Deck 1: Adult Health

Question 1

A 62-year-old client is scheduled for open abdominal aneurysm repair.  What key assessment should be made by the nurse preoperatively?

A)Assess and compare blood pressure in each arm
B)Assess character and quality of peripheral pulses
C)Assess for presence or absence of hair on lower extremities
D)Assess for presence of bowel sounds

Answer 1

Assess character and quality of peripheral pulses

Question 2

The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department.  Which hospital protocol would be the most appropriate to follow initially?

A)Food poisoning
B)Influenza
C)Myocardial infarction
D)Stroke

Answer 2

Myocardial infarction

Question 3

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside.  Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded.  Which is the priority nursing action?

A)Auscultate the client's lungs
B)Check the client's capillary refill
C)Measure the client's blood pressure
D)Review the client's electrocardiogram (ECG)

Answer 3

Measure the client's blood pressure

Question 4

The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure.  Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%.  Which of these findings supports the diagnosis of acute heart failure exacerbation?

A)B-type natriuretic peptide (BNP) 1382 pg/mL [1382 pmol/L]
B)Flat jugular veins when seated at a 45-degree angle
C)Sodium 150 mEq/L [150 mmol/L]
D)Urine output greater than 100 mL/hr

Question 5

A client is in suspected shock state from major trauma.  Which parameters best indicate the adequacy of peripheral perfusion?  Select all that apply.

A)Apical pulse
B)Capillary refill
C)Lung sounds
D)Pupillary response
E)Skin color and temperature

Question 6

A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient.  The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI.  What teaching should the nurse initiate with this client?

A)If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP
B)Inform the client that medications such as sildenafil or tadalafil are available as prescriptions from the HCP
C)It will be 6 months before the heart is healthy enough for sexual activity
D)The client will be ready for sexual activity after completion of cardiac rehabilitation

Question 7

A client is hospitalized with worsening chronic heart failure.  Which clinical manifestations does the admitting nurse most likely assess in this client?  Select all that apply.

A)Crackles on auscultation
B)Dry mucous membranes
C)Increased jugular venous distention
D)Rhonchi on auscultation
E)Skin "tenting"
F)3+ pitting edema of the lower extremities

Question 8

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP).  The nurse will need to notify the HCP about which client?

A)A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg
B)A client just admitted from the emergency department with a BP of 150/72 mm Hg
C)A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin
D)A client with heart failure on metoprolol with a BP of 106/42 mm Hg

Question 9

A client comes to the emergency department in acute decompensated heart failure.  The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum.  After placing the client on oxygen via nasal cannula, which of these actions is the next priority?

A)Administer digoxin 0.25 mg
B)Administer furosemide 40 mg IV push
C)Initiate dopamine infusion at 5 mcg/kg/min
D)Obtain blood sample for arterial blood gases

Question 10

The nurse is caring for a client who just had aortic valve replacement surgery.  Which assessment information is most important to report to the health care provider (HCP)?

A)Chest tube output of 175 mL in past hour
B)International Normalized Ratio (INR) of 1.5
C)Temperature of 100.3 F (37.9 C)
D)Total urine output of 85 mL over past 3 hours

Question 11

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure.  Which of the following statements indicates that further teaching is required?

A)"I should supplement my potassium intake."
B)"I should weigh myself daily."
C)"Moderate exercise may be helpful in my condition."
D)"Potato chips are an acceptable snack in moderation."

Question 12

The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT).  Which action by the client would require an immediate intervention by the nurse?

A)The client has a temperature of 100 F (37.7 C)
B)The client is ambulating up and down the hallways
C)The client is breathing at a rate of 16/min
D)The client is massaging the leg at the site of inflammation

Question 13

A client is seen following a motor vehicle collision.  An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital.  The IV line is now infusing at 200 mL/hr.  Which assessment finding alerts the nurse to the development of hypovolemic shock?

A)Jugular venous distension
B)Mean arterial blood pressure 65 mm Hg
C)Urine output <0.5 mL/kg/hr
D)Warm, flushed skin

Question 14

A client is being discharged after receiving an implantable cardioverter defibrillator.  Which statement by the client indicates that teaching has been effective?

A)"I'm not worried about the device firing now because I know it won't hurt."
B)"I will let my daughter fix my hair until my health care provider says I can do it."
C)"I will look into public transportation because I won't be able to drive again."
D)"I will notify my travel agent that I can no longer travel by plane."

Question 15

A cardiac catheterization was performed on a client 2 hours ago.  The catheter was inserted into the left femoral artery.  What signs of potential complications should the nurse report immediately to the health care provider (HCP)?  Select all that apply.

A)Bleeding at the catheterization site
B)Client lying down and quietly watching television
C)Client taking only sips of fluids
D)Left foot remarkably cooler than right foot
E)Urine output of 100 mL since the procedure

Question 16

A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min.  Which of the following actions should the nurse take?

A)Give scheduled dose of metoprolol 50 mg orally
B)Instruct client to cough forcefully
C)Place client in reverse Trendelenburg position
D)Prepare to administer atropine 0.5 mg intravenous (IV) push

Question 17

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes.  Which instructions should the nurse include?  Select all that apply.

A)Avoid excessive caffeine
B)Immerse hands in cold water
C)Practice yoga or tai chi
D)Refrain from using tobacco products
E)Wear gloves when handling cold objects

Question 18

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG).  Which teaching is correct?  Select all that apply.

A)No sexual activity for at least 6 weeks postoperatively
B)Notify health care provider (HCP) of redness, swelling, or drainage at the incision site
C)Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP
D)Take a shower daily without soaking chest and leg incisions
E)Use lotion on incision sites with dressing changes if the area is dry

Question 19

A client comes to the emergency department with severe dyspnea and a cough.  Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min.  The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure.  Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure?

A)Arterial blood gases (ABGs)
B)B-type natriuretic peptide (BNP)
C)Cardiac enzymes (CK-MB)
D)Chest x-ray

Question 20

The nurse is providing community health screening.  Which of the following clients should be referred to a health care provider for further evaluation?

A)30-year-old athlete with a heart rate of 50/min
B)45-year-old client with a body mass index of 35 kg/m² and fingerstick glucose of 150 mg/dL (8.3 mmol/L)
C)55-year-old client missing all the hair on the lower legs and failing the pinprick test
D)80-year-old client with a blood pressure of 150/90 mm Hg

Question 21

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw.  The nurse understands that angina pectoris may be precipitated by which of these factors?  Select all that apply.

A)Amphetamine use
B)Cigarette smoking
C)Cold exposure
D)Deep sleep
E)Sexual intercourse

Question 22

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures?

A)Client who had a large anterior wall myocardial infarction (MI) with subsequent heart failure
B)Client who had a mitral valvuloplasty repair
C)Client with a mechanical aortic valve replacement
D)Client with mitral valve prolapse with regurgitation

Question 23

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved.  Which of the following instructions should the nurse include to prevent the reoccurrence of DVT?  Select all that apply.

A)"Do not take car rides longer than 4 hours for at least 3-4 weeks."
B)"Drink plenty of fluids every day and limit caffeine and alcohol intake."
C)"Elevate legs on a footstool when sitting and dorsiflex the feet often."
D)"Resume your walking program as soon as possible after getting home."
E)"Sit in a cross-legged position for 5-10 minutes to improve circulation."

Question 24

The client is scheduled to have a cardiac catheterization.  Which of the following findings would cause the nurse to question the safety of the test proceeding?  Select all that apply.

A)Elevated serum C-reactive protein level
B)History of previous allergic reaction to IV contrast
C)Prolonged PR interval on ECG
D)Received metformin today for type 2 diabetes mellitus
E)Serum creatinine of 2.5 mg/dL (221 µmol/L)

Question 25

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis.  Which of the following clinical manifestations should the nurse expect?  Select all that apply.

A)Blue, cyanotic toes
B)Calf pain
C)Dry, shiny, hairless skin
D)Lower leg warmth and redness
E)Unilateral leg edema

Question 26

A client comes to the emergency department with crushing, substernal chest pain.  Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min.  Oxygen saturation is 95% on room air.  What is the nurse's next priority action?

A)Attach defibrillator pads to the client's chest
B)Check the lipid profile laboratory results
C)Obtain a 12-lead electrocardiogram (ECG)
D)Prepare to administer a heparin drip

Question 27

The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve.  Which statement by the client indicates that teaching has been effective?

A)"I'm glad that I can continue taking my Ginkgo biloba."
B)"I will increase my intake of leafy green vegetables."
C)"I will start applying vitamin E to my chest incision after showering."
D)"I will shave with an electric razor from now on."

Question 28

The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago.  Which finding is most important to report to the health care provider (HCP)?

A)Nausea and vomiting
B)New S₃ heart sound
C)Occasional unifocal premature ventricular contractions (PVCs)
D)Temperature of 100.4 F (38 C)

Question 29

The nurse is admitting a client with heart failure-related fluid overload.  Which action should the nurse complete first?

A)Administer oxygen
B)Assess the client's breath sounds
C)Initiate cardiac monitoring
D)Insert a peripheral IV catheter

Question 30

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain.  Which serum value requires the most immediate action by the nurse?

A)Glucose 200 mg/dL (11.1 mmol/L)
B)Hematocrit 38% (0.38)
C)Potassium 3.4 mEq/L (3.4 mmol/L)
D)Troponin 0.7 ng/mL (0.7 mcg/L)

Question 31

What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) of 24 mm Hg?  Select all that apply.

A)Crackles in lungs
B)Dry mucous membranes
C)Hypotension
D)Jugular venous distension
E)Pedal edema

Question 32

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness.  The health care provider prescribes a beta blocker.  What additional teaching should the nurse include for this client?

A)Avoid aerobic exercise
B)Ensure you receive antibiotics prior to dental work
C)Stay well hydrated and avoid caffeine
D)Wear a medical alert bracelet

Question 33

The nurse is caring for a client with newly diagnosed infective endocarditis (IE).  Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)?

A)Pain and pallor in one foot
B)Pain in both knees
C)Splinter hemorrhages in the nail beds
D)Temperature of 102.2 F (39 C)

Question 34

The nurse is assigned to the following clients.  Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)?

A)A 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives
B)A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56%
C)A 72-year-old client with a fever who is 2 days post coronary stent placement
D)An 80-year-old client who is 4 days postoperative from repair of a fractured hip

Question 35

The nurse has just administered a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mmHg.  Which rhythm strip would indicate that the medication achieved the desired outcome?

A)
B)
C)
D)

Question 36

The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours.  Which instructions are important to review with the client?

A)How to transmit the readings over the phone
B)Keep a diary of activities and any symptoms experienced
C)Refrain from exercising while wearing the monitor
D)The monitor may be removed only when bathing

Question 37

A client with chest pain is diagnosed with acute pericarditis by the health care provider.  The nurse explains that the pain will improve with which of the following?

A)Coughing and deep breathing
B)Left lateral position
C)Pursed-lip breathing
D)Sitting up and leaning forward

Question 38

A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days.  Which information is most important for the nurse to ask this client?

A)Diet recall for this current week
B)Fluid intake for the past 2 days
C)Medications and dosages taken over the past 2 days
D)Presence of shortness of breath, coughing, or edema

Question 39

A client with newly diagnosed chronic heart failure is being discharged home.  Which statement(s) by the client indicate a need for further teachingby the nurse?  Select all that apply.

A)"I don't plan on eating any more frozen meals."
B)"I plan to take my diuretic pill in the morning."
C)"I will weigh myself at least every other day."
D)"I'm going to look into joining a cardiac rehabilitation program."
E)"Ibuprofen works best for me when I have pain."

Question 40

A client with peripheral arterial disease is visiting the health clinic.  The nurse completes a health assessment.  Which statement by the client indicates a priority need for follow-up teaching?

A)"I always take my simvastatin in the evening."
B)"I prop my legs up in the recliner and use a heating pad when my feet are cold."
C)"I've been walking on my treadmill at home for 15 minutes each day."
D)"I've noticed that I don't have much hair on my lower legs anymore."

Question 41

A client diagnosed with heart failure has an 8-hour urine output of 200 mL.  What is the nurse's first action?

A)Auscultate the client's breath sounds
B)Encourage the client to increase fluid intake
C)Report the findings to the health care provider (HCP)
D)Start an intravenous line for diuretic administration

Question 42

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting.  The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths.  What is the best response by the nurse?

A)"I am sorry you have so much pain.  I'll go get your pain medication right now."
B)"Let me call the health care provider (HCP) to see if we can increase the dose of your pain medicine."
C)"Take deep breaths while splinting your chest with a pillow, and use your incentive spirometer every 2 hours.  This will help your recovery."
D)"The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incisions are made between the ribs."

Question 43

An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit.  Which assessment technique by the new nurse requires intervention by the RN?

A)Nurse carefully auscultates for heart murmurs at Erb's point
B)Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry
C)Nurse places client in semi-Fowler's position to assess for jugular venous distension
D)Nurse positions client supine to assess the point of maximal impulse

Question 44

A 62-year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago.  The client reports to the nurse that the left calf is very tender and feels warm to the touch.  Which assessment by the nurse is the priority?

A)Ask the client how long the leg has been tender and warm
B)Assess the electrocardiogram (ECG) for any ectopic beats
C)Check vital signs including pulse oximetry
D)Complete neurovascular assessment on lower extremities

Question 45

A client is 48 hours post abdominal aneurysm repair.  Which assessment by the nurse is cause for greatest concern?

A)Diminished breath sounds in bilateral lung bases
B)Hypoactive bowel sounds in all 4 quadrants
C)Urinary output of 90 mL in the past 4 hours
D)Warm extremities with 1+ bilateral pedal pulses

Question 46

When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first?

A)Assess for jugular venous distension
B)Attach the cardiac monitor to the client
C)Auscultate heart and breath sounds
D)Obtain the client's vital signs

Question 47

The nurse is performing a cardiac assessment on a client.  The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border.  How should the nurse document this finding?

A)Arterial bruit
B)Murmur heard at the aortic area
C)Pericardial friction rub
D)S₃ gallop heard at the mitral area

Question 48

A clinic nurse is caring for a client who has hypertension and is prescribed hydrochlorothiazide, lisinopril, and clonidine.  The current blood pressure reading is 190/102 mm Hg, and the client reports a headache that has lasted several days.  Which question is most important for the nurse to ask next?

A)"Have you noticed any abnormal swelling in your legs?"
B)"How are you currently taking your blood pressure medications?"
C)"How has your stress level been the past few weeks?"
D)"What over-the-counter medications have you taken today?"

Question 49

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day.  Which instructions should the nurse give the clients?  Select all that apply.

A)Decaffeinated coffee or tea can be consumed
B)Do not consume caffeine for 24 hours before the test
C)Do not smoke on the day of the test
D)Do not take beta blockers on the day of the test
E)Take diabetic medications as usual before the test

Question 50

The nurse is caring for a client with cardiomyopathy and coronary artery disease.  The client is reporting increasing chest pain and has bilateral lung crackles on auscultation.  The health care provider has written several new prescriptions.  Which new prescription should the nurse clarify?  Select all that apply.

A)Administer 2,000 mL normal saline bolus
B)Administer IV nitroglycerin
C)Apply 4 L oxygen by nasal cannula
D)Obtain a STAT 12-lead ECG
E)Obtain blood for cardiac enzyme testing

Question 51

A client with suspected moderate to large pericardial effusion is admitted for monitoring.  The nurse performs a head-to-toe assessment.  Which of these findings indicate likely cardiac tamponade and require immediate intervention?  Select all that apply.

A)Blood pressure of 90/70 mm Hg
B)Bounding peripheral pulses
C)Decreased breath sounds on left side
D)Distant heart tones
E)Jugular venous distension

Question 52

A nurse is making initial client rounds at the beginning of the shift.  Which client should the nurse see first?

A)36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur
B)40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension
C)67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min
D)70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV

Question 53

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension.  Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?  Select all that apply.

A)"I need to eat less red meat and more fresh vegetables."
B)"I'll limit drinking soda to only one at a time as an occasional treat."
C)"I'm going to replace potato chips with fruit during meals and snacking."
D)"I'm really going to miss drinking as much milk as I normally do."
E)"Taking the salt shaker off the table should be enough to reduce my sodium intake."

Question 54

The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA).  The client's blood pressure today is 170/88 mm Hg.  What teaching topic is a priority for the nurse to discuss with this client?

A)Decreasing sodium intake
B)Decreasing stress levels at work and home
C)Increasing activity level
D)Taking blood pressure medications as prescribed

Question 55

A client is scheduled for a coronary arteriogram procedure.  Which information should the nurse provide to the client prior to the procedure?  Select all that apply.

A)Client may be required to lie flat for several hours following the procedure
B)Client may feel warm or flushed when contrast dye is injected during the procedure
C)Client should expect to stay in the hospital for 1-3 days following the procedure
D)Client should not eat or drink anything for 6-12 hours before the procedure
E)Client will receive general anesthesia and will not be awake during the procedure

Question 56

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure.  Which is the best position for the nurse to place the client in when observing for JVD?

A)Head of the bed elevated to a 45-degree angle
B)Head of the bed elevated to a 60-degree angle
C)Head of the bed elevated to a 90-degree angle
D)Head of the bed flat

Question 57

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit.  The new RN is measuring orthostatic blood pressure (BP) for a client.  Which situation would warrant intervention by the experienced nurse?

A)Nurse has client lie supine for 5-10 minutes prior to starting procedure
B)Nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding
C)Nurse starts by measuring BP and heart rate (HR) with the client standing
D)Nurse takes BP and HR after standing at 1- and 3-minute intervals

Question 58

A client with a blood pressure (BP) of 250/145 mm Hg is admitted for hypertensive crisis.  The health care provider prescribes a continuous IV infusion of nitroprusside sodium.  Which of these is the priority goal in initial management of hypertensive crisis?

A)Decrease mean arterial pressure (MAP) by no more than 25%
B)Keep blood pressure at or below 120/80 mm Hg
C)Maintain heart rate (HR) of 60-100/min
D)Maintain urine output of at least 30 mL/hr

Question 59

A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI).  Which laboratory test should the nurse monitor to determine if the client has had an MI?

A)D-dimer test
B)Low-density lipoprotein (LDL)
C)Myoglobin
D)Troponin

Question 60

An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking."  What is the priority assessment the nurse should perform?

A)Assess for dry, scaly skin on the lower legs
B)Assess for presence or absence of hair growth on lower extremities
C)Check for presence and quality of posterior tibial and dorsalis pedis pulses
D)Obtain a dietary history

Question 61

The nurse is planning discharge teaching for a client who just received a permanent pacemaker.  Which topics should the nurse include?  Select all that apply.

A)Avoid MRI scans
B)Do not place cell phones directly over the pacemaker
C)Notify airport security when traveling
D)Perform shoulder range-of-motion exercises
E)Refrain from using microwave ovens

Question 62

The nurse receives hand-off report on assigned clients.  Which client should the nurse assess first?

A)Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler
B)Client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities
C)Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity
D)Client with peripheral arterial disease who reports severe cramping pain in the calf with activity such as walking

Question 63

A nurse cares for a client after cardiac catheterization.  During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client's leg.  What should the nurse do first?

A)Apply direct manual pressure at and above the skin puncture site
B)Call the health care provider to report active bleeding
C)Check the peripheral pulse distal to the catheterization site
D)Place a new pressure dressing over the catheterization site

Question 64

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago.  Which assessment findings would indicate possible graft leakage and require a report to the primary care provider?  Select all that apply.

A)Ecchymosis of the scrotum
B)Increased abdominal girth
C)Increased urinary output
D)Report of groin pain
E)Report of increased thirst and appetite loss

Question 65

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP).  Which assessment data is most important for the nurse to report to the HCP?

A)Blood pressure (BP) of 140/86 mm Hg
B)Difficulty swallowing
C)Dry, hacking cough
D)Low back pain

Question 66

A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min.  IV fluids of 2-liter normal saline were administered.  Which parameters indicate that adequate rehydration has occurred?  Select all that apply.

A)Capillary refill is less than 3 seconds
B)Pulse pressure is narrowed
C)Systolic blood pressure drops only when standing
D)Urine output is 360 mL in 4 hours
E)Urine specific gravity is 1.020

Question 67

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago.  Which assessment would require immediate follow-up?

A)Abdomen is soft, nondistended, and tender to touch
B)Blood pressure is 96/66 mm Hg and apical pulse is 112/min
C)Client rates pain as 4 on a scale of 0-10
D)Green bile is draining from the nasogastric tube

Question 68

The nurse is preparing to administer 40 mg of IV furosemide.  Prior to administering the medication, the nurse should assess which parameters?  Select all that apply.

A)Blood pressure
B)Blood urea nitrogen
C)Liver enzymes
D)Potassium
E)White blood cell count

Question 69

The nurse on the step-down cardiothoracic unit receives the change-of-shift hand-off report.  Which client should the nurse assess first?

A)2 days postabdominal aortic aneurysm repair with a pedal pulse decreased from baseline
B)2 days postcoronary bypass graft surgery with a white blood cell count of 18,000/mm³ (18.0 × 10⁹/L)
C)Cardiomyopathy with an ejection fraction of 25% and dyspnea on exertion
D)Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

Question 70

The nurse is assessing a client with a possible diagnosis of peripheral artery disease.  Which client statement is consistent with the diagnosis?

A)"At the end of the day, my shoes and socks are tight."
B)"I have a slow-healing sore right above my ankle."
C)"My legs ache when I stand for extended periods."
D)"When I sit down to rest and elevate my legs, the pain increases."

Question 71

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis?

A)Bounding peripheral pulses
B)Diastolic murmur
C)Loud second heart sound
D)Syncope on exertion

Question 72

The nurse is caring for a client who just had a permanent ventricular pacemaker inserted.  The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat.  How should the nurse assess for mechanical capture of the pacemaker?

A)Auscultate the client's apical pulse rate
B)Measure the client's blood pressure
C)Obtain a 12-lead ECG
D)Palpate the client's radial pulse rate

Question 73

The nurse is caring for a client with acute pericarditis.  Which clinical finding would require immediate intervention by the nurse?

A)Client reports chest pain that is worse with deep inspiration
B)Distant heart tones and jugular venous distension
C)ECG showing ST-segment elevations in all leads
D)Pericardial friction rub auscultated at the left sternal border

Question 74

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum.  What would the nurse anticipate when auscultating the breath sounds of this client?

A)Bronchial breath sounds at lung periphery
B)Clear vesicular breath sounds at lung bases
C)Diffuse bilateral crackles at lung bases
D)Stridor in upper airways

Question 75

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier.  Which laboratory report requires priority follow-up?

A)Client with chronic obstructive pulmonary disease who has a PaCO₂ of 52 mm Hg (6.9 kPa)
B)Client with heart failure who has a brain natriuretic peptide level of 800 pg/mL (800 ng/L)
C)Client with infected pressure ulcer who has a white blood cell count of 13,000/mm³ (13.0 x 10⁹/L)
D)Client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

Question 76

Which client is in need of follow-up education by the nurse?

A)Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping
B)Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out
C)Client with venous leg ulcer who refuses to wear elastic compression stockings during the day
D)Postsurgical client who points and flexes feet when lying in bed

Question 77

A client with aortic stenosis is scheduled for surgery in 2 weeks.  The client reports episodes of angina and passing out twice at home.  Which would be the best response by the nurse to explain the appropriate activity for this client at this time?

A)"Avoid strenuous activity before the surgery."
B)"Continue to exercise, even if angina occurs.  It will strengthen your heart muscles."
C)"Take short walks 3 times a day."
D)"There are no activity restrictions unless angina occurs."

Question 78

The unlicensed assistive personnel reports a client blood pressure of 90/60 mm Hg to the nurse.  The client's prescriptions say to notify the health care provider (HCP) if systolic blood pressure is <100 mm Hg.  What should the nurse do first?

A)Assess the client for other signs and symptoms
B)Immediately notify the client's HCP
C)Notify the charge nurse on duty for the shift
D)Review the client's medication administration record

Question 79

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm?  Select all that apply.

A)Assess abdominal incision every 4 hours
B)Check for bleeding at groin puncture sites
C)Measure chest tube drainage
D)Monitor fluid intake and urine output
E)Palpate and monitor peripheral pulses

Question 80

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis.  The client is receiving a heparin infusion and suddenly develops epistaxis.  Which laboratory value would indicate that the heparin infusion needs to be turned off?

A)Hematocrit of 30% (0.30)
B)Partial thromboplastin time of 110 seconds
C)Platelet count of 80,000/mm³ (80 x 10⁹/L)
D)Prothrombin time of 11 seconds