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After noting a pulse deficit when assessing a patient who has just arrived in the emergency department, the nurse will anticipate that the patient may require
A) a. a 2-D echocardiogram.
B) b. a cardiac catheterization.
C) c. hourly blood pressure (BP) checks.
D) d. electrocardiographic (ECG) monitoring.

D electrocardiographic (ECG) monitoring.

When reviewing the 12-lead electrocardiograph (ECG) for a healthy 86-year-old patient who is having an annual physical examination, which of the following will be of most concern to the nurse?
A) a. The heart rate (HR) is 43 beats/minute.
B) b. The PR interval is 0.21 seconds.
C) c. There is a right bundle-branch block.
D) d. The QRS duration is 0.13 seconds.

A The heart rate (HR) is 43 beats/minute.

During a physical examination of a patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The most appropriate action for the nurse to take next will be to
A) a. document that the PMI is in the normal anatomic location.
B) b. ask the patient about risk factors for coronary artery disease.
C) c. auscultate both the carotid arteries for the presence of a bruit.
D) d. assess the patient for symptoms of left ventricular hypertrophy.

D assess the patient for symptoms of left ventricular hypertrophy.

To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
A) a. bell of the stethoscope with the patient in the left lateral position.
B) b. bell of the stethoscope with the patient sitting and leaning forward.
C) c. diaphragm of the stethoscope with the patient in a reclining position.
D) d. diaphragm of the stethoscope with the patient lying flat on the left side.

A bell of the stethoscope with the patient in the left lateral position.

To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review?
A) a. Myoglobin
B) b. Homocysteine (Hcy)
C) c. Low-density lipoprotein (LDL)
D) d. B-type natriuretic peptide (BNP)

D B-type natriuretic peptide (BNP)

While doing the admission assessment for a thin 72-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take?
A) a. Notify the hospital rapid response team.
B) b. Instruct the patient to remain on bed rest.
C) c. Teach the patient about aortic aneurysms.
D) d. Document the finding in the patient chart.

D Document the finding in the patient chart.

A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
A) a. electrocardiographic (ECG) monitoring will be required for 24 hours after the test.
B) b. it will be important to lie completely still during the procedure.
C) c. a warm feeling may be noted when the contrast dye is injected.
D) d. monitored anesthesia care will be provided during the procedure.

C a warm feeling may be noted when the contrast dye is injected

While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Which action should the nurse take next?
A) a. Use a ruler to measure the level of the JVD.
B) b. Document this finding in the patient's record.
C) c. Observe for JVD with the head at 30 degrees.
D) d. Have the patient perform the Valsalva maneuver.

C Observe for JVD with the head at 30 degrees.

The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
A) a. exercise more than usual while the monitor is in place.
B) b. remove the electrodes when taking a shower or tub bath.
C) c. keep a diary of daily activities while the monitor is worn.
D) d. connect the recorder to a telephone transmitter once daily.

C keep a diary of daily activities while the monitor is worn.

When auscultating over the patient's abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a
A) a. thrill.
B) b. bruit.
C) c. heave.
D) d. murmur.

B bruit.

Which action will the nurse in the hypertension clinic take in order to obtain an accurate baseline blood pressure (BP) for a new patient?
A) a. Obtain a BP reading in each arm and average the results.
B) b. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
C) c. Have the patient sit in a chair with the feet flat on the floor.
D) d. Assist the patient to the supine position for BP measurements.

C Have the patient sit in a chair with the feet flat on the floor.

The nurse obtains this information from a patient with prehypertension. Which finding is most important to address with the patient?
A) a. Low dietary fiber intake
B) b. No regular aerobic exercise
C) c. Weight 5 pounds above ideal weight
D) d. Drinks wine with dinner once a week

B No regular aerobic exercise

After giving a patient the initial dose of oral labetalol (Normodyne) for treatment of hypertension, which action should the nurse take?
A) a. Encourage oral fluids to prevent dry mouth or dehydration.
B) b. Instruct the patient to ask for help if heart palpitations occur.
C) c. Ask the patient to request assistance when getting out of bed.
D) d. Teach the patient that headaches may occur with this medication.

C Ask the patient to request assistance when getting out of bed.

After the nurse teaches the patient with stage 1 hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective?
A) a. The patient avoids eating nuts or nut butters.
B) b. The patient restricts intake of dietary protein.
C) c. The patient has only one cup of coffee in the morning.
D) d. The patient has a glass of low-fat milk with each meal.

D. The patient has a glass of low-fat milk with each meal.

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient?
A) a. Check BP daily before taking the medication.
B) b. Increase fluid intake if dryness of the mouth is a problem.
C) c. Include high-potassium foods such as bananas in the diet.
D) d. Change position slowly to help prevent dizziness and falls.

D. Change position slowly to help prevent dizziness and falls.

A patient is diagnosed with hypertension and nadolol (Corgard) is prescribed. The nurse should consult with the health care provider before giving this medication upon finding a history of
A) a. asthma.
B) b. peptic ulcer disease.
C) c. alcohol dependency.
D) d. myocardial infarction (MI).

A. asthma.

A 52-year-old patient who has no previous history of hypertension or other health problems suddenly develops a BP of 188/106 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that
A) a. a BP recheck should be scheduled in a few weeks.
B) b. the dietary sodium and fat content should be decreased.
C) c. there is an immediate danger of a stroke and hospitalization will be required.
D) d. more diagnostic testing may be needed to determine the cause of the hypertension.

D. more diagnostic testing may be needed to determine the cause of the hypertension.

Which action will be included in the plan of care when the nurse is caring for a patient who is receiving sodium nitroprusside (Nipride) to treat a hypertensive emergency?
A) a. Organize nursing activities so that the patient has undisturbed sleep for 6 to 8 hours at night.
B) b. Assist the patient up in the chair for meals to avoid complications associated with immobility.
C) c. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements.
D) d. Place the patient on NPO status to prevent aspiration caused by nausea and the associated vomiting.

C. Use an automated noninvasive blood pressure machine to obtain frequent BP measurements.

The nurse has just finished teaching a hypertensive patient about the newly prescribed quinapril (Accupril). Which patient statement indicates that more teaching is needed?
A) a. "The medication may not work as well if I take any aspirin."
B) b. "The doctor may order a blood potassium level occasionally."
C) c. "I will call the doctor if I notice that I have a frequent cough."
D) d. "I won't worry if I have a little swelling around my lips and face."

D. "I won't worry if I have a little swelling around my lips and face."

During change-of-shift report, the nurse obtains this information about a hypertensive patient who received the first dose of propranolol (Inderal) during the previous shift. Which information indicates that the patient needs immediate intervention?
A) a. The patient's most recent BP reading is 156/94 mm Hg.
B) b. The patient's pulse has dropped from 64 to 58 beats/minute.
C) c. The patient has developed wheezes throughout the lung fields.
D) d. The patient complains that the fingers and toes feel quite cold

C The patient has developed wheezes throughout the lung fields.

When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the
A) a. family history of coronary artery disease.
B) b. increased risk associated with the patient's gender.
C) c. high incidence of cardiovascular disease in older people.
D) d. elevation of the patient's serum low density lipoprotein (LDL) level.

D elevation of the patient's serum low density lipoprotein (LDL) level.

To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective?
A) a. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary.
B) b. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.
C) c. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible.
D) d. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

C Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible.

Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)?
A) a. The pain increases with deep breathing.
B) b. The pain has persisted longer than 30 minutes.
C) c. The pain worsens when the patient raises the arms.
D) d. The pain is relieved after the patient takes nitroglycerin.

B The pain has persisted longer than 30 minutes.

Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
A) a. The patient rates the pain at a level 3 to 5 (0 to 10 scale).
B) b. The patient states that the pain "wakes me up at night."
C) c. The patient says that the frequency of the pain has increased over the last few weeks.
D) d. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

D The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?
A) a. "I can expect indigestion as a side effect of nitroglycerin."
B) b. "I can only take the nitroglycerin if I start to have chest pain."
C) c. "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin."
D) d. "I will help slow down the progress of the plaque formation by taking nitroglycerin."

C "I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin."

Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?
A) a. "I will switch from whole milk to 1% or nonfat milk."
B) b. "I like fresh salmon and I will plan to eat it more often."
C) c. "I will miss being able to eat peanut butter sandwiches."
D) d. "I can have a cup of coffee with breakfast if I want one."

C "I will miss being able to eat peanut butter sandwiches."

After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective?
A) a. "It is important not to suddenly stop taking the atenolol."
B) b. "Atenolol will increase the strength of my heart muscle."
C) c. "I can expect to feel short of breath when taking atenolol."
D) d. "Atenolol will improve the blood flow to my coronary arteries."

A "It is important not to suddenly stop taking the atenolol."

A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI?
A) a. Homocysteine
B) b. C-reactive protein
C) c. Cardiac-specific troponin I and troponin T
D) d. High-density lipoprotein (HDL) cholesterol

C Cardiac-specific troponin I and troponin T

Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetal's (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will
A) a. reduce the "fight or flight" response.
B) b. decrease spasm of the coronary arteries.
C) c. increase the force of myocardial contraction.
D) d. help prevent clotting in the coronary arteries.

B decrease spasm of the coronary arteries.

The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if
A) a. the patient is restless and agitated.
B) b. the blood pressure is 190/110 mm Hg.
C) c. the patient complains about feeling anxious.
D) d. the cardiac monitor shows a heart rate of 45.

D the cardiac monitor shows a heart rate of 45.

Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for
A) a. decreased blood pressure and apical pulse rate.
B) b. fewer complaints of having cold hands and feet.
C) c. improvement in the quality of the peripheral pulses.
D) d. the ability to do daily activities without chest discomfort.

D the ability to do daily activities without chest discomfort.

A patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin?
A) a. Platelet aggregation is enhanced by IV heparin infusion.
B) b. Heparin will dissolve the clot that is blocking blood flow to the heart.
C) c. Coronary artery plaque size and adherence are decreased with heparin.
D) d. Heparin will prevent the development of new clots in the coronary arteries.

D Heparin will prevent the development of new clots in the coronary arteries.

. When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication?
A) a. Check blood pressure.
B) b. Monitor apical pulse rate.
C) c. Monitor for dysrhythmias.
D) d. Ask about chest discomfort.

D Ask about chest discomfort.

A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy?
A) a. "Do you take aspirin on a daily basis?"
B) b. "What time did your chest pain begin?"
C) c. "Is there any family history of heart disease?"
D) d. "Can you describe the quality of your chest pain?"

B "What time did your chest pain begin?"

Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient's response, which of these assessment data would indicate that the exercise level should be decreased?
A) a. BP changes from 118/60 to 126/68 mm Hg.
B) b. Oxygen saturation drops from 100% to 98%.
C) c. Heart rate increases from 66 to 90 beats/minute.
D) d. Respiratory rate goes from 14 to 22 breaths/minute.

C) c. Heart rate increases from 66 to 90 beats/minute.

During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences
A) a. bleeding from the gums.
B) b. surface bleeding from the IV site.
C) c. a decrease in level of consciousness.
D) d. a nonsustained episode of ventricular tachycardia.

C) c. a decrease in level of consciousness.

Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next?
A) a. Palpate the radial pulses bilaterally.
B) b. Assess the feet for peripheral edema.
C) c. Auscultate for a pericardial friction rub.
D) d. Check the cardiac monitor for dysrhythmias.

C) c. Auscultate for a pericardial friction rub.

After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective?
A) a. "I will put on the nitroglycerin patch as soon as I develop any chest pain."
B) b. "I will check the pulse rate in my wrist just before I take any nitroglycerin."
C) c. "I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin."
D) d. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

D) d. "I will stop what I am doing and sit down before I put the nitroglycerin under my tongue."

Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, "I am too nervous to take care of myself." Based on this information, which nursing diagnosis is appropriate?
A) a. Ineffective coping related to anxiety
B) b. Activity intolerance related to weakness
C) c. Denial related to lack of acceptance of the MI
D) d. Social isolation related to lack of support system

A) a. Ineffective coping related to anxiety

When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient
A) a. that sudden cardiac death events rarely reoccur.
B) b. about the purpose of outpatient Holter monitoring.
C) c. how to self-administer low-molecular-weight heparin.
D) d. to limit activities after discharge to prevent future events.

B) b. about the purpose of outpatient Holter monitoring.

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the length of the patient's
A) a. P wave.
B) b. PR interval.
C) c. QT interval.
D) d. QRS complex.

A) a. P wave.

The nurse needs to estimate quickly the heart rate for a patient with a regular heart rhythm. Which method will be best to use?
A) a. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS complexes.
B) b. Count the number of large squares in the R-R interval and divide by 300.
C) c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.
D) d. Calculate the number of small squares between one QRS complex and the next and divide into 1500.

C) c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of how many beats/minute?
A) a. 15 to 20
B) b. 20 to 40
C) c. 40 to 60
D) d. 60 to 100

C) c. 40 to 60

The nurse obtains a monitor strip on a patient who has had a myocardial infarction and makes the following analysis: P wave not apparent, ventricular rate 162, R-R interval regular, P-R interval not measurable, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as
A) a. atrial fibrillation.
B) b. sinus tachycardia.
C) c. ventricular fibrillation.
D) d. ventricular tachycardia.

D) d. ventricular tachycardia.

The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How will the nurse document the rhythm?
A) a. Ventricular couplets
B) b. Ventricular bigeminy
C) c. Ventricular R-on-T phenomenon
D) d. Ventricular multifocal contractions

B) b. Ventricular bigeminy

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute, except that the PR interval is 0.24 seconds. The appropriate intervention by the nurse is to
A) a. notify the patient's health care provider immediately.
B) b. administer atropine per agency bradycardia protocol.
C) c. prepare the patient for temporary pacemaker insertion.
D) d. document the finding and continue to monitor the patient.

D) d. document the finding and continue to monitor the patient.

A patient who was admitted with a myocardial infarction experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which action should the nurse take next?
A) a. Notify the health care provider.
B) b. Perform synchronized cardioversion.
C) c. Administer the PRN IV lidocaine (Xylocaine).
D) d. Document the rhythm and monitor the patient.

C) c. Administer the PRN IV lidocaine (Xylocaine).

After the nurse administers IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective?
A) a. Increase in the patient's heart rate
B) b. Decrease in premature contractions
C) c. Increase in peripheral pulse volume
D) d. Decrease in ventricular ectopic beats

A) a. Increase in the patient's heart rate

A patient with dilated cardiomyopathy has an atrial fibrillation that has been unresponsive to drug therapy for several days. The nurse anticipates that the patient may need teaching about
A) a. electrical cardioversion.
B) b. IV adenosine (Adenocard).
C) c. anticoagulant therapy with warfarin (Coumadin).
D) d. insertion of an implantable cardioverter-defibrillator (ICD).

C) c. anticoagulant therapy with warfarin (Coumadin).

Which information will the nurse include when teaching a patient who is scheduled to have a permanent pacemaker inserted for treatment of chronic atrial fibrillation with slow ventricular response?
A) a. The pacemaker prevents or minimizes ventricular irritability.
B) b. The pacemaker paces the atria at rates up to 500 impulses/minute.
C) c. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur.
D) d. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

D) d. The pacemaker stimulates a heart beat if the patient's heart rate drops too low.

A patient has received instruction on the management of a new permanent pacemaker before discharge from the hospital. The nurse recognizes that teaching has been effective when the patient tells the nurse,
A) a. "It will be 6 weeks before I can take a bath or return to my usual activities."
B) b. "I will notify the airlines when I make a reservation that I have a pacemaker."
C) c. "I won't lift the arm on the pacemaker side up very high until I see the doctor."
D) d. "I must avoid cooking with a microwave oven or being near a microwave in use."

C) c. "I won't lift the arm on the pacemaker side up very high until I see the doctor."

Which action by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs?
A) a. The nurse assists the patient to do active range of motion exercises for all extremities.
B) b. The nurse assists the patient to fill out the application for obtaining a Medic Alert ID and bracelet.
C) c. The nurse gives atenolol (Tenormin) to the patient without consulting first with the health care provider.
D) d. The nurse teaches the patient that sexual activity usually can be resumed once the surgical incision is healed.

A) a. The nurse assists the patient to do active range of motion exercises for all extremities.

Which action should the nurse take when preparing for cardioversion of a patient with supraventricular tachycardia who is alert and has a blood pressure of 110/66 mm Hg?
A) a. Turn the synchronizer switch to the "off" position.
B) b. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct position.
C) c. Set the defibrillator/cardioverter energy to 300 joules.
D) d. Administer a sedative before cardioversion is implemented.

D) d. Administer a sedative before cardioversion is implemented.

A 19-year-old has a mandatory electrocardiogram (ECG) before participating on a college swim team and is found to have sinus bradycardia, rate 52. BP is 114/54, and the student denies any health problems. What action by the nurse is appropriate?
A) a. Allow the student to participate on the swim team.
B) b. Refer the student to a cardiologist for further assessment.
C) c. Obtain more detailed information about the student's health history.
D) d. Tell the student to stop swimming immediately if any dyspnea occurs.

A) a. Allow the student to participate on the swim team.

When analyzing the waveforms of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a
A) a. T wave of 0.16 second.
B) b. P-R interval of 0.18 second.
C) c. Q-T interval of 0.34 second.
D) d. QRS interval of 0.14 second.

D) d. QRS interval of 0.14 second.

A patient has ST segment changes that indicate an acute inferior wall myocardial infarction. Which lead will be best for monitoring the patient?
A) a. I
B) b. II
C) c. V6
D) d. MCL1

B) b. II

Which laboratory result for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?
A) a. Blood glucose 228 mg/dL
B) b. Serum chloride 90 mEq/L
C) c. Serum sodium 133 mEq/L
D) d. Serum potassium 2.8 mEq/L

D) d. Serum potassium 2.8 mEq/L

. A patient's cardiac monitor has a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first?
A) a. Defibrillate at 360 joules.
B) b. Give O2 per bag-valve-mask.
C) c. Give epinephrine (Adrenalin) IV.
D) d. Prepare for endotracheal intubation.

A) a. Defibrillate at 360 joules.

A patient's cardiac monitor shows sinus rhythm, rate 60 to 70. The P-R interval is 0.18 seconds at 1:00 AM, 0.20 seconds at 2:30 PM, and 0.23 seconds at 4:00 PM. Which action should the nurse take at this time?
A) a. Prepare for possible temporary pacemaker insertion.
B) b. Administer atropine sulfate 1 mg IV per agency protocol.
C) c. Document the patient's rhythm and assess the patient's response to the rhythm.
D) d. Call the health care provider before giving the prescribed metoprolol (Lopressor).

D) d. Call the health care provider before giving the prescribed metoprolol (Lopressor).

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a BP of 80/36 mm Hg, and is complaining of feeling faint. Which action should the nurse take?
A) a. Continue to monitor the rhythm and BP.
B) b. Apply the transcutaneous pacemaker (TCP).
C) c. Have the patient perform the Valsalva maneuver.
D) d. Give the scheduled dose of diltiazem (Cardizem).

B) b. Apply the transcutaneous pacemaker (TCP).

During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate?
A) a. "Tell me more about what happened to your mother."
B) b. "You will receive medications to reduce your anxiety."
C) c. "You should talk to the doctor again about the surgery."
D) d. "Surgical techniques have improved a lot in recent years."

A) a. "Tell me more about what happened to your mother."

A patient arrives at the ambulatory surgery center for a scheduled outpatient surgery. Which information is of most concern to the nurse?
A) a. The patient has not had outpatient surgery before.
B) b. The patient is planning to drive home after surgery.
C) c. The patient's insurance does not cover outpatient surgery.
D) d. The patient had a glass of water a few hours before arriving.

B) b. The patient is planning to drive home after surgery.

. A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?
A) a. The patient's lack of knowledge about postoperative pain control measures
B) b. The patient's statement that her last menstrual period was 8 weeks previously
C) c. The patient's history of a postoperative infection following a prior cholecystectomy
D) d. The patient's concern that she will be unable to care for her children postoperatively

B) b. The patient's statement that her last menstrual period was 8 weeks previously

. A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take?
A) a. Notify the dietitian about the food allergies.
B) b. Alert the surgery center about the latex allergy.
C) c. Reassure the patient that all allergies are noted on the medical record.
D) d. Ask whether the patient uses antihistamines to reduce allergic reactions.

B) b. Alert the surgery center about the latex allergy.

Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of
A) a. value-belief.
B) b. cognitive-perceptual.
C) c. sexuality-reproductive.
D) d. coping-stress tolerance.

A) a. value-belief.

During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. John's wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may
A) a. experience increased pain.
B) b. have hypertensive episodes.
C) c. take longer to recover from the anesthesia.
D) d. have more postoperative bleeding than expected.

C) c. take longer to recover from the anesthesia.

On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time?
A) a. Auscultate for adventitious breath sounds.
B) b. Ask whether the patient has smoked recently.
C) c. Remind the patient about harmful effects of smoking.
D) d. Calculate the cigarette smoking history in pack-years.

A) a. Auscultate for adventitious breath sounds.

A patient is seen at the health care provider's office several weeks before hip surgery for preoperative assessment. The patient reports use of echinacea, saw palmetto, and glucosamine/chondroitin. The nurse should
A) a. ascertain that there will be no interactions with anesthetic agents.
B) b. discuss the supplement use with the patient's health care provider.
C) c. teach the patient that these products may be continued preoperatively.
D) d. advise the patient to stop the use of all herbs and supplements at this time.

B) b. discuss the supplement use with the patient's health care provider.

Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, "I do not really understand what the doctor said." Which action is best for the nurse to take?
A) a. Provide an explanation of the planned surgical procedure.
B) b. Notify the surgeon that the informed consent process is not complete.
C) c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications.
D) d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

B) b. Notify the surgeon that the informed consent process is not complete.

Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection?
A) a. Care for the surgical incision
B) b. Medications used during surgery
C) c. Deep breathing and coughing techniques
D) d. Oral antibiotic therapy after discharge home

C) c. Deep breathing and coughing techniques

Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse is to
A) a. assist the patient to the bathroom and stay with the patient to prevent falls.
B) b. offer a urinal or bedpan and position the patient in bed to promote voiding.
C) c. allow the patient up to the bathroom because the onset of the medication takes more than 10 minutes.
D) d. ask the patient to wait because catheterization is performed at the beginning of the surgical procedure.

B) b. offer a urinal or bedpan and position the patient in bed to promote voiding.

An alert 82-year-old who has poor hearing and vision is receiving preoperative teaching from the nurse. His wife answers most questions directed to the patient. Which action should the nurse take when doing the teaching?
A) a. Use printed materials for instruction so that the patient will have more time to review the material.
B) b. Direct the teaching toward the wife because she is the obvious support and caregiver for the patient.
C) c. Provide additional time for the patient to understand preoperative instructions and carry out procedures.
D) d. Ask the patient's wife to wait in the hall in order to focus preoperative teaching with the patient himself.

C) c. Provide additional time for the patient to understand preoperative instructions and carry out procedures.

A diabetic patient who uses insulin to control blood glucose has been NPO since midnight before having a mastectomy. The nurse will anticipate the need to
A) a. withhold the usual scheduled insulin dose because the patient is NPO.
B) b. obtain a blood glucose measurement before any insulin administration.
C) c. give the patient the usual insulin dose because stress will increase the blood glucose.
D) d. administer a lower dose of insulin because there will be no oral intake before surgery.

B) b. obtain a blood glucose measurement before any insulin administration.

The clinic nurse reviews the complete blood cell count (CBC) results for a patient who is scheduled for surgery in a few days. The results are white blood cell count (WBC) 10.2 ´ 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 ´ 103/µL. Which action should the nurse take?
A) a. Send the CBC results to the surgery facility.
B) b. Call the surgeon and anesthesiologist immediately.
C) c. Ask the patient about any symptoms of a recent infection.
D) d. Discuss the possibility of blood transfusion with the patient

A) a. Send the CBC results to the surgery facility.

As the nurse prepares a patient the morning of surgery, the patient refuses to remove a wedding ring, saying, "I have never taken it off since the day I was married." The nurse should
A) a. have the patient sign a release and leave the ring on.
B) b. tape the wedding ring securely to the patient's finger.
C) c. tell the patient that the hospital is not liable for loss of the ring.
D) d. suggest that the patient give the ring to a family member to keep.

B) b. tape the wedding ring securely to the patient's finger.

The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to
A) a. ensure the proper identification of the patient before surgery.
B) b. protect the patient from cross-contamination with other patients.
C) c. assist the perioperative nurse to obtain a complete patient history.
D) d. help relieve the stress of separation for the patient and significant others.

D) d. help relieve the stress of separation for the patient and significant others.

Which description best defines the role of the nurse anesthetist as a member of the surgical team?
A) a. Functions independently in the administration of anesthetics
B) b. Has the same credentials and responsibilities as an anesthesiologist
C) c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist
D) d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient

A) a. Functions independently in the administration of anesthetics

Which outcome measure will be best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room?
A) a. Smooth functioning of the OR team
B) b. Effective protection of patient privacy
C) c. Rapid completion of surgical procedure
D) d. Low incidence of perioperative infection

D) d. Low incidence of perioperative infection

Which action will the scrub nurse use to maintain aseptic technique during surgery?
A) a. Use waterproof shoe covers.
B) b. Wear personal protective equipment.
C) c. Insist that all operating room (OR) staff perform a surgical scrub.
D) d. Change gloves after touching the upper arm of the surgeon's gown.

D) d. Change gloves after touching the upper arm of the surgeon's gown.

After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member
A) a. documents all patient care accurately.
B) b. labels all specimens to send to the lab.
C) c. keeps both hands above the operating table level.
D) d. takes the patient to the postanesthesia recovery area.

C) c. keeps both hands above the operating table level.

Data that were obtained during the perioperative nurse's assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include
A) a. a stated allergy to cats and dogs.
B) b. a history of spinal and hip arthritis.
C) c. verbalization of anxiety by the patient.
D) d. having a sip of water 2 hours previously.

B) b. a history of spinal and hip arthritis.

The nurse from the general surgical unit is asked to bring the patient's hearing aid to the surgical suite. The nurse will take the hearing aid to the
A) a. clean core.
B) b. scrub sink areas.
C) c. nursing station or information desk.
D) d. corridors of the operating room area.

C) c. nursing station or information desk.

preoperative patient in the holding area asks the nurse, "Will the doctor put me to sleep with a mask over my face?" The most appropriate response by the nurse is,
A) a. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately."
B) b. "Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?"
C) c. "General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face."
D) d. "Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep."

A) a. "A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately"

A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for
A) a. tachypnea.
B) b. myoclonia.
C) c. hypertension.
D) d. incisional pain.

D) d. incisional pain.

When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the
A) a. surgeon.
B) b. anesthesiologist.
C) c. circulating nurse.
D) d. registered nurse first assistant (RNFA).

B) b. anesthesiologist.

A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation with monitored anesthesia care (MAC). The nurse anticipates the administration of
A) a. IV midazolam (Versed).
B) b. inhaled desflurane (Suprane).
C) c. epidural lidocaine (Xylocaine).
D) d. eutectic mixture of local anesthetics (EMLA).

A) a. IV midazolam (Versed).

Which action will the nurse include in the plan of care immediately after surgery for a patient who received ketamine (Ketalar) as an anesthetic agent?
A) a. Administer larger doses of analgesic agents.
B) b. Monitor for severe slowing of the heart rate.
C) c. Provide a quiet environment in the postanesthesia care unit.
D) d. Avoid the use of benzodiazepines in the postoperative period.

C) c. Provide a quiet environment in the postanesthesia care unit.

A patient's family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that
A) a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications.
B) b. as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction should not occur.
C) c. surgery must be performed under local anesthetic to prevent development of a sudden, extreme increase in body temperature.
D) d. surgery will be delayed until the patient is genetically tested to determine whether he or she is susceptible to malignant hyperthermia.

A) a. anesthesia can be administered with minimal risks with the use of appropriate precautions and medications.

A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. At completion of the surgery, it is most important that the nurse monitor the patient for
A) a. nausea.
B) b. confusion.
C) c. bronchospasm.
D) d. weak chest-wall movement.

D) d. weak chest-wall movement.

Which action by an inexperienced member of the surgical team requires rapid intervention by the charge nurse?
A) a. Wearing street clothes into the nursing station
B) b. Wearing a surgical mask into the holding room
C) c. Walking into the hallway outside an operating room without the hair covered
D) d. Putting on a surgical mask, cap, and scrubs before entering the operating room

C) c. Walking into the hallway outside an operating room without the hair covered

A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to
A) a. increase the rate of the IV fluid replacement.
B) b. continue to take vital signs every 15 minutes.
C) c. administer oxygen therapy at 100% per mask.
D) d. notify the anesthesia care provider (ACP) immediately.

B) b. continue to take vital signs every 15 minutes.

During recovery from anesthesia in the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?
A) a. Place the patient in a side-lying position.
B) b. Encourage the patient to take deep breaths.
C) c. Prepare to transfer the patient from the PACU.
D) d. Increase the rate of the postoperative IV fluids.

B) b. Encourage the patient to take deep breaths.

After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse
A) a. places a patient in the Trendelenburg position when the blood pressure (BP) drops.
B) b. assists a patient to the prone position when the patient is nauseated.
C) c. turns an unconscious patient to the side when the patient arrives in the PACU.
D) d. positions a newly admitted unconscious patient supine with the head elevated.

C) c. turns an unconscious patient to the side when the patient arrives in the PACU.

A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, "I do not know if I can take care of myself with this patch over my eye." The most appropriate nursing action is to
A) a. refer the patient for home health care services.
B) b. discuss the specific concerns regarding self-care.
C) c. give the patient written instructions regarding care.
D) d. assess the patient's support system for care at home.

B) b. discuss the specific concerns regarding self-care.

After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?
A) a. Reinsert the NG tube.
B) b. Give the PRN IV opioid.
C) c. Assist the patient to ambulate.
D) d. Place the patient on NPO status.

C) c. Assist the patient to ambulate.

Following gallbladder surgery, a patient's T-tube is draining dark green fluid. Which action should the nurse take?
A) a. Place the patient on bed rest.
B) b. Notify the patient's surgeon.
C) c. Document the color and amount of drainage.
D) d. Irrigate the T-tube with sterile normal saline.

C) c. Document the color and amount of drainage.

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?
A) a. Discuss the complications of immobility and poor cough effort.
B) b. Teach the patient the purpose of respiratory care and ambulation.
C) c. Administer ordered analgesic medications before these activities.
D) d. Give the patient positive reinforcement for accomplishing these activities.

C) c. Administer ordered analgesic medications before these activities

The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the
A) a. patient drinks 2 to 3 L of fluid in 24 hours.
B) b. patient uses the spirometer 10 times every hour.
C) c. patient's breath sounds are clear to auscultation.
D) d. patient's temperature is less than 100.4° F orally.

C) c. patient's breath sounds are clear to auscultation.

. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient's oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?
A) a. Insert an oral or nasal airway.
B) b. Notify the anesthesia care provider.
C) c. Orient the patient to time, place, and person.
D) d. Be sure that the patient's IV lines are secure.

D) d. Be sure that the patient's IV lines are secure.

Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?
A) a. Help with the transfer of the patient onto a stretcher.
B) b. Give a verbal report to the surgical unit charge nurse.
C) c. Document the appearance of the patient's incision in the chart.
D) d. Ensure that the receiving nurse understands the postoperative orders.

A) a. Help with the transfer of the patient onto a stretcher.

When a patient is transferred from the postanesthesia care unit (PACU) to the clinical surgical unit, the first action by the nurse on the surgical unit should be to
A) a. assess the patient's pain.
B) b. take the patient's vital signs.
C) c. read the postoperative orders.
D) d. check the rate of the IV infusion.

B) b. take the patient's vital signs.

An 83-year-old who had a surgical repair of a hip fracture 2 days previously has restrictions on ambulation. Based on this information, the nurse identifies the priority collaborative problem for the patient as
A) a. potential complication: hypovolemic shock.
B) b. potential complication: venous thromboembolism.
C) c. potential complication: fluid and electrolyte imbalance.
D) d. potential complication: impaired surgical wound healing.

B) b. potential complication: venous thromboembolism.

A patient who is just waking up after having a general anesthetic is agitated and confused. Which action should the nurse take first?
A) a. Check the O2 saturation.
B) b. Administer the ordered opioid.
C) c. Take the blood pressure and pulse.
D) d. Notify the anesthesia care provider.

A) a. Check the O2 saturation.

A postoperative patient has not voided for 7 hours after return to the postsurgical unit. Which action should the nurse take first?
A) a. Notify the surgeon.
B) b. Perform a bladder scan.
C) c. Assist the patient to ambulate to the bathroom.
D) d. Insert a straight catheter as indicated on the PRN order.

B) b. Perform a bladder scan.

While caring for a patient with abdominal surgery the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this finding, the nurse should first
A) a. reinforce the dressing.
B) b. take the patient's vital signs.
C) c. recheck the dressing in 1 hour for increased drainage.
D) d. notify the patient's surgeon of a potential hemorrhage.

B) b. take the patient's vital signs.

During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
A) a. decreased fluid volume.
B) b. jugular vein atherosclerosis.
C) c. elevated right atrial pressure.
D) d. incompetent jugular vein valves.

C) c. elevated right atrial pressure.

The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is
A) a. weight loss of 2 pounds overnight.
B) b. hourly urine output greater than 60 mL.
C) c. reduction in patient complaints of chest pain.
D) d. decreased dyspnea with the head of bed at 30 degrees.

D) d. decreased dyspnea with the head of bed at 30 degrees.

Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%?
A) a. Need to participate in an aerobic exercise program several times weekly
B) b. Use of salt substitutes to replace table salt when cooking and at the table
C) c. Importance of making a yearly appointment with the primary care provider
D) d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

D) d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors

Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to adjust the nitroprusside rate if the patient develops
A) a. a dry, hacking cough.
B) b. any ventricular ectopy.
C) c. a systolic BP <90 mm Hg.
D) d. a heart rate <50 beats/minute.

C) c. a systolic BP <90 mm Hg.

A patient who has chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment information as
A) a. pulsus alternans.
B) b. two-pillow orthopnea.
C) c. acute bilateral pleural effusion.
D) d. paroxysmal nocturnal dyspnea.

D) d. paroxysmal nocturnal dyspnea.

During a visit to a 72-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain, and complains of "feeling too tired to do anything." Based on these data, the best nursing diagnosis for the patient is
A) a. activity intolerance related to fatigue.
B) b. disturbed body image related to leg swelling.
C) c. impaired skin integrity related to peripheral edema.
D) d. impaired gas exchange related to chronic heart failure.

A) a. activity intolerance related to fatigue.

The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient
A) a. uses an additional pillow to sleep when feeling short of breath at night.
B) b. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime.
C) c. calls the clinic when the weight increases from 124 to 130 pounds in a week.
D) d. says that the nitroglycerin patch will be used for any chest pain that develops.

C) c. calls the clinic when the weight increases from 124 to 130 pounds in a week.

When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be restricted include
A) a. canned and frozen fruits.
B) b. fresh or frozen vegetables.
C) c. milk, yogurt, and other milk products.
D) d. eggs and other high-cholesterol foods.

C) c. milk, yogurt, and other milk products.

The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide (HydroDIURIL). Appropriate instructions for the patient include
A) a. avoid dietary sources of potassium.
B) b. take the hydrochlorothiazide before bedtime.
C) c. notify the health care provider about any nausea.
D) d. never take digoxin if the pulse is below 60 beats/minute

C) c. notify the health care provider about any nausea.

While admitting an 80-year-old with heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate
A) a. transfer to a dementia care service.
B) b. referral to a home health care agency.
C) c. placement in a long-term care facility.
D) d. arrangements for around-the-clock care.

B) b. referral to a home health care agency.

Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about
A) a. angiotensin-converting enzyme (ACE) inhibitors.
B) b. digitalis preparations.
C) c. b-adrenergic agonists.
D) d. calcium channel blockers.

A) a. angiotensin-converting enzyme (ACE) inhibitors.

A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate?
A) a. "Since you are diabetic, you would not be a candidate for a heart transplant."
B) b. "The choice of a patient for a heart transplant depends on many different factors."
C) c. "Your heart failure has not reached the stage in which heart transplants are considered."
D) d. "People who have heart transplants are at risk for multiple complications after surgery."

B) b. "The choice of a patient for a heart transplant depends on many different factors."

. Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure?
A) a. Serum creatine kinase (CK)
B) b. Arterial blood gases (ABGs)
C) c. B-type natriuretic peptide (BNP)
D) d. 12-lead electrocardiogram (ECG)

C) c. B-type natriuretic peptide (BNP)

Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)?
A) a. Monitor blood pressure frequently.
B) b. Encourage patient to ambulate in room.
C) c. Titrate nesiritide rate slowly before discontinuing.
D) d. Teach patient about safe home use of the medication.

A) a. Monitor blood pressure frequently.

A patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After administering the first dose and teaching the patient about captopril, which statement by the patient indicates that teaching has been effective?
A) a. "I will call for help when I need to get up to use the bathroom."
B) b. "I will be sure to take the medication after eating something."
C) c. "I will need to include more high-potassium foods in my diet."
D) d. "I will expect to feel more short of breath for the next few days."

A) a. "I will call for help when I need to get up to use the bathroom."

1) Which of the following is not found in acute decompensated heart failure?
A. ORTHOPNEA
B. TACHYCARDIA
C. DYSPNEA
D. UNPRODUCTIVE COUGH

D. UNPRODUCTIVE COUGH

2) Which patient should the nurse attend to first?
A. Diabetic patient experiencing an increased blood sugar at 8am in the morning.
B. Influenza patient experiencing a fever spike of 100.0 F
C. Pneumonia patient experiencing productive cough with green sputum.
D. Heart failure patient experiencing abnormal (symptomatic) Bradycardia at rest.

D. Heart failure patient experiencing abnormal (symptomatic) Bradycardia at rest.

3) What statement by a pre-operative patient indicates the need for further teaching by the nurse?
A. Someone will help take care of my home.
B. I can drive myself home after surgery.
C. My brother will bring his pet gerbil to keep me entertained.
D. I'll notify the health care provider if I develop a fever.

B. I can drive myself home after surgery.

4) To improve gas exchange and oxygenation for a patient with heart failure, what nursing management should be implemented?
A. Check vital signs
B. Place patient in high Fowlers position.
C. Place patient in semi-Fowlers position.
D. Administer diuretic.

B. Place patient in high Fowlers position.

5) Which of the following is not effective nursing management of heart failure?
A. High Fowlers position
B. Assisting with rigorous exercise 2x a day
C. Daily weights, intake & output monitoring
D. Continuous EKG monitoring

B. Assisting with rigorous exercise 2x a day

6) Which of the following is not a correct nursing and collaborative management action for heart failure?
A. High Fowlers position
B. Improve gas exchange and oxygenation
C. Increase fluid intake
D. ECG monitoring

C. Increase fluid intake

7) Which test is most important for the nurse to carry out if heart failure is suspected in a patient?
A.12-lead EKG
B. BNP
C. ABG
D. Exercise treadmill testing

B. BNP

8) A nurse is assessing the client with left sided heart failure. The client states that he needs to use 3 pillows under the head and chest at night to be able to breathe comfortably while sleeping. The documents that the client is experience:
A. ORTHOPNEA
B. DYSPNEA at rest
C. DYSPNEA on exertion
D. Paroxysmal nocturnal dyspnea

D. Paroxysmal nocturnal dyspnea

9) How does a nurse assess for dysrhythmias?
A. 12 lead EKG
B. Listen to lung sounds
C. blood test
D. Urine sample

A. 12 lead EKG

10) A patient with potential heart failure enters the emergency room. What symptom should the nurse not consider for heart failure?
A. cyanosis, cold and clammy skin
B. lung sounds-- crackling and wheezing
C. orthopnea, shortness of breath
D. tightness & burning from the chest

D. tightness & burning from the chest

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