30 Med Surge Q's
MS Q's (Cardiovascular)
* Answers w/ Rationale to be posted after 2-3 days...
1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?
A. "The pain lasted for about 45 minutes."
B. "The pain resolved after I ate a sandwich."
C. "The pain worsened when I took a deep breath."
D. "The pain occurred while I was mowing the lawn."
2. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
A. right-sided heart failure.
B. acute pulmonary edema.
C. pneumonia.
D. cardiogenic shock.
3. A client with a history of chronic obstructive pulmonary disease (COPD) develops right-sided heart failure. Which symptom is common in this disorder?
A. Respiratory acidosis
B. Hypertension
C. Dyspnea
D. Jugular vein distention
4. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms
5. A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
A. negative history of tonic-clonic seizures.
B. ampule of naloxone (Narcan) at the bedside.
C. continuous electrocardiogram (ECG) monitoring.
D. up-to-date activated partial thromboplastin time (APTT) result in his record.
6. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence
7. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength
8. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain
9. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.
10. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility
11. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD)?
A. neffective thermoregulation
B. Impaired gas exchange
C. Risk for injury
D. Decreased cardiac output
12. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:
A. hypertension.
B. high urine output.
C. dry mucous membranes.
D. pulmonary crackles.
13.A client with severe left-sided heart failure has a decrease in the total amount of blood ejected per minute. This quantity is known as:
A. stroke volume.
B. ejection fraction.
C. cardiac output.
D. heart rate.
14. Which statement from a client who takes nitroglycerin (Nitrostat) as needed for anginal pain indicates that further teaching is necessary?
A. "I store the tablets in a dark bottle."
B."I take the tablet with a full glass of water."
C. "I check for my tongue to tingle when I take a tablet."
D. "I'll go to the hospital if three tablets, 5 minutes apart, don't relieve the pain."
15. The nurse is caring for a client taking an anticoagulant. The nurse should teach the client to:
A. report incidents of diarrhea.
B. avoid foods high in vitamin K.
C. use a straight razor when shaving.
D. take aspirin for pain relief.
16. In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:
A. vestibular dysfunction.
B. sudden vascular fluid shifting.
C. postural hypotension.
D. bradyrhythmia.
17. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
A. realize the surgeon has the right to refuse to care for the client.
B. advise the surgeon to arrange for an alternate cardiac surgeon.
C. tell the client that she can donate her own blood for the procedure.
D. inform the client that her decision could shorten her life.
18. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
A. administer oxygen.
B. have the client take deep breaths and cough.
C. place the client in high Fowler's position.
D. perform chest physiotherapy.
19. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
A. narrowing complex.
B. widening complex.
C. amplitude increase.
D. amplitude decrease.
21. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
22. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
23. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
C. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
24. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature?
A. Oral
B. Rectal
C. Axillary
D. Tympanic
25. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion
26. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. a skin rash.
B. peripheral edema.
C. a dry cough.
D. postural hypotension.
27. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.
28. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly
29. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis
30. Murmurs that indicate heart disease are commonly accompanied by other symptoms such as:
A. dyspnea on exertion.
B. subcutaneous emphysema.
C. thoracic petechiae.
D. periorbital edema.
* Answers w/ Rationale to be posted after 2-3 days...
1. When assessing a client with chest pain, the nurse obtains a thorough history. Which statement by the client is most suggestive of angina pectoris?
A. "The pain lasted for about 45 minutes."
B. "The pain resolved after I ate a sandwich."
C. "The pain worsened when I took a deep breath."
D. "The pain occurred while I was mowing the lawn."
2. A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:
A. right-sided heart failure.
B. acute pulmonary edema.
C. pneumonia.
D. cardiogenic shock.
3. A client with a history of chronic obstructive pulmonary disease (COPD) develops right-sided heart failure. Which symptom is common in this disorder?
A. Respiratory acidosis
B. Hypertension
C. Dyspnea
D. Jugular vein distention
4. Which client characteristic would be an example of noncompliance?
A. Undesired drug action
B. Multiple questions
C. Failure to progress
D. Resolved symptoms
5. A client with refractory angina is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The cardiologist orders an infusion of abciximab (ReoPro). Before beginning the infusion, the nurse should ensure the client has:
A. negative history of tonic-clonic seizures.
B. ampule of naloxone (Narcan) at the bedside.
C. continuous electrocardiogram (ECG) monitoring.
D. up-to-date activated partial thromboplastin time (APTT) result in his record.
6. A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, is withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice the client demands the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis what is an appropriate goal for this client?
A. Identifying one way to increase social interaction
B. Reporting increased adaptation to changes in health status
C. Identifying at least one factor contributing to altered sexuality patterns
D. Returning a demonstration of measures that can increase independence
7. When developing a plan of care for an older adult the nurse should consider which challenges faced by clients in this age group?
A. Selecting vocation, becoming financially independent, and managing a home
B. Developing leisure activities, preparing for retirement, and resolving empty nest crisis
C. Managing a home, developing leisure activities, and preparing for retirement
D. Adjusting to retirement, deaths of family members, and decreased physical strength
8. Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports midsternal chest pain radiating down the left arm. The nurse notices that the client is restless and slightly diaphoretic, and measures a temperature of 99.6° F (37.6° C), a heart rate of 102 beats/minute; regular, slightly labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes highest priority?
A. Risk for imbalanced body temperature
B. Decreased cardiac output
C. Anxiety
D. Acute pain
9. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position possible.
C. instructing the client not to get out of bed without assistance.
D. keeping the bedpan available so that the client doesn't have to get out of bed.
10. While caring for a client who is immobile, the nurse documents the following information in the client's chart: "Turn client from side to back every two hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?
A. Risk for impaired skin integrity related to immobility
B. Impaired skin integrity related to immobility
C. Constipation related to immobility
D. Disturbed body image related to immobility
11. Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD)?
A. neffective thermoregulation
B. Impaired gas exchange
C. Risk for injury
D. Decreased cardiac output
12. A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." The CSU nurse should be especially observant for:
A. hypertension.
B. high urine output.
C. dry mucous membranes.
D. pulmonary crackles.
13.A client with severe left-sided heart failure has a decrease in the total amount of blood ejected per minute. This quantity is known as:
A. stroke volume.
B. ejection fraction.
C. cardiac output.
D. heart rate.
14. Which statement from a client who takes nitroglycerin (Nitrostat) as needed for anginal pain indicates that further teaching is necessary?
A. "I store the tablets in a dark bottle."
B."I take the tablet with a full glass of water."
C. "I check for my tongue to tingle when I take a tablet."
D. "I'll go to the hospital if three tablets, 5 minutes apart, don't relieve the pain."
15. The nurse is caring for a client taking an anticoagulant. The nurse should teach the client to:
A. report incidents of diarrhea.
B. avoid foods high in vitamin K.
C. use a straight razor when shaving.
D. take aspirin for pain relief.
16. In caring for a client with vasovagal syncope, the nurse should know that the associated temporary loss of consciousness is most commonly related to:
A. vestibular dysfunction.
B. sudden vascular fluid shifting.
C. postural hypotension.
D. bradyrhythmia.
17. A client with mitral valve prolapse is advised to have elective mitral valve replacement. Because the client is a Jehovah's Witness, she declares in her advance directive that no blood products are to be administered. As a result, the consulting cardiac surgeon refuses to care for the client. It would be most appropriate for the nurse caring for the client to:
A. realize the surgeon has the right to refuse to care for the client.
B. advise the surgeon to arrange for an alternate cardiac surgeon.
C. tell the client that she can donate her own blood for the procedure.
D. inform the client that her decision could shorten her life.
18. The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
A. administer oxygen.
B. have the client take deep breaths and cough.
C. place the client in high Fowler's position.
D. perform chest physiotherapy.
19. The nurse may use one of the many nursing theories to guide client care. What are the four key concepts of most nursing theories?
A. Man, health, illness, and health care
B. Health, illness, health restoration, and caring
C. Man, environment, health, and nursing
D. Health, environment, disease, and treatment
Rationale: Most nursing theories deal with the key concepts of man (or person — the individual), the environment (external conditions affecting life and development), health (optimal functioning), and nursing. Illness, health care, health restoration, caring, disease, and treatment are concepts addressed by specific theorists.
20. Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead II electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is:
A. narrowing complex.
B. widening complex.
C. amplitude increase.
D. amplitude decrease.
21. A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain related to surgery
B. Deficient fluid volume related to blood and fluid loss from surgery
C. Impaired physical mobility related to surgery
D. Risk for aspiration related to anesthesia
22. Which type of evaluation occurs continuously throughout the teaching and learning process?
A. Formative
B. Retrospective
C. Summative
D. Informative
23. A client with a history of heart failure is examined in the outpatient department to investigate the recent onset of peripheral edema and increased shortness of breath. Physical findings include bilateral crackles, a third heart sound (S3), distended neck veins, elevated blood pressure, and pitting edema of the ankles. The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
A. Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
B. Detectable depression of less than 5 mm when the thumb is released from the swollen area; normal foot and leg contours
C. A 5- to 10-mm depression when the thumb is released from the swollen area; foot and leg swelling
D. A depression of more than 1 cm when the thumb is released from the swollen area; severe foot and leg swelling
24. A client is admitted with a suspected diagnosis of an acute myocardial infarction. When providing care for the client, the nurse should avoid which route when taking a temperature?
A. Oral
B. Rectal
C. Axillary
D. Tympanic
25. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?
A. Deficient fluid volume
B. Excess fluid volume
C. Decreased cardiac output
D. Ineffective gastrointestinal tissue perfusion
26. A client is receiving captopril (Capoten) for heart failure. The nurse should notify the physician that the medication therapy is ineffective if an assessment reveals:
A. a skin rash.
B. peripheral edema.
C. a dry cough.
D. postural hypotension.
27. One aspect of implementation related to drug therapy is:
A. developing a content outline.
B. documenting drugs given.
C. establishing outcome criteria.
D. setting realistic client goals.
28. After a cerebrovascular accident (CVA) a client develops aphasia. Which assessment finding is most typical in aphasia?
A. Arm and leg weakness
B. Absence of the gag reflex
C. Difficulty swallowing
D. Inability to speak clearly
29. Which intervention is an example of a primary prevention?
A. Administering digoxin (Lanoxicaps) to a client with heart failure
B. Administering a measles, mumps, and rubella immunization to an infant
C. Obtaining a Papanicolaou (Pap) test to screen for cervical cancer
D. Using occupational therapy to help a client cope with arthritis
30. Murmurs that indicate heart disease are commonly accompanied by other symptoms such as:
A. dyspnea on exertion.
B. subcutaneous emphysema.
C. thoracic petechiae.
D. periorbital edema.
posted by UNDERGROUND at 1:22 AM
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