Question 1

A client with coronary artery disease is being seen in the clinic for a follow-up examination.  During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?

Accepted Answer

Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen, ibuprofen) are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use. The nurse should investigate the reason a client with cardiovascular disease is taking an NSAID and alert the health care provider of the medication usage (Option C). (Option A) Isosorbide dinitrate (Isordil) is a long-acting nitrate medication prescribed to prevent angina in clients with CAD. Nitrate medications prevent angina by causing vasodilation of the peripheral vessels (decreasing cardiac workload) and the coronary arteries (improving coronary artery perfusion). (Option B) Atorvastatin (Lipitor) is a statin drug prescribed to lower cholesterol, which can reduce the risk of atherosclerosis and coronary artery disease. (Option D) Fish oil is an over-the-counter nutritional supplement often taken by clients with heart disease or individuals at risk. Fish oil contains omega-3 fatty acids, which may decrease blood triglyceride levels with consistent use. Educational objective: Clients with cardiovascular disease (eg, coronary artery disease) are cautioned against taking nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, naproxen), which increase the risk of thrombotic events (eg, heart attack, stroke). Nurses who identify clients with cardiovascular disease taking NSAIDs should investigate the reasons for use and notify the health care provider.

Question 2

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first?

Accepted Answer

11ecbb05_c962_8478_b433_e7ab9682e683_MD0009_00 When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular (dual-chambered) pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes (electrical capture). If the pacemaker is not working properly (eg, failure to capture, failure to sense), the health care provider should be contacted immediately (Option C). The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure. (Option A) Checking for bleeding or hematoma formation at the insertion site is appropriate but should occur after attaching the cardiac monitor. (Option B) Postoperative lung sounds are auscultated to assess for atelectasis, but lung assessments do not take priority over ensuring pacemaker functionality. (Option D) IV fluids and postoperative antibiotics help to reestablish fluid volume and prevent infection, respectively, and should be initiated after cardiac monitoring. Educational objective: Assessing the function of a new permanent pacemaker is a priority after operative placement. The nurse should immediately attach the cardiac monitor before making other appropriate assessments.

Question 3

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.

Accepted Answer

11ecbb05_c966_2e01_b433_39102b743d67_MD0009_00 Air embolism is a rare but life-threatening complication of central venous catheter (CVC) placement in which air enters the bloodstream. This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs. Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site. Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse. Nurses caring for clients with symptoms of air embolism (eg, hypoxemia, dyspnea, sense of impending doom) after CVC removal or dislodgement should perform these actions: Apply an occlusive dressing to the insertion site to prevent entry of additional air into the bloodstream (Option B) Administer 100% oxygen via non-rebreather mask to improve oxygenation (Option A) Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than the lung capillary beds Continuously monitor vital signs and client respiratory effort to identify changes in client status (Option D) Notify the health care provider immediately (Option E) (Option C) High Fowler position may worsen respiratory distress caused by air embolism by promoting displacement of venous air emboli into pulmonary circulation. Educational objective: Air embolism is a rare, life-threatening complication of central venous catheter (CVC) insertion/removal. Nurses caring for clients with symptoms of air embolism after CVC removal should apply an occlusive dressing to the site, administer oxygen, position the client in left lateral Trendelenburg position, monitor client status, and immediately notify the health care provider.

Question 4

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider?

Accepted Answer

11ecbb05_c965_43a0_b433_6b1a08bba7c8_MD0009_00 Transgender women clients are often prescribed antiandrogen medications (eg, spironolactone) to reduce androgen levels (eg, testosterone) and estrogen therapies to induce feminizing traits (eg, breast enlargement, reduction in body hair, decrease in testicular size and erectile function). Estrogen places clients at an increased risk for developing blood clots, due to hypercoagulability, and therefore adverse thrombotic events (eg, stroke, myocardial infarction, venous thromboembolism). Signs and symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider (HCP) immediately (Option C). The client should also be taught smoking cessation and diabetes management, and to avoid long periods of immobilization to further decrease the risk of thrombus formation. (Option A) Breast tenderness and enlargement are common, expected side effects of estrogen therapy. (Option B) Generalized weight gain during estrogen therapy is caused by fluid retention and is generally mild. However, if weight gain with cardiovascular symptoms (eg, pedal edema) occurs, the HCP should be notified. (Option D) Nausea and vomiting can occur with estrogen therapy and may be remedied with dosage adjustments or taking oral estrogen with food. Educational objective: Clients taking estrogen therapy are at an increased risk for hypercoagulability and thromboembolic complications. Signs or symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be reported to the health care provider immediately.

Question 5

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

Accepted Answer

A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately. (Option A) Clients with atrial fibrillation are usually prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased risk for blood clots that can lead to stroke. This client's ventricular rate is controlled, so there is no urgency. (Option C) First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as atenolol (Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval on ECG. Although first-degree AV block should be monitored for progression, it is an expected adverse drug effect. Only second- or third-degree heart block should be the priority. (Option D) Dehydration can cause hypotension. Tachycardia is a normal compensatory mechanism to increase the cardiac output associated with hypotension. Educational objective: A demand electronic pacemaker should deliver an impulse when it senses an intrinsic pacemaker drop below a predetermined rate. Bradycardia with failure to capture (pacer spike with no QRS complex) indicates malfunction and requires immediate notification of the health care provider.

Question 6

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?

Accepted Answer

New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option A) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option B) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option D) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly. Educational objective: New onset of dependent edema in an elderly client could be due to heart failure; the client needs further assessment for characteristic signs such as lung crackles and increased body weight (fluid retention).

Question 7

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU?

Accepted Answer

11ecbb05_c963_20bd_b433_4f072b43f326_MD0009_00 Occasional premature ventricular contractions (PVCs) are common dysrhythmias that may be precipitated by several factors, including electrolyte imbalances (eg, potassium), stimulants (eg, caffeine, nicotine), and stress. Occasional PVCs typically do not cause hemodynamic instability. The client who is stable one day post extubation can be safely transferred to a telemetry or medical-surgical unit, where the occasional PVCs may be further investigated and treated (Option C). (Option A) Sinus tachycardia may not present an immediate risk of hemodynamic instability; however, the client who recently underwent arterial sheath removal may be tachycardic due to bleeding. This client requires further investigation and continuous monitoring, and is not appropriate for transfer. (Option B) The client with atrial fibrillation and rapid ventricular response has decreased cardiac output and may progress to hemodynamic instability. Treatment goals include reducing the ventricular rate to <100/min with medications (eg, diltiazem), preventing thrombotic events (eg, ischemic stroke) with anticoagulants (eg, warfarin), and possibly conversion to normal sinus rhythm with antiarrhythmics (eg, amiodarone). This client is not the best choice for transfer. (Option D) Complete heart block (ie, third-degree atrioventricular block) requires temporary pacing followed by permanent pacemaker insertion. This client, who is at risk for severe bradycardia and hemodynamic instability, should not be transferred. Educational objective: Occasional premature ventricular complexes are common dysrhythmias and usually do not cause hemodynamic instability. Clients with atrial fibrillation and rapid ventricular response, complete heart block, or other threats to cardiovascular stability require continuous observation in the intensive care unit.

Question 8

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply.

Accepted Answer

11ecbb05_c960_88a5_b433_a5d47ef97f21_MD0009_00 Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided heart failure include: Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option D). Jugular venous distension (Option C). Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option B). Hepatomegaly due to hepatic venous congestion. (Options A and E) Orthopnea (dyspnea with recumbency), paroxysmal nocturnal dyspnea (PND), and crackles in lung bases are clinical manifestations of left-sided heart failure. Blood is not effectively pumped into systemic circulation, resulting in the backup of blood into the pulmonary vessels that causes congestion of the pulmonary vessels and, potentially, pulmonary edema. Pulmonary hypertension and right-sided heart failure typically present with dyspnea on exertion rather than orthopnea or PND. Educational objective: In clients with right-sided heart failure, the heart cannot effectively pump blood to the lungs. Clinical manifestations result from systemic venous congestion and include peripheral edema, jugular venous distension, increased abdominal girth (hepatomegaly, splenomegaly), and ascites.

Question 9

The nurse identifies which risk factors as contributing to the development of peripheral artery disease? Select all that apply.

Accepted Answer

11ecbb05_c964_593f_b433_7fca9c629ccc_MD0009_00 In peripheral artery disease (PAD), the arteries of the extremities become atherosclerotic (progressive thickening and hardening due to chronic vascular damage). PAD reduces tissue perfusion and can cause ischemic pain of the lower extremities with movement or exercise (intermittent claudication). Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: Hypertension: Vessel damage from chronically elevated vascular resistance Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option B) Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option C) Smoking: Chronic vasoconstriction from nicotine inhalation (Option A) (Option D) Elevated estrogen levels (eg, oral contraceptive use, pregnancy, hormone replacement therapy) make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins than in arteries due to lower venous pressure and slower blood flow (eg, venous stasis). (Option E) Unlike chronic venous insufficiency, in which vessels ineffectively return blood from the feet to the central circulation, standing is not a risk factor for PAD, as standing facilitates blood flow by gravity to the lower extremities. Educational objective: In peripheral artery disease, arteries in the extremities become atherosclerotic (progressive thickening and hardening due to chronic damage). Peripheral tissue perfusion is impaired, causing pain with exercise (eg, intermittent claudication) and at rest. Risk factors include hypertension, diabetes mellitus, hyperlipidemia, and smoking.

Question 10

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.

Accepted Answer

11ecbb05_c95d_0631_b433_bd9d9fca9516_MD0009_00 Peripheral arterial disease (PAD) is a chronic, atherosclerotic disease caused by buildup of plaque within the arteries. PAD commonly affects the lower extremities and can lead to tissue necrosis (gangrene). Home management instructions for PAD include: Lower the extremities below the heart when sitting and lying down - improves arterial blood flow Engage in moderate exercise (eg, 30- to 45-minute walk, twice daily) - promotes collateral circulation and distal tissue perfusion Perform daily skin care, including application of lotion - prevents skin breakdown from dry skin Maintain mild warmth (eg, lightweight blankets, socks) - improves blood flow and circulation Stop smoking - prevents vessel spasm and constriction Avoid tight clothing and stress - prevents vasoconstriction Take prescribed medications (eg, vasodilators, antiplatelets) - increases blood flow and prevents blood clot development (Option B) Elevating the legs promotes venous return, but does not promote arterial circulation. (Option E) Heating pads should not be used in clients with altered perfusion or sensation due to the increased risk for burns. Educational objective: Peripheral artery disease increases the risk of tissue necrosis and limb loss. Management focuses on improving blood flow and circulation to the extremities through lifestyle changes and medications.

Question 11

The nurse is teaching a client who is scheduled to have an inferior vena cava filter inserted via the right femoral vein. Which statement by the client requires further teaching?

Accepted Answer

11ecbb05_c961_7306_b433_f3085463bde6_MD0009_00 An inferior vena cava filter is a device that is inserted percutaneously, usually via the femoral vein. The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents them from migrating to the lungs and causing a pulmonary embolism (PE). It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated. Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team prior to radiologic imaging, specifically MRI (Option A). Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the legs (Option B). Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately (Option C). (Option D) Symptoms of PE (eg, chest pain, shortness of breath) and vascular injury (bleeding causing back pain) are not expected findings after the procedure and should be reported immediately. Educational objective: An inferior vena cava filter traps thrombi migrating from the lower extremities to the lungs. Discharge teaching includes promotion of physical exercise, reporting of symptoms of pulmonary embolism (eg, chest pain, shortness of breath) and impaired lower extremity circulation (eg, pain, numbness), and notification of the health care team prior to MRI.

Question 12

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?

Accepted Answer

11ecbb05_c968_77f4_b433_6f36b97f4df4_MD0009_00 Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option A). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. (Options B, C, and D) Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues. Educational objective: Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).

Question 13

The charge nurse is assisting with a nonemergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene?

Accepted Answer

11ecbb05_c967_dbb3_b433_8706c450db78_MD0009_00 Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia, ventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The shock in cardioversion is timed by the defibrillator ("sync" feature enabled) to be delivered only during the R wave of the QRS complex, when the ventricles depolarize. Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T phenomenon, which frequently results in lethal arrhythmias (eg, ventricular fibrillation). The nurse must ensure that the defibrillator's "sync" feature is enabled when preparing to perform synchronized cardioversion. Disabling or failing to enable the "sync" feature may result in a potentially lethal, asynchronous shock being delivered to the client (Option B). (Option A) During nonemergent cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. (Option C) Defibrillator pads should be placed on the right upper chest next to the sternum and on the left lower chest. (Option D) Prior to delivery of electrical shock (eg, cardioversion, defibrillation), oxygen should be turned off and moved away. Oxygen is flammable and may explode when subjected to electric currents. Educational objective: Synchronized cardioversion is a cardiac procedure used to convert tachyarrhythmias with a pulse to stable cardiac rhythms. Nurses preparing to perform cardioversion must verify that the defibrillator's "sync" feature is engaged to prevent delivery of an asynchronous shock, which may cause life-threatening arrhythmias.

Question 14

The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply.

Accepted Answer

11ecbb05_c962_0f47_b433_aba488f7d73f_MD0009_00 Hypertension is referred to as the "silent killer" as many clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure. Appropriate client screening based on risk factors is key to preventing complications. This client has both nonmodifiable (eg, African American ethnicity) and modifiable (eg, diabetes mellitus type 2, chronic stress, smoking) risk factors (Options A, B, C, and E). To prevent future comorbidities, the nurse should educate the client on smoking cessation, appropriate diabetes management, and therapeutic strategies for stress management at work. (Option D) Clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]). Educational objective: Key risk factors for developing hypertension include African American ethnicity, increasing age, positive family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia, chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery disease, stroke, heart failure, and renal failure.

Question 15

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time?

Accepted Answer

Immunosuppressive therapy (eg, mycophenolate, tacrolimus, corticosteroids) is required after organ transplantation to prevent acute and chronic rejection of the organ. This is a lifelong drug regimen for the transplant client, and it has adverse side effects (eg, nephrotoxicity, hepatotoxicity, infection susceptibility). Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required. It is important for the nurse at every opportunity to emphasize strict immunosuppressive therapy compliance to prevent acute transplanted organ rejection. (Option B) Daily weight monitoring is important for identifying signs of heart failure; however, immunosuppressive therapy compliance is the priority. (Option C) Endomyocardial biopsies are performed regularly, in addition to routine blood tests, to check for signs of rejection. This is important for the client to know; however, it is not the priority over strict immunosuppressive therapy compliance. (Option D) Surgical incision care and signs of infection are important teaching topics; however, prior to transplantation, it is most important to ensure that the client understands and will comply with lifelong immunosuppressive therapy. Educational objective: Clients on the organ donation waiting list are educated regarding strict compliance with immunosuppressive therapy, which requires a lifelong commitment to prevent acute transplanted organ rejection.

Question 16

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first?

Accepted Answer

11ecbb05_c963_e40e_b433_41210e2e0224_MD0009_00 Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction (MI), such as diaphoresis, nausea, fatigue, or dyspnea, but may not always experience chest discomfort. Pain may be absent or atypical or may radiate to unusual locations (eg, jaw, back). Some clients may report pain as "indigestion" (epigastric burning or gas). The nurse should obtain a 12-lead electrocardiogram (ECG) on any client with atypical MI symptoms to assess for evidence of ischemia, injury, or infarction (Option D). ST-segment elevation MI is life-threatening and requires rapid coronary intervention. (Option A) Morphine is administered to relieve pain and anxiety. A 12-lead ECG must be obtained to verify that the symptoms are cardiac in nature before giving medications. (Option B) In clients with diabetes, diaphoresis may indicate hypoglycemia, but other symptoms, such as epigastric pain, in this client make MI more likely. (Option C) Nausea and generalized weakness may result from some electrolyte imbalances, and the nurse should send blood for routine studies (eg, basic metabolic panel, complete blood count). However, a 12-lead ECG will give more immediate assessment information, allowing for quicker intervention if MI is present. Educational objective: Female, elderly, and diabetic clients tend to present with atypical symptoms of myocardial infarction. The nurse should obtain a 12-lead electrocardiogram immediately for any client with atypical symptoms before assessing for other causes.

Question 17

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first?

Accepted Answer

11ecbb05_c95d_c982_b433_cf6dca8c8013_MD0009_00 Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention. (Option A) Kidney transplant recipients are on an immunosuppressant regimen to prevent rejection of the transplanted organ, which can leave them susceptible to infections such as candidiasis (thrush) of the oral cavity. (Option C) The client with a spider bite is displaying signs and symptoms of infection, and further assessment is required to evaluate for conditions such as cellulitis. This client should be called second. (Option D) Clients with hypertension who develop sinus or nasal congestion have limited options for symptom relief. Decongestants containing a vasoconstrictor (eg, pseudoephedrine) can exacerbate hypertension. Educational objective: Chronic mitral valve regurgitation is often asymptomatic, but many clients eventually develop heart failure; therefore, early recognition of symptoms is a priority. Mitral regurgitation causes a backflow of blood from the left ventricle to the left atrium, resulting in pulmonary edema (eg, dyspnea, orthopnea) and decreased cardiac output (eg, fatigue). Left atrial enlargement can also result in atrial fibrillation (eg, palpitations).

Question 18

The telemetry nurse is reviewing a client's cardiac rhythm strip.  What is the correct interpretation for this strip?

Accepted Answer

11ecbb05_c95e_8cd4_b433_ef24bad9c9c6_MD0009_00 The rhythm strip of a client with a single-chamber atrial pacemaker displays a pacer spike before the P wave, followed by a QRS complex, on an electrocardiogram (ECG). The P wave may appear normal or somewhat distorted following the spike. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks). (Option B) In first-degree atrioventricular block, every impulse is conducted to the ventricles, but the time of atrioventricular conduction is prolonged. This is evidenced by a prolonged PR interval of >0.20 second. Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option C) Normal sinus rhythms do not have pacer spikes. Unlike the QRS complexes in this client's ECG, PVCs are not associated with P waves, and the QRS complexes are wide and distorted. (Option D) Failure to sense appears on an ECG as asynchronous pacer spikes in inappropriate or random locations (eg, pacer spike on the T wave). It should not be confused with failure to capture, in which pacer spikes are located appropriately but there is no electrical response elicited from the heart (eg, no QRS complex after a pacer spike). Educational objective: An atrial paced rhythm displays a pacer spike followed by a normal or distorted P wave, then a QRS complex. Atrial pacemakers are often placed for clients experiencing sinoatrial node dysfunction (eg, atrial fibrillation, bradycardia, heart blocks).

Question 19

A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection?

Accepted Answer

11ecbb05_c967_3f72_b433_fbb1b482a048_MD0009_00 Aortic dissection is a tear in the inner lining of the aorta that allows blood to surge between the layers of the arterial wall, separating and weakening the aortic wall. Perfusion to vital organs may become impaired, and the dissection can rapidly progress to life-threatening cardiac tamponade or aortic rupture. Aortic dissection is characterized by acute onset of excruciating, sharp or "ripping" chest pain that radiates to the back. Emergency surgical repair is usually required. Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering IV beta blocker medication (eg, labetalol, metoprolol, propranolol) helps achieve this by lowering the heart rate and blood pressure, which are often elevated with aortic dissection (Option A). (Option B) Bed rest and a low-stimulation environment help lower heart rate and blood pressure, but antihypertensive medication is more effective and rapid-acting, making it the highest priority. (Option C) Assessing peripheral pulses helps monitor for complications of aortic dissection but is not a priority over interventions that reduce the risk of aortic rupture. (Option D) Informed consent is required before all surgical interventions; however, consent forms can be completed any time prior to surgery and are not a priority over reducing the risk of aortic rupture. Educational objective: Before emergency surgical repair of aortic dissection, the priority is decreasing the risk of aortic rupture by maintaining normal pressure in the aorta. Administering an IV beta blocker helps achieve this by rapidly lowering elevated heart rate and blood pressure.

Question 20

A nurse in the intensive care unit is caring for a postoperative cardiac transplant client. What intervention is most important to include in the plan of care?

Accepted Answer

Clients receiving transplanted organs are prescribed lifelong immunosuppressive medications (eg, cyclosporine, mycophenolate) to prevent rejection. Posttransplant infection is the most common cause of death. Signs of infection may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions; however, common signs of infection (eg, redness, swelling) may be absent due to immunosuppression. Critical postoperative infection control measures incorporate vigilant hand washing, aseptic technique for line/dressing changes, and possibly reverse isolation. (Option A) Sequential compression devices are one of the options available to prevent deep venous thrombosis (DVT) postoperatively. Ideally, anticoagulants are used to prevent DVT. Regardless, in the client's immunosuppressed state, infection prevention is the priority. (Option B) The newly transplanted heart is denervated from the autonomic nervous system and is unable to appropriately respond to physical demand (eg, increased heart rate with increased activity). The client is taught how to avoid orthostatic hypotension (eg, change positions slowly). However, the priority is careful hand washing and infection prevention. (Option C) Coughing, deep breathing, and incentive spirometry are important interventions to prevent atelectasis and pneumonia. However, infection prevention is the priority in immunosuppressed clients. Educational objective: Posttransplant infection is the most common cause of death due to immunosuppressive therapy. Strict hand washing and aseptic technique are critical to infection prevention. Symptoms of infection should be monitored and may include fever >100.4 F (38 C), productive or dry cough, and changes in secretions.

Exam 1: Adult Health

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first?

The nurse cares for a transgender client who is prescribed estrogen therapy. Which side effect is most important for the nurse to report to the health care provider?

The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first?

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?

The house supervisor has notified the charge nurse on the intensive care unit (ICU) that a bed is needed for an admission from the emergency department. All ICU beds are currently full. Which client should the charge nurse consider as most appropriate for transfer out of the ICU?

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply.

The nurse identifies which risk factors as contributing to the development of peripheral artery disease? Select all that apply.

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply.

The nurse is teaching a client who is scheduled to have an inferior vena cava filter inserted via the right femoral vein. Which statement by the client requires further teaching?

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency?

The charge nurse is assisting with a nonemergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene?

The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply.

The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time?

A 70-year-old female client with type 2 diabetes mellitus comes to the emergency department with diaphoresis, nausea, generalized weakness, and epigastric burning pain. Which intervention should the nurse implement first?

The nurse in the outpatient clinic is reviewing phone messages. Which client should the nurse call back first?

The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip?

A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection?

A nurse in the intensive care unit is caring for a postoperative cardiac transplant client. What intervention is most important to include in the plan of care?