Chapter 51 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/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 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 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: Page Reference: 1427

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Describe three major alterations in cardiovascular function.

Question 2

Type: MCSA

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

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. The period of time between S2 and the next S1 is diastole.

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. The period of time between S2 and the next S1 is diastole.

Global Rationale: Page Reference: 1429

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Outline the structure and physiology of the cardiovascular system.

Question 3

Type: MCSA

The nurse detects an extra heart sound that occurs between heartbeats. How would the nurse document the timing of this sound?

1. Diastolic

2. Holosystolic

3. Systolic

4. Pansystolic

Correct Answer: 1

Rationale 1: The period between heartbeats is the time between S2 and the next S1. This period of time is diastole. Systole is the period of time between S1 and S2.

Rationale 2: The period between heartbeats is the time between S2 and the next S1. This period of time is diastole. Systole is the period of time between S1 and S2.

Rationale 3: The period between heartbeats is the time between S2 and the next S1. This period of time is diastole. Systole is the period of time between S1 and S2.

Rationale 4: The period between heartbeats is the time between S2 and the next S1. This period of time is diastole. Systole is the period of time between S1 and S2.

Global Rationale: Page Reference: 1429

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Outline the structure and physiology of the cardiovascular system.

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. While extreme changes in blood sugar, electrolyte disturbances, and liver damage 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. While extreme changes in blood sugar, electrolyte disturbances, and liver damage 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. While extreme changes in blood sugar, electrolyte disturbances, and liver damage 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 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. While extreme changes in blood sugar, electrolyte disturbances, and liver damage 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: Page Reference: 1429

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 03 Describe three major alterations in cardiovascular function.

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 heart rate. Since 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 heart rate. Since 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: Page Reference: 1429

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 6

Type: MCSA

The client has complaints of being tired, listless, and unable to tolerate activity at usual levels. Which laboratory value would 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 complaint 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: Page Reference: 1432

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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: Page Reference: 1432

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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: Page Reference: 1434

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 9

Type: MCSA

The post-myocardial 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: 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 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. 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 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: 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.

Global Rationale: Page Reference: 1441

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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: While 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: 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: Page Reference: 1436

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 11

Type: MCSA

The client has a history of recurrent transient ischemic attack (TIA). Based upon this history the nurse is 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 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: Page Reference: 1437

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Describe three major alterations in cardiovascular function.

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: Page Reference: 1437

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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: Page Reference: 1438

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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. The ABI is calculated by dividing either the posterior tibial or dorsalis pedis pulse (whichever is higher) by the left or right brachial systolic pressure (whichever is higher).

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: Page Reference: 1439

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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 which 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: Page Reference: 1439

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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 is not the most important for the nurse to discuss with the physician.

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

Global Rationale: Page reference: 1426-1443

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 17

Type: MCSA

The client exhibits confusion, decreased capillary refilling time, low oxygen saturation readings, and decreased renal output. What NANDA nursing diagnosis problem statement would 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 occurs when there is inadequate blood pumped by the heart to meet the demands of the body.

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

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

Global Rationale: Page Reference: 1440

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 18

Type: MCSA

The 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 calf muscles is also used for this purpose.

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

Global Rationale: Page Reference: 1441

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

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, the nurse suspects which of the following?

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: Page Reference: 1445

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 05 Describe the critical nature of cardiopulmonary resuscitation.

Question 20

Type: MCSA

The client has a long history of hypertension and has developed heart failure. The nurse would anticipate giving medications to do which of the following?

1. Increase preload.

2. Decrease afterload.

3. Decrease contractility.

4. 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 a 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: Page Reference: 1430, 1442

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 21

Type: MCSA

The nurse finds an adult client pulseless and breathless. After calling the code, the nurse begins single rescuer cardiopulmonary resuscitation at what rate?

1. Five compressions to each breath

2. Fifteen compressions to each two breaths

3. Thirty compressions to each two breaths

4. Forty-five compressions to each breath

Correct Answer: 3

Rationale 1: The 2005 guidelines from the American Heart Association recommend a compression to ventilation ratio of 30:2 for single rescuers for all clients except newborns.

Rationale 2: The 2005 guidelines from the American Heart Association recommend a compression to ventilation ratio of 30:2 for single rescuers for all clients except newborns.

Rationale 3: The 2005 guidelines from the American Heart Association recommend a compression to ventilation ratio of 30:2 for single rescuers for all clients except newborns.

Rationale 4: The 2005 guidelines from the American Heart Association recommend a compression to ventilation ratio of 30:2 for single rescuers for all clients except newborns.

Global Rationale: Page Reference: 1426-1443

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe the critical nature of cardiopulmonary resuscitation.

Question 22

Type: MCSA

The client requires defibrillation during resuscitation. What sequence should the nurse use for this defibrillation?

1. Deliver three shocks without CPR between shocks.

2. Deliver two shocks and a precordial thump before beginning CPR.

3. Deliver one shock followed by immediate CPR.

4. Deliver shocks every 3 seconds until conversion occurs.

Correct Answer: 3

Rationale 1: The 2005 guidelines from the American Heart Association recommend delivery of one shock followed by immediate CPR beginning with chest compressions.

Rationale 2: The 2005 guidelines from the American Heart Association recommend delivery of one shock followed by immediate CPR beginning with chest compressions.

Rationale 3: The 2005 guidelines from the American Heart Association recommend delivery of one shock followed by immediate CPR beginning with chest compressions.

Rationale 4: The 2005 guidelines from the American Heart Association recommend delivery of one shock followed by immediate CPR beginning with chest compressions.

Global Rationale: Page Reference: 1427-1443

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe the critical nature of cardiopulmonary resuscitation.

Question 23

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, since 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: Page Reference: 1443

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 07 Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed assistive personnel.

Question 24

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: Page Reference: 1433

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 25

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: Page Reference: 1348

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 26

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. 46 minutes.

4. 2040 minutes.

Correct Answer: 3

Rationale 1: Extensive damage occurs after 46 minutes.

Rationale 2: Extensive damage occurs after 46 minutes.

Rationale 3: After 46 minutes, the lack of oxygen supply to the brain causes permanent and extensive damage.

Rationale 4: The person is clinically dead 2040 minutes after the heart stops beating.

Global Rationale: Page Reference: 1444

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 05 Describe the critical nature of cardiopulmonary resuscitation.

Question 27

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: Page Reference: 1445

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 28

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: Page Reference: 1442

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Outline the nursing management of a client with cardiovascular disease.

Question 29

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. 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 3555 mm Hg.

Global Rationale: Page Reference: 1443

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 07 Recognize when it is appropriate to delegate aspects of applying a sequential compression device to unlicensed assistive personnel.

Question 30

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: Page Reference: 1443

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 08 Demonstrate appropriate documentation and reporting when applying a sequential compression device.

Question 31

Type: MCSA

After an assessment, the nurse determines that a clients sequential compression devices need to be removed. What will 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: Page Reference: 1443

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 08 Demonstrate appropriate documentation and reporting when applying a sequential compression device.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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