1. A health care provider orders thigh-high antiembolism stockings for a client with varicose veins. The client’s thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?
Replace the thigh-high stockings with knee-high stockings.
Leave the antiembolism stockings off to prevent tissue damage.
Roll the top of the stockings to below the knees to limit popliteal pressure.
Ask the health care provider if an elastic bandage can be used in place of the stockings.
2. A nurse inspects a two-day-old intravenous site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?
Irrigate the IV tubing.
Discontinue the infusion.
Slow the rate of the infusion.
Obtain a prescription for an analgesic.
3. A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction?
Whole milk with oatmeal
Garden salad with olive oil
Tuna fish with a small apple
Soluble fiber cereal with skim milk
4. A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure?
Stroke volume
Venous pressure
Coronary artery patency
Left ventricular functioning
5. A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client’s medications?
ACE inhibitors
Thiazide diuretics
Calcium channel blockers
Angiotensin receptor blockers
6. Which client statement indicates an understanding of the nurse’s instructions concerning a Holter monitor?
“The only times the monitor should be taken off is for showering and sleep.”
“The monitor will record my activities and symptoms if an abnormal rhythm occurs.”
“The results from the monitor will be used to determine the size and shape of my heart.”
“The monitor will record any abnormal heart rhythms while I go about my usual activities.”
7. A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member’s questions about the condition?
An irreversible phenomenon
A failure of the circulatory pump
Usually a fleeting reaction to tissue injury
Generally caused by decreased blood volume
8. Which nursing action is most important when caring for a client after a cardiac catheterization?
Provide for rest.
Administer oxygen.
Check a pulse distal to the insertion site.
Assess the electrocardiogram every fifteen minutes.
9. A client with a bundle branch block is on a cardiac monitor. What ECG change should the nurse identify on the client’s cardiac monitor?
Sagging ST segments
Absence of P wave configurations
Inverted T waves following each QRS complex
Widening of QRS complexes to a minimum of 0.12 second
10. What client response indicates to the nurse that a vasodilator medication is effective?
Pulse rate decreases from 110 to 75
Absence of adventitious breath sounds
Increase in the daily amount of urine produced
Blood pressure changes from 154/90 to 126/72
11. A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse’s best response?
“Hot drinks such as coffee are not good for your heart.”
“Coffee is not permitted on the diet that was ordered for you.”
“You cannot have coffee. I can bring you a cup of tea if you like.”
“Coffee has caffeine that can affect your heart. It should be avoided.”
12. After a bilateral lumbar sympathectomy a client has a sudden drop in blood pressure, but there is no evidence of bleeding. What should the nurse identify as the most likely cause of the change in blood pressure?
Inadequate fluid intake
Consequence of anesthesia
Increased level of epinephrine
Reallocation of the blood supply
13. While a pacemaker catheter is being inserted, the client’s heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe?
Digoxin (Lanoxin)
Lidocaine (Xylocaine)
Amiodarone (Cordarone)
Atropine sulfate (Atropine)
14. Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)?
“Increase your intake of fiber and fluid.”
“Take the medication before you go to bed.”
“Check your pulse before taking the medication.”
“Contact your health care provider if your skin or sclera turn yellow.”
15. A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention?
Substitute a supplemental drink for the meal.
Spoon-feed the client until the food is completely eaten.
Allow the client a longer period of time to complete the meal.
Arrange a consultation for the placement of a gastrostomy tube.
16. After abdominal surgery a client suddenly reports numbness in the right leg and a “funny feeling” in the toes. What should the nurse do first?
Elevate the legs and tell the client to drink more fluids.
Instruct the client to remain in bed and notify the health care provider.
Rub the client’s legs to stimulate circulation and cover the client with a blanket.
Tell the client about the dangers of prolonged bed rest and encourage ambulation.
17. What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus?
Knowledge reduces general anxiety.
Capacity to learn decreases with age.
Continued reinforcement is advantageous.
Readiness of the learner precedes instruction.
18. Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider?
Blurred vision
Dizziness on rising
Excessive urination
Difficulty breathing
19. What specifically should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel (Plavix)?
Nausea
Epistaxis
Chest pain
Elevated temperature
20. In addition to atrial fibrillation, what ventricular rhythm exhibited by a client does the nurse determine may be converted to a sinus rhythm by cardioversion?
Standstill
Fibrillation
Tachycardia with a pulse
Frequent premature complexes
21. An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective?
A reduction of confusion
An APPT twice the usual value
An absence of ecchymotic areas
A decreased viscosity of the blood
22. A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?
Constriction of the superficial vessels dilates the deep vessels.
Constriction of the peripheral vessels increases the force of flow.
Dilation of the superficial vessels causes constriction of collateral circulation.
Dilation of the peripheral vessels causes reflex constriction of visceral vessels.
23. What must the nurse do to determine a client’s pulse pressure?
Multiply the heart rate by the stroke volume.
Subtract the diastolic from the systolic reading.
Determine the mean blood pressure by averaging the two.
Calculate the difference between the apical and radial rate.
24. What instructions about the use of nitroglycerin should the nurse provide to a client with angina?
1. “Identify when pain occurs, and place 2 tablets under the tongue.”
“Place 1 tablet under the tongue, and swallow another when pain is intense.”
“Before physical activity place 1 tablet under the tongue, and repeat the dose in 5 minutes if pain occurs.”
“Place 1 tablet under the tongue when pain occurs, and use an additional tablet after the attack to prevent recurrence.”
25. A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide (Bumex) and digoxin (Lanoxin). What does the nurse determine is the cause of the depletion?
Diuretic therapy
Sodium restriction
Continuous dyspnea
Inadequate oral intake
26. A nurse is caring for a client with chronic occlusive arterial disease. What precipitating cause is the nurse most likely to identify for the development of ulceration and gangrenous lesions?
Emotional stress, which is short-lived
Poor hygiene and limited protein intake
Stimulants such as coffee, tea, or cola drinks
Trauma from mechanical, chemical, or thermal sources
27. When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?
Kidney dysfunction
Cardiovascular diseases
Eye problems, such as glaucoma
Accidents, including their prevention
28. A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?
Head injury
Fractured femur
Ventricular fibrillation
Penetrating abdominal wound
29. What is the priority when working with a group of middleaged adult clients?
Cessation of smoking
Prevention of infection
Abstinence from alcohol
Decreasing high-density lipoproteins levels
30. A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the health care provider?
Client pushes the airway out.
Client has snoring respirations.
Respirations of 16 breaths/min are shallow.
Systolic blood pressure drops from 130 to 90 mm Hg.
31. A client with a history of dysrhythmias is to wear a Holter monitor for 24 hours on an outpatient basis. What should the nurse teach the client to do while wearing the monitor?
Discontinue medications.
Avoid using a microwave oven.
Keep a written account of activities.
Record the blood pressure periodically.
32. What should the nurse teach a client to expect when preparing for discharge after surgery for a coronary artery bypass graft?
Mild fever and extreme fatigue for several weeks after surgery
Cessation of drainage from the incisions after hospitalization
Mild incisional pain and tenderness up to three weeks after surgery
Some edema in the leg used for the donor graft is expected with activity
33. What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?
Arterial spasm
Heart muscle ischemia
Blocking of the coronary veins
Irritation of nerve endings in the cardiac plexus
34. A 78-year-old client who has hypertension is beginning treatment with furosemide (Lasix). Considering the client’s age, what should the nurse teach the client to do?
Limit fluids at bedtime.
Change positions slowly.
Take the medication between meals.
Assess the skin for breakdown daily.
35. Which topic should the nurse determine is most appropriate when presenting health-related instruction to clients from an African-American community?
Osteoporosis
Hypertension
Uterine cancer
Thyroid disorders
36. A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?
Cerebral embolism
Pulmonary embolism
Dry gangrene of a limb
Coronary vessel occlusion
37. During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client’s rectum. What response to disimpac- tion is the nurse attempting to prevent by presenting other strategies to regulate the client’s bowel movements?
Increased pulse rate
Slowing of the heart
Dilation of the bronchioles
Coronary artery vasodilation
38. What information should the nurse include when teaching a client with heart disease about cholesterol?
Can be found in both plant and animal sources
Causes an increase in serum high-density lipoprotein
Should be eliminated because it causes the disease process
Decreases when unsaturated fats are substituted for saturated fats
39. What should the nurse assess to determine if a client is experiencing the therapeutic effect of valsartan (Diovan)?
Lipid profile
Apical pulse
Urinary output
Blood pressure
40. A 76-year-old male client asks the nurse about the chances of getting osteoporosis like his wife. Which is the best response by the nurse?
“This is only a problem for women.”
“Exercise is a good way to prevent this problem.”
“You are not at risk because of your small frame.”
“You might think about having a bone density test.”
41. After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client’s temperature?
A fever may lead to diaphoresis.
A fever increases the cardiac output.
An increased temperature indicates cerebral edema.
An increased temperature may be a sign of hemorrhage.
42. A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram. Which explanation should the nurse include when teaching the client about this procedure?
“This is a noninvasive test to check your heart’s response to physical activity.”
“This test is the definitive method to identify the actual cause of your chest pain.”
“The findings of this test will be of minimal assistance in the treatment of angina.”
“The findings from this minimally invasive test will show how your body reacts to exercise.”
43. For which common complication of myocardial infarction should the nurse monitor clients in the coronary care unit?
Dysrhythmia
Hypokalemia
Anaphylactic shock
Cardiac enlargement
44. A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?
Keep both legs dependent.
Notify the health care provider.
Apply a warm soak to the left calf.
Administer the prescribed analgesic.
45. A nurse is teaching a client about the use of antiembolism stockings. What instruction should the nurse include?
Keep the stockings on two hours and off two hours.
Wear the stockings only at bedtime when activity lessens.
Put the stockings on before getting out of bed in the morning.
Leave the stockings in place until the health care provider advises otherwise.
46. What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?
Syncope
Headache
Tachycardia
Hemiparesis
47. What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension?
Wear support hose continuously.
Lie down for 30 minutes after taking medication.
Avoid tasks that require high-energy expenditure.
Sit on the edge of the bed for 5 minutes before standing.
48. A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?
INR
APTT
Bleeding time
Sedimentation rate
49. A client is admitted with chest pain unrelieved by nitroglycerin, an elevated temperature, decreased blood pressure, and diaphoresis. A myocardial infarction is diagnosed. Which should the nurse consider as a valid reason for one of this client’s physiologic responses?
Parasympathetic reflexes from the infarcted myocardium cause diaphoresis.
Inflammation in the myocardium causes a rise in the systemic body temperature.
Catecholamines released at the site of the infarction cause intermittent localized pain.
Constriction of central and peripheral blood vessels causes a decrease in blood pressure.
50. Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults?
