Question: A nurse is teaching a client who has mitral valve stenosis that has not responded to pharmacological therapies about other treatment options. Which of the following statements should the nurse include in their teaching?
Answer Choices:
A flexible catheter will be inserted into a vessel of the arm, neck, or groin and advanced to the heart to dilate a narrowed or occluded artery.
A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated.
A heparin bolus is administered and followed with a continuous infusion to help keep the blood thinner.
Pentoxifylline can be administered to help the platelets from sticking together and occluding the vessels.
Answer: A small catheter with a balloon on the end is threaded into a vessel in the groin and advanced to the heart where the balloon will be inflated, and the narrowed valve will be dilated.
Question: A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Answer Choices:
Suggest that the client rests before eating the meal.
Check the client’s vital signs.
Request a dietitian consult.
Request an order for an antiemetic.
Answer: Check the client’s vital signs.
Question: A nurse is assessing a 3-year-old child who has aortic stenosis. Which of the following findings should the nurse expect? (Select all that apply.)
Answer Choices:
Hypotension, Murmur, Clubbing of the nail beds, Bradycardia, Weak pulses
Answer: Murmur, Weak pulses
Question: A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect?
Answer Choices:
Systolic murmur.
Weak pulses.
Cyanosis with crying.
Chronic hypoxemia.
Answer: Systolic murmur.
Question: A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?
Answer Choices:
Maintain oxygen saturations greater than or equal to 92%, Obtain an EKG, Administer enteric-coated acetaminophen, Administer ibuprofen
Answer: Obtain an EKG
Question: A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?
Answer Choices:
Hct 44%, Hgb 16 g/dL, Platelets 190,000/mm³, PT 45 seconds
Answer: PT 45 seconds
Question: A nurse in an emergency department (ED) is admitting a client. The vital signs include a heart rate of 48/min, respiratory rate of 28/min, blood pressure of 106/55 mm Hg, and oxygen saturation of 90% on room air. Select the 3 findings that require immediate follow-up.
Answer Choices:
Heart rate, Neurological assessment, 12 Lead EKG report, Temperature, Respiratory assessment
Answer: Heart rate, Respiratory assessment, 12 Lead EKG report
Question: A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?
Answer Choices:
Breathlessness, Weight gain, Distended abdomen, Anorexia
Answer: Breathlessness
Question: A nurse is caring for a child who has rheumatic fever. When obtaining the child’s medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child’s infection?
Answer Choices:
A classmate who has fifth disease, A neighbor’s child who has chickenpox, A sibling who had a sore throat 3 weeks ago, The father who had gastritis 2 weeks ago
Answer: A sibling who had a sore throat 3 weeks ago
Question: The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)
Answer Choices:
Obtain informed consent by informing the patient of procedural risks, Inflate the balloon during the procedure when indicated by the physician, Allay the patient’s anxiety by providing information about the procedure, Ensure that a sterile field is maintained during the insertion procedure, Monitor the patient’s cardiac rhythm throughout the entire procedure
Answer: Ensure that a sterile field is maintained during the insertion procedure, Monitor the patient’s cardiac rhythm throughout the entire procedure
Question: A nurse is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client’s pain and anxiety?
Answer Choices:
Morphine, Oxygen, Aspirin, Nitroglycerin
Answer: Morphine
Question: A patient with supraventricular tachycardia has a maintenance infusion of Brevibloc 100 mcg/kg/min ordered. The Brevibloc concentration is 10 mg/mL. The patient’s weight is 176 pounds. How many milliliters per hour should the IV pump be set for?
Answer Choices:
Enter text here.
Answer: 0.6 mL/hr
Question: A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn’t understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response?
Answer Choices:
“Exercise is good for you and good for your heart.”, “Your doctor is the expert here, and I’m sure he would only recommend what is best for you.”, “Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.”, “It’s not unusual to feel that way at first, but once you learn the routine, you’ll enjoy it.”
Answer: “Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely.”
Question: A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
Answer Choices:
Differences in upper and lower lung sounds, Differences between oral and axillary temperatures, Different blood pressures in the upper limbs, Different apical and radial pulses
Answer: Different apical and radial pulses
Question: A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client’s apical pulse?
Answer Choices:
Bounding pulsations.
Tachycardia.
Irregular pulsations.
Bradycardia.
Answer: Irregular pulsations.
Question: The patient is alert and talking when the nurse notices the following rhythm. The patient’s blood pressure is 90/44 mm Hg. The nurse should:
Answer Choices:
Begin basic life support, Begin advanced life support, Treat with intravenous antidysrhythmic, Defibrillate immediately
Answer: Treat with intravenous antidysrhythmic
Question: A client newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and dyspnea as a result of pulmonary venous hypertension. What valvular disorder would cause pulmonary venous hypertension?
Answer Choices:
Aortic regurgitation, Mitral valve prolapse, Mitral stenosis, Aortic stenosis
Answer: Mitral stenosis
Question: A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?
Answer Choices:
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart, Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues, Troponin is a protein that helps transport oxygen throughout the body, Troponin is a lipid whose levels reflect the risk for coronary artery disease
Answer: Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart