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Med Surg 2 All Exam Questions
Exam 1, 2 & 3
1. A client is sent home with a Holter monitor. The most important information the client should receive from the nurse a. Keep a record of daily activities 2. A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? a. Allergy to iodine or shellfish. 3. In developing a standard teaching plan for the outpatient unit where stress testing is performed, the nurse should include information that: a. The test may cause the client to experience chest pain 4. The diagnostic study that should provide the nurse with the most relevant information related to cardiac perfusion is a. Thallium 201 scintigoraphy 5. In advising a client with higher levels of HDL in proportion to LDL, an appropriate outcome is that this client: a. Is less likely to develop CAD 6. Nursing care of a client immediately after a PTCA should include: a. Encouraging oral fluids for the client 7. A nurse is caring for a client who has had angiography with the entrance site in the left femoral artery. 2 hours after the procedure, the nurse is unable to palpate the left pedal pulse. The priority action at this time would be to: a. Attempt to locate pulse using a Doppler 8. The client participates in a thallium imaging during exercise. The nuclear camera results obtained 10 minutes later show diffuse uptake of the thallium in all areas of the heart. What does this mean for the nurse? a. The test shows no myocardial scarring or impairment of myocardial perfusion 9. The CK-MB level is markedly elevated in a client with chest pain 12 hours after admission. The nurse interprets this finding as evidence of: a. Cellular tissue necrosis 10. CK-MB and troponin levels are ordered for a client. The client asks the nurse for the test. The nurse bases the response on the knowledge that: a. The presence of myocardial damage occurring several days earlier can be validated best by the troponin level. (P.743 text: often as long as 3 weeks, and it therefore can be used to detect recent myocardial damage) 11. The nurse is about to perform a physical assessment of the distal extremities for a client with Buerger’s disease. What clinical manifestations should the nurse expect to see in this client? a. Extremities are reddened and distal pulses are diminished 12. A nurse caring for a client who is overweight, HTN, and smokes is newly diagnosed with thromboangitis obliterans (Buerger’s disease). The priority for teaching should focus on: a. Smoking cessation
13. After walking one block the client complains of muscular, cramp-like pain to his lower extremities that is relieved by rest. Based on the clinical findings, the nurse should further assess the patient for possible: a. Peripheral arterial disease 14. A client comes to the health care provider with complaints of pain after walking five blocks is experiencing intermittent claudication, the nurse should ask: a. Does pain always occur when you walk that distance? 15. A female client with severe arterial disease has difficulty falling asleep due to pain in her legs. The first action by the nurse would be to: a. Assist the client to dangle her legs 16. A nurse is educating a client who has Raynaud’s disease. Which intervention is aimed at preventing complications? a. Wear warm clothing when exposed to cool temperature 17. A client who has returned to the unit after arterial revascularization states, “The pain is similar to the pain felt before the procedure.” What would be the nurse’s priority action? a. Assess peripheral pulses of the extremities 18. A client recovering from aortofemoral bypass surgery has developed swelling, pain, and complains of tightness of the operative limb. What complication of the procedure is most likely the cause of the client’s symptoms? a. Compartment syndrome 19. A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The nurse interprets that the neurovascular status is : a. Normal because of increased blood flow through the leg 20. A nurse is caring for a client who has early peripheral vascular disease. While inspecting the lower extremities the nurse should expect to find: a. Decreased peripheral pulse 21. A nurse is caring for a young client who is brought to the ED after experiencing a rapid heart rate and chest discomfort. The client reports using cocaine adding that “everybody always tells me coke is bad for your heart. What does cocaine do?” The nurse should respond: a. “a fight or flight reaction occurs when cocaine is used, stressing the heart, often beyond its capacity. 22. A nurse is caring for a client who has an MI. The client reports chest pain and EKG shows intermittent premature ventricular contractions. The nurse’s first priority for this client would be to: a. Relief of pain and pain management 23. A client is admitted to the tele unit with a diagnosis of MI within the last 24 hours. The immediate care plan for this client should include which of the following measure: a. Use a bedpan commode for bowel movement 24. The client is undergoing progressive ambulation on the third day after an MI. Which clinical manifestation should indicate to the nurse that the client should not be advanced yet to the next level? a. Onset of chest pain
a. Bleeding ( P. 751 , complication after the procedure may include abrupt closure of the coronary artery. and variety of vascular complication such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion).
26. A nurse has just received a client from the cardiac cath lab. Nursing care of a client immediately after a PTCA should include: a. Encouraging oral fluids for the client 27. A nurse is monitoring a client with CHF. Which of the following would require further evaluation by the nurse? a. Weight gain of 1.5 pounds in 24 hours 28. A nurse in a cardiac step down unit is preparing discharge instruction, which includes dietary information. Which breakfast food recommendations should be most appropriate for a client with coronary heart disease? a. Skim milk, whole wheat toast, decaf coffee 29. While caring for a client with angina, the nurse plans interventions that decrease Myocardial oxygen demand and promote coronary blood flow. Appropriate interventions are those that primarily prevent: a. An increase in heart rate 30. A client who has experienced a myocardial infarction develops left ventricular heart failure. For which sign of poor organ perfusion should the nurse monitor this client? a. Urine output of <30ml/hr 31. A nurse is assessing a client who has a diagnosis of left ventricular heart failure. Which of the following statements if made by the client would be of concern to the nurse? a. I cannot climb the stair in my house without becoming short of breath. 32. A nurse should determine that teaching regarding a 2 gram Na diet for a client who has a history of cardiac disease, is effective if the client states: “ I can eat most foods as long as I do not add salt when cooking or at the table.” 33. When the client with left sided heart failure develops bilateral 2+ pitting edema of the ankles, the nurse should assess that this could be early manifestation of: a. Right sided failure
A client with CHF has tachypnea, severe dyspnea, and a SaO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange r/t increased preload & mechanical failure. An appropriate nursing intervention for this diagnosis is to:
Place the client in a high-fowlers position with the feet dangling.
The nurse has written an outcome goal “demonstrates tolerance for increased activity” for a client diagnosed with CHF. Which intervention should the nurse implement to assist the client to achieve this outcome?
Plan for frequent rest periods
34. A nurse is developing a teaching plan for a client with congestive heart failure, which of the following outcomes indicates to the nurse that the treatment is effective? All that apply
a. Clients weight today is 79.5 kg and yesterday’s weight was 80.2 kg b. Urinary output of 480cc over the previous 24 hours
should concern the nurse as indicating possible “target organ” damage? All that apply a. Retinal changes b. BUN 28 and creatinine 1.
c. Headaches
46. A client recently diagnosed with peripheral arterial disease reports in the lower extremities after walking five blocks. Which of the following questions should the nurse ask to determine if the disease is progressing? a. Do you have the pain while resting 47. The nurse is caring for a client who has been diagnosed with cardiovascular disease. Which of these assessment findings is most consistent with a nursing diagnosis of decreased cardiac output related to mechanical failure of heart? a. Diminished pedal pulses 48. The nurse and an UAP are caring for 4 clients on the tele unit. Which nursing task should the nurse delegate to the UAP? a. Help position the client who’s having a portable x-ray. 49. A care team composed of an RN, LPN, and UAP in a long-term care facility developed a plan for ongoing assessment of all residents who have a diagnosis of heart failure. Which of these activities included in the plan is most appropriate to delegate to nursing assistant staff? a. Weigh all residents with heart failure each morning 50. The client who has just had an IV started in the right cephalic vein tells the nurse that the wrist and hand below the IV site feels like there are “pins and needles” in them. What is the nurse’s next action should be to? a. Discontinue the IV and restart it at another site
- A nurse should inform a client who is diagnosed with angina that angina pain usually differs from the pain of a myocardial infarction (MI) in that angina pain
-Is often relieved by rest.
- While caring for a client with angina, the nurse plans interventions that decrease myocardial oxygen demand and promote coronary blood flow. Appropriate interventions are those that primarily prevent
-An increase in heart rate
- When instructing a client in the proper administration of sublingual nitroglycerin (NTG), the nurse should include in the teaching plan that the client should
-Repeat the dosage every 5 minutes for three times if pain is not relieved.
- A nurse is instructing a client who has stable angina. Which of these client responses would indicate to the nurse that the client has a proper understanding of their conditions? - “My chest pain can occur if I overexert myself.”
- Why is the administration of aspirin recommended along with nitroglycerin when a client is experiencing angina-like chest pain?
- Aspirin inhibits platelet aggregation and clot formation
these lab values will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standards orders?
-Troponin
- A nurse is performing an assessment on a client who had a cardiac catheterization three hours ago. Which of the following findings would require immediate intervention?
-Catheterized extremity cold with decreased peripheral pulses.
A nurse is discussing pre-procedure instructions with a client who is scheduled for a resting ECG. Which of the following instructions should the nurse give to the client? You must lie as still as possible during the procedure
A client is admitted to the emergency room after developing severe chest pain while mowing the lawn. He has dull pain in the mid-chest area and a normal ECG. The physician orders a cardiac catheterization with coronary angiography and possible PTCA. The nurse prepares the client for the procedure by explaining that it is used to: visualize any blockages in the coronary arteries and, if necessary, to dilate an obstructed artery with the use of a small balloon
- A nurse is performing a cardiac assessment on a client. In auscultating heart sounds, the nurse hears the closure of the aortic and pulmonic valves. The nurse documents this as
-The S2 heart sound.
- A client who is admitted for chest pain asks the nurse the reason for having an exercise stress test. The nurse should explain to a client that an exercise ECG is useful as one means of detecting
-Coronary artery disease.
While ambulating a client, the nurse observes changes in mental status, orientation and chest pain. These manifestations would substantiate a nursing diagnosis of activity intolerance.
The nurse is preparing a community presentation for a group of women about risk factors for cardiovascular disease. Which of the following clients is at risk for CV disease? A woman (SELECT ALL THAT APPLY)
With elevated LDL levels
With abdominal obesity
A client with LV HF is discharged with a prescription for furosemide (Lasix) 40 mg p.o. daily. The client complains to the home care nurse that they need to get up several times during the night to urinate. The nurse’s first question should be, “What time do you take your daily furosemide?”
- A client is scheduled for a cardiac catheterization. Which of these actions should the nurse implement?
SELECT ALL THAT APPLY
-Check for iodine sensitivity
-Verify that written consent has been obtained
-Impairment of the contractile function of the ventricle.
- A nurse is assessing a client with left sided heart failure and finds bilateral 2+pitting edema of the ankles. Which of the following signs or symptoms should the nurse also anticipate findings?
-Jugular venous distention.
- A nurse is caring for a client with an admitting diagnosis of HF. The medical record contains a notation that the client is orthopnea. The most appropriate nursing intervention to assist with this client’s problem would be to
-Provide several additional pillows for sleeping.
- A client who experiences a MI develops left ventricular heart failure. For which sign of poor organ perfusion should the nurse monitor this client?
-Urine output of 50 mL in two hours
- A nurse is caring for a client with congestive heart failure. A priority assessment at this time would be to
-Obtain daily weights.
- The nurse assesses the complex marked as “A” on the following 6 second strip as a
-PVC (premature ventricular contraction).
- A client who has A-Fib is ambulating in the hallway on the coronary step down unit and suddenly tells the nurse, “I feel really dizzy.” After assisting the client to sit down, which of the following interventions should become a priority for the nurse?
SELECT ALL THAT APPLY
-Check the client’s apical heart rate.
-Take the client’s blood pressure.
- In reviewing an ECG tracing from a client undergoing preadmission testing for surgery, the nurse observes
A nurse is caring for a client admitted to the telemetry unit with dysrhythmias and left ventricular heart failure. Which of the following is a priority assessment for the nurse?
Auscultate breath sounds.
A nurse is caring for a client with episodes of PVCs. The client shows VFib on the telemetry at the nurse’s station. After validating the information, which action should the telemetry nurse implement first?
Call a STAT code.
- The nurse is caring for a client with newly diagnosed hypertension. What dietary teaching should be included in the plan of care for this client? - “Avoid the use of canned or processed foods.”
- A client is diagnosed with hypertension. Initial nursing assessment reveals a body mass index of 30, reports a sedentary lifestyle, and smoked half a pack of cigarettes daily. For the behavioral change with the most immediate and positive impact on his blood pressure, the nurse should focus on
-Regular exercise.
- A client is being treated for hypertension. Which of the following outcomes demonstrates to the nurse effective management of a client’s hypertension?
-There is no indication of target organ damage.
- The RN is teamed with a LPN in caring for a group of clients on the cardiac unit. Which action by the LPN indicated the need by the RN to intervene immediately? The LPN
-Assists a client to the bathroom 30 minutes after the client has returned from a cardiac catheterization. (because the pt. need to be on bed rest for 4-6 hours with keep affected extremity straight 1-2 hours)
- A client is admitted with a diagnosis of MI. Which information should the nurse include in the discharge planning?
-Begin walking for short periods every day. Chart 27-12 P. 750
- A nurse is caring for a client admitted to the hospital with a complaint of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states that there is no change in their pain level. Which of these actions should the nurse implement first?
-Notify the HCP.
- When a client with a history of coronary artery disease is at home and experiences chest pain or suspects they are having a heart attack, the HCP will typically advise the client to - Ingest aspirin
- Along with persistent, crushing chest pain, which clinical manifestation should lead the nurse to suspect the
client is experiencing a MI?
- Diaphoresis and cool, clammy skin (p.742/rr, p99: cool, pale, moist skin diaphoresis, nausea, fear, anxiety)
Exam 2 Pg. 9 - 15
1. A nurse is obtaining a history from an adult client who has cardiac valve disease. Which of the following questions should be most important for the nurse to ask? “Do you have: a. A childhood history of rheumatic fever?” 2. A client with a history of mitral valve stenosis is admitted for SOB. What pertinent data should the nurse expect from the client regarding a history of mitral valve stenosis? a. Elevated T waves on the ECG 3. A nurse is caring for a client who is taking digoxin, Lasix, and a ferrous sulfate. The tele monitor shows frequent ventricular dysrhythmias. The nurse interprets these findings to be consistent with a. K 3. 4. In evaluating a client’s ECG tracing, the nurse notes three small squares between the upstroke and downstroke of the QRS complex. The nurse should record the QRS complex as a. 0.12 seconds 5. The nurse evaluates the understanding of preoperative teaching with a client scheduled for CABG using a saphenous vein. The nurse determines that additional teaching is needed when the client states a. I will need to remain in the bed for 48 hours after my sx 6. A client one-day post op CABG. The client complains of chest pain. Which intervention should the nurse implement first? a. Assess the client’s chest dressing and vital signs 7. A nurse is teaching a client who has a demand pacemaker. Which of the following statements by the client would indicate a correct understanding of the teaching? This pacemaker functions by a. Firing the heart’s electrical activity when it drops below a present rate. 8. A client with an MI has undergone ECG. What changes in the ECG tracing should the nurse expect to see in this client? a. ST segment elevation, T wave inversion, abnormal Q wave 9. A nurse notes the mediastinal tubes of a client who is 6 hours post op following CABG surgery have stopped draining. Which action most appropriate for the nurse to take at this time? a. Notify the doctor 10. When performing cardiac auscultation on an apparently healthy adult with mitral regurgitation, the nurse should anticipate hearing a a. Systolic murmur 11. A client with mitral stenosis tells the nurse that she will not seek treatment for this disorder because she “doesn’t really feel that bad”. The nurse’s best response should be that untreated mitral stenosis can result in a. Develop of atrial thrombus 12. In caring for a client considering mechanical valve replacement surgery. The most essential determination for the health care team to make should be whether the client is able to a. Comply with the lifelong requirement for anticoagulant program 13. A nurse is preparing a client who has endocarditis for discharge. The nurse should instruct the client that to avoid further complications the client should
a. Notify the dentist who has invasive dental procedures are planned
14. A client with a medical diagnosis of aortic prolapsed is admitted to the tele unit and placed on BR with bathroom privileges. Based on a understanding of this disorder, a priority nursing diagnosis should be a. Decreased cardiac output 15. The UAP report to the nurse that a client admitted with a diagnosis of mitral valve prolapsed has a weight gain of 2 pounds since yesterday. The nurse evaluates that the amount of fluid is approximately ml. a. 1000 16. The nurse is caring for client on a step down unit. Prior to discharge the nurse will instruct the family of a client who has had a CABG regarding …All that apply a. Medication actions and side effects b. Physical activity restrictions c. Incisional care 17. A nurse caring for a client scheduled to have chest tubes removed. The nurse’s most appropriate action should be to a. Medicate for pain ½ hour before removal 18. When the chest tube detaches from the closed-chest drainage system and the client experiences sudden dyspnea, the nurse should a. Reconnect the chest tube to the system 19. The client is 12 hours post op after a thoracotomy for lung cancer. During a portable Chest XR procedure at the bedside, the lower chest tube tubing is accidently pulled out. What is the nurse’s best initial action? a. Cover the insertion site with Vaseline or occlusive gauze 20. A nurse evaluates that the intervention carried out to promote airway clearance in the client with COPD are successful, based on finding that the a. Client has effective and productive coughing 21. The nurse identifies a goal of improving nutrition for a client with recent weight loss following an exacerbation of COPD. An appropriate intervention to achieve this goal is a. Order a high calorie, high protein diet divided into six small meals a day 22. The nurse teaches the client to with COPD how to perform pursed lip breathing, explaining that this technique will assist respiration by: Preventing collapse of small airways in the lungs during expiration Slowing the respiratory rate and giving the client control of resp. patterns 23. A client was scheduled for bronchoscopy and was given pre-procedure instructions by the RN. Which statements made by the client would indicate need for further teaching? “I may swallow the anesthetic sprayed in my throat before the procedure” 24. A client with COPD has a barrel chest. The nurse should expect the results of a chest x-ray to reveal Over inflation of the alveoli with air 25. The client has COPD. Which intervention for airway management should the nurse delegate to the nursing assistant? Assist client to sit up on side of bed
