not need resuscitation.

Rationale 3: An irregular heart rate of 140 is common and normal in an infant of this age. The finding should be recorded in the medical record.

Rationale 4: This infant does not need stimulation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1293

Question 8

Type: MCSA

The 50-year-old who is postmenopausal asks the nurse about the use of estrogen replacement therapy to protect the heart. How should the nurse respond?

1. This therapy is well proven to protect the heart in postmenopausal women.

2. Estrogen replacement therapy is helpful to reduce the sleep disturbances and hot flashes associated with menopause, but does not protect the heart.

3. Estrogen replacement therapy has been proven to have no effect on any postmenopausal symptoms and is not protective of the heart.

4. The use of estrogen replacement therapy is complex and requires a thoughtful review of the balance between possible benefits and possible risks.

Correct Answer: 4

Rationale 1: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk.

Rationale 2: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk.

Rationale 3: Research on estrogen replacement therapy is ongoing. Currently, it is thought that there may be some benefit in reducing cardiac risk.

Rationale 4: There is some concern about the risk of administering this therapy and the development of other health problems such as cancers. The choice to use this therapy should be made only after careful consideration of these benefits and risks.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1301

Question 9

Type: MCSA

The postmyocardial infarction client asks the nurse about return to exercise. What information should the nurse give this client?

1. It is better to exercise when it is cold.

2. Environmental temperatures have little impact on cardiac function.

3. Avoid exercise when the weather is hot or cold.

4. Hot temperatures increase peripheral blood vessel contraction.

Correct Answer: 3

Rationale 1: Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood.

Rationale 2: The nurse should advise the client to avoid exercise in hot or cold weather, as these extremes of temperature increase the workload on the heart.

Rationale 3: The nurse should advise the client to avoid exercise in hot or cold weather, as these extremes of temperature increase the workload on the heart. Cold temperatures increase peripheral blood vessel contraction and therefore peripheral vascular resistance, making it more difficult for the heart to circulate blood. Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the hearts workload.

Rationale 4: Hot temperatures decrease systemic vascular resistance by dilating peripheral vessels. This decrease makes the heart rate increase, thereby increasing the hearts workload.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1301

Question 10

Type: MCSA

What dietary teaching should the nurse provide to the client who has homocysteine elevation?

1. Reduce salt intake.

2. Take a B-complex vitamin supplement daily.

3. Increase fluid intake to 2,000 mL per day.

4. Avoid alcohol intake.

Correct Answer: 2

Rationale 1: Although reduction of salt intake may help to prevent hypertension, there is no connection to homocysteine levels.

Rationale 2: Supplementation with a vitamin that provides folate, vitamin B6, vitamin B12, and riboflavin can reduce homocysteine levels, although results can vary.

Rationale 3: An increase in fluid intake is not associated with decreased homocysteine levels.

Rationale 4: Alcohol in moderation can reduce the risk of heart disease.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1296

Question 11

Type: MCSA

The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse should be most concerned about the clients potential to develop

1. renal failure.

2. gangrene.

3. myocardial infarction.

4. stroke.

Correct Answer: 4

Rationale 1: Renal failure would result from atherosclerotic changes in the renal artery.

Rationale 2: Gangrene may occur if atherosclerosis reduces blood flow to the extremities.

Rationale 3: Myocardial infarction results from atherosclerosis of the coronary arteries.

Rationale 4: Transient ischemic attacks may result from atherosclerosis of the cerebral vessels. Continued development of this atherosclerosis may result in stroke.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Describe three major alterations in cardiovascular function.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1298

Question 12

Type: MCSA

The nurse is assessing a newly admitted client for the presence of impaired peripheral arterial circulation. Which finding would be significant to this condition?

1. Ruddy skin color over legs

2. Bounding pedal pulses

3. Hot spots on the feet and legs

4. Decreased hair on the legs

Correct Answer: 4

Rationale 1: The skin color of the legs is more likely to be pale.

Rationale 2: The pulses will be weak.

Rationale 3: The feet and legs will be cool to the touch.

Rationale 4: When peripheral arterial blood flow is reduced, the amount of oxygen to support hair growth is decreased and there is a reduction of hair distribution on the legs.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1298

Question 13

Type: MCSA

The client is admitted with a possible deep vein thrombosis. Nursing interventions should be designed to prevent which complication?

1. Myocardial infarction

2. Renal failure

3. Pulmonary embolism

4. Pneumonia

Correct Answer: 3

Rationale 1: The thrombus is less likely to cause a myocardial infarction.

Rationale 2: The thrombus is not going to cause renal failure.

Rationale 3: The presence of a deep vein thrombosis is a risk factor for the development of a pulmonary embolism. The nurse should design interventions to help prevent that development.

Rationale 4: The thrombus is not going to cause pneumonia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1298

Question 14

Type: MCSA

The nurse is collecting equipment to assess a clients ankle/brachial index (ABI). What equipment should be taken to the clients bedside?

1. Blood pressure cuff and a Doppler ultrasound device

2. None, as no special equipment is needed

3. Stethoscope and penlight

4. Reflex hammer and tuning fork

Correct Answer: 1

Rationale 1: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement.

Rationale 2: The nurse should take a blood pressure cuff and a Doppler ultrasound device to the bedside for this measurement.

Rationale 3: No other equipment is used in this assessment.

Rationale 4: No other equipment is used in this assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1299

Question 15

Type: MCSA

The nurse notes a widely bizarre pattern on the clients cardiac monitor. What is the nurses priority action?

1. Call a code blue.

2. Check the clients pulse.

3. Immediately defibrillate the client.

4. Check the rhythm in a different lead.

Correct Answer: 2

Rationale 1: This is not the first thing that the nurse should do.

Rationale 2: The nurse should always remember to verify any changes on the cardiac monitor by assessing the client (in this case, checking the pulse). The cardiac monitor reports electrical activity that may not directly reflect the mechanical activity occurring in the heart.

Rationale 3: The nurse should not immediately defibrillate the client.

Rationale 4: The nurse should not check the rhythm in a different lead first.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1300

Question 16

Type: MCSA

The nurse is reviewing the laboratory results of a client who is being observed for possible myocardial infarction. Which laboratory result would be most important for the nurse to discuss with the physician?

1. Increased hemoglobin

2. Decreased creatine kinase

3. Increased troponin

4. High normal potassium

Correct Answer: 3

Rationale 1: An increased hemoglobin level is significant; however, it is not the most important result for the nurse to discuss with the physician.

Rationale 2: A decreased creatine kinase level is significant; however, it is not the most important result for the nurse to discuss with the physician.

Rationale 3: Of these options, the most important finding to discuss with the physician is the increase in troponin, which may help diagnose myocardial infarction.

Rationale 4: A high normal potassium level is significant; however, it is not the most important result for the nurse to discuss with the physician.

Global Rationale: Page reference:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1300

Question 17

Type: MCSA

A client exhibits confusion, decreased capillary refill time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement should the nurse choose for this client?

1. Ineffective Tissue Perfusion

2. Decreased Cardiac Output

3. Activity Intolerance

4. Risk for Injury

Correct Answer: 1

Rationale 1: Ineffective Tissue Perfusion is the diagnosis assigned when there is a decrease in oxygenation from failure to nourish tissues at the capillary level.

Rationale 2: Decreased Cardiac Output is the diagnosis assigned when there is inadequate blood pumped by the heart to meet the demands of the body.

Rationale 3: Activity Intolerance is the diagnosis assigned when the client does not have the energy for daily activities.

Rationale 4: Risk for Injury is the diagnosis assigned when the client has an increased chance of being injured.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1300

Question 18

Type: MCSA

A client is on strict bed rest following hip surgery. What nursing intervention would support vascular health?

1. Place pillows under the unaffected knee for support.

2. Position the bed to flex the knees at least 20 degrees.

3. Have the client alternately flex and extend the feet several times a day.

4. Keep the client in a prone position for at least 20 minutes twice a day.

Correct Answer: 3

Rationale 1: Placing pillows under the knees supports the development of clotting.

Rationale 2: Positioning the bed so that the knees are in more than 15 degrees of flexion supports the development of clotting.

Rationale 3: Alternating flexion and extension of the feet will help keep clots from forming in the extremities. Active contraction and relaxation of the calf muscles is also used for this purpose.

Rationale 4: The client would not be placed in the prone (on abdomen) position.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1301

Question 19

Type: MCSA

The nurse finds a client pulseless and breathless. The clients skin is pale and cool, but not cyanotic. Because of this finding, what should the nurse suspect?

1. Respiratory arrest occurred prior to cardiac arrest.

2. Cardiac arrest occurred prior to respiratory arrest.

3. The client cannot be resuscitated.

4. Arrest was caused by airway obstruction.

Correct Answer: 2

Rationale 1: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest.

Rationale 2: In the absence of cyanosis, the logical sequence of events would be cardiac arrest followed by respiratory arrest.

Rationale 3: Unless the client has do-not-resuscitate orders, a code should be called.

Rationale 4: There is no indication that the arrest was caused by airway obstruction or that the client cannot be resuscitated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1304

Question 20

Type: MCSA

A client has a long history of hypertension and has developed heart failure. The nurse should anticipate giving medications for which purpose?

1. To increase preload

2. To decrease afterload

3. To decrease contractility

4. To decrease cardiac output

Correct Answer: 2

Rationale 1: There is no reason to provide medication to increase preload.

Rationale 2: The client likely has developed heart failure secondary to the hypertension, which is an increase in afterload. The nurse would anticipate giving medication to decrease afterload.

Rationale 3: There is no reason to decrease this clients contractility.

Rationale 4: There is no reason to provide medications to decrease this clients cardiac output.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1291

Question 21

Type: SEQ

The nurse is preparing to apply sequential compression devices to a client. In which order should the nurse apply these devices?

Standard Text: Click and drag the options below to move them up or down.

1. Place in the dorsal recumbent or semi-Fowlers position.

2. Place a sleeve under each leg with the opening at the knee.

3. Wrap the sleeve securely around the leg, securing the Velcro tabs.

4. Turn on the control unit and adjust the alarms and pressures as needed.

5. Connect the sleeves to the control unit and adjust the pressure as needed.

Correct Answer: 1, 2, 3, 5, 4


Rationale 1: When applying sequential compression devices, the nurse should first place the client in the dorsal recumbent or semi-Fowlers position.

Rationale 2: The second step is to place a sleeve under each leg with the opening at the knee.


Rationale 3: The third step is to wrap the sleeve securely around the leg, securing the Velcro tabs.


Rationale 4: The fifth step is to turn on the control unit and adjust the alarms and pressures as needed.

Rationale 5: The fourth step is to connect the sleeves to the control unit and adjust the pressure as needed.


Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Verbalize the steps used in: A. Applying a sequential compression device.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1303

Question 22

Type: MCSA

The nurse is planning morning care for a client who has sequential compression devices in place. How should the nurse instruct the UAP who will be giving the bath?

1. Come get me when it is time to remove the devices, because that must be done by a nurse.

2. You may remove the devices, but standards require that only a nurse put them back on the client.

3. You may leave the devices off until the clients legs air dry.

4. Put the devices on as quickly as possible after the bath.

Correct Answer: 4

Rationale 1: The UAP is able to perform this activity.

Rationale 2: The UAP can reapply the devices.

Rationale 3: The UAP should dry the clients legs and reapply the devices.

Rationale 4: The nurse should remind the UAP that the devices are being used to support circulation and should be off the client for as short a period of time as possible. The UAP who knows the correct removal and application process may remove and apply these devices.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed assistive personnel.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1303

Question 23

Type: MCSA

The nurse is assessing the vital signs of a 5-year-old client. Should the nurse measure this childs blood pressure?

1. Yes, blood pressure is measured for all children over the age of 3 years.

2. No, blood pressure measurements are not required until age 13.

3. Only if the child complains of headache or has an elevated pulse rate.

4. Yes, but the measurement must be taken in the childs thigh.

Correct Answer: 1

Rationale 1: Blood pressure measurements should be included for all children over the age of 3 years.

Rationale 2: Blood pressure measurements should be included for all children over the age of 3 years.

Rationale 3: Blood pressure measurements should be included for all children over the age of 3 years.

Rationale 4: The blood pressure is measured with a child-size cuff and can be taken in any extremity.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1294

Question 24

Type: MCMA

A client is diagnosed with anemia. What will the nurse most likely assess in this client as evidence of an alteration in cardiovascular functioning?

Standard Text: Select all that apply.

1. Chronic fatigue

2. Lower-extremity edema

3. Pallor

4. Shortness of breath

5. Hypotension

Correct Answer: 1, 3, 4, 5

Rationale 1: A lack of red blood cells to transport oxygen to tissues can lead to chronic fatigue.

Rationale 2: A lack of red blood cells does not cause lower-extremity edema.

Rationale 3: A lack of red blood cells within tissues can cause skin pallor.

Rationale 4: A lack of red blood cells to transport oxygen to tissues can cause shortness of breath.

Rationale 5: A lack of red blood cells to transport oxygen to tissues can cause hypotension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1298

Question 25

Type: MCSA

The nurse seeing a client stop breathing realizes that there is how much time before the onset of permanent damage?

1. 3 minutes

2. 2 minutes

3. 4 to 6 minutes

4. 20 to 40 minutes

Correct Answer: 3

Rationale 1: Extensive damage occurs after 4 to 6 minutes.

Rationale 2: Extensive damage occurs after 4 to 6 minutes.

Rationale 3: After 4 to 6 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage.

Rationale 4: The person is clinically dead 20 to 40 minutes after the heart stops beating.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1304

Question 26

Type: MCSA

A client with a terminal illness without an advance directive stops breathing, and does not have a heartbeat. What should the nurse do?

1. Call a slow code.

2. Call a partial code.

3. Call the physician.

4. Call a code.

Correct Answer: 4

Rationale 1: Both legally and ethically, there is no such thing as a slow code.

Rationale 2: Both legally and ethically, there is no such thing as a partial code.

Rationale 3: The nurse should start CPR, and not stop to phone the physician.

Rationale 4: If there is no do-not-resuscitate order, all clients who arrest will have resuscitation efforts begun.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe the critical nature of cardiopulmonary resuscitation.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1304

Question 27

Type: MCSA

A client asks why sequential compression devices have been prescribed. How should the nurse respond to the client?

1. They stimulate the blood return that would occur with walking.

2. They prevent lymph drainage buildup in the tissues.

3. They exercise the muscles of the leg.

4. They are used instead of walking out of bed.

Correct Answer: 1

Rationale 1: Sequential compression devices simulate the blood flow that results from walking.

Rationale 2: Sequential compression devices do not prevent lymph drainage buildup in the tissues.

Rationale 3: Sequential compression devices do not exercise the muscles of the leg.

Rationale 4: Sequential compression devices are not used instead of walking out of bed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Outline the nursing management of a client with cardiovascular disease.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1302

Question 28

Type: MCSA

The nurse determines that UAP can apply sequential compression devices to a client when what is observed?

1. The devices are left off for 1 hour after morning care.

2. The alarm is turned off.

3. The tubing is not kinked.

4. Ankle pressure is set at 100 mm Hg.

Correct Answer: 3

Rationale 1: The client should wear the devices as much as possible.

Rationale 2: The alarm should be activated.

Rationale 3: The tubing should not be kinked.

Rationale 4: Ankle pressure should be set at 35 to 55 mm Hg.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7. Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed assistive personnel.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1303

Question 29

Type: MCMA

The nurse is documenting the use of sequential compression devices in a clients medical record. What should be included in this documentation?

Standard Text: Select all that apply.

1. Calf circumference

2. Skin integrity

3. Peripheral vascular status

4. Neurovascular status

5. Control unit settings

Correct Answer: 2, 3, 4, 5

Rationale 1: The nurse does not need to document the clients calf circumference unless it is warranted for another health problem.

Rationale 2: The nurse should document the clients skin integrity.

Rationale 3: The nurse should document the clients peripheral vascular status.

Rationale 4: The nurse should document the clients neurovascular status.

Rationale 5: The nurse should document the control units settings.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Management of Care

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1303

Question 30

Type: MCSA

After an assessment, the nurse determines that a clients sequential compression devices need to be removed. What should the nurse document about this clients status in the medical record?

1. Client ambulating without assistance.

2. Client complains of numbness, tingling, and leg pain with the sequential compression devices.

3. Client requested devices to be removed.

4. Client to wear sequential compression devices during sleep.

Correct Answer: 2

Rationale 1: The devices should be worn as prescribed.

Rationale 2: The nurse should remove the devices if the client complains of numbness, tingling, or leg pain.

Rationale 3: The devices should be worn as prescribed.

Rationale 4: The devices should be worn as prescribed.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Demonstrate appropriate documentation and reporting when applying a sequential compression device.

MNL Learning Outcome: 4.10.4. Implement the nursing process in the care of the client with altered cardiopulmonary function.

Page Number: 1303

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