FLASHCARD Cardiovascular

7/25/2019 FLASHCARD Cardiovascular

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Cardiovascular-Nclex

1. A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like

symptoms. The client suddenly complains of chest pain. Which of the followin !uestions would best

help a nurse discriminate pain caused by a noncardiac problem"

1. #Can you describe the pain to me"#

$. #%ave you ever had this pain before"#

&. #'oes the pain et worse when you breathe in"#

(. #Can you rate the pain on a scale of 1 to 1)* with 1) bein the worst"#

1. & +ationale, Chest pain is assessed by usin the standard pain assessment parameters e..*

characteristics* location* intensity* duration* precipitatin and alleviatin factors* and associated

symptoms. /ptions 1* $* and ( may or may not help discriminate the oriin of pain. 0ain of

pleuropulmonary oriin usually worsens on inspiration.

Test-Takin tratey 2se the process of elimination* focusin on the sub3ect* pain resultin from a

noncardiac problem. The three incorrect options* althouh appropriate to use in practice* are eneral

assessment !uestions only. /ption & will discriminate between a cardiac and noncardiac cause of pain.

+eview pain assessment measures for the client with a cardiovascular problem if you had difficulty with

this !uestion.

$. A client develops atrial fibrillation with a ventricular rate of 1() beats4min and sins of decreased

cardiac output. Which of the followin medications should the nurse first anticipate administerin"

1. Atropine sulfate

$. Warfarin Coumadin

&. 5idocaine 6ylocaine

(. 7etoprolol 5opressor

$. ( +ationale, b-8lockers such as metoprolol slow conduction of impulses throuh the A9 node and

decrease the heart rate. :n rapid atrial fibrillation* the oal first is to slow the ventricular rate and improve

the cardiac output and then attempt to restore normal sinus rhythm.

Test-Takin tratey, 2se the process of elimination. ;liminate option 1 because atropine sulfate will

further increase the heart rate and will further decrease the cardiac output. ;liminate option & because

lidocaine is only useful in suppressin ventricular dysrhythmias. Althouh warfarin Coumadin is


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administered to clients with atrial fibrillation to prevent clots from formin in the atria it will have no

effect in decreasin the ventricular rate or restorin normal sinus rhythm. +eview these medications if

you had difficulty with this !uestion.

&. A client with myocardial infarction has been transferred from a coronary care unit to a eneral medical

unit with cardiac monitorin via telemetry. A nurse plans to allow for which of the followin client

activities"

1. trict bed rest for $( hours after transfer

$. 8athroom privilees and self-care activities

&. Ad lib activities because the client is monitored

(. 2nsupervised hallway ambulation with distances under $)) feet

&. $ +ationale, /n transfer from the coronary care unit* the client is allowed self-care activities and

bathroom privilees. upervised ambulation in the hall for brief distances is encouraed* with distances

radually increased


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loop diuretics* which lead to the side effect of hypokalemia. Next eliminate option ( because it is a

thia=ide diuretic* which acts on the distal tubule and inhibits sodium* chloride* and potassium

reabsorption. +eview the effects of these medications if you had difficulty with this !uestion.


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option ( is correct. +eview the sins of toxicity and the nursin interventions if you had difficulty with

this !uestion.

. A nurse notes bilateral 1$ edema in the lower extremities of a client with myocardial infarction who

was admitted $ days ao. The nurse would plan to do which of the followin next"

1. /rder daily weihts startin on the followin mornin.

$. +eview the intake and output records for the last $ days.

&. +e!uest a sodium restriction of 1 4day from the physician.

(. Chane the time of diuretic administration from mornin to evenin.

. $ +ationale, ;dema* the accumulation of excess fluid in the interstitial spaces* can be measured by

intake reater than output and by a sudden increase in weiht. 'iuretics should be iven in the mornin

whenever possible to avoid nocturia. trict sodium restrictions are reserved for clients with severe

symptoms.

Test-Takin tratey 2se the process of elimination* notin the strateic word next. 2se the steps of the

nursin process to prioriti=e. /ption $ is the only option that addresses assessment of data. +eview care of

the client with a myocardial infarction if you had difficulty with this !uestion.

D. A nurse is conductin a health history of a client with a primary dianosis of heart failure. Which of the

followin disorders reported by the client is unlikely to play a role in exacerbatin the heart failure"

1. Atrial fibrillation

$. Nutritional anemia

&. 0eptic ulcer disease

(. +ecent upper respiratory infection

D. & +ationale, %eart failure is precipitated or exacerbated by physical or emotional stress* dysrhythmias*

infections* anemia* thyroid disorders* prenancy* 0aets disease* nutritional deficiencies thiamine*

alcoholism* pulmonary disease* and hypervolemia.

Test-Takin tratey 2se the process of elimination and note the strateic word unlikely. +ememberin

that heart failure is exacerbated by factors that increase the workload of the heart will assist you in

eliminatin options 1* $* and (. +eview the precipitatin factors associated with heart failure if you had

difficulty with this !uestion.


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?. A home health care nurse is visitin an older client at home. Burosemide 5asix is prescribed for the

client and the nurse teaches the client about the medication. Which of the followin statements* if made

by the client* indicates the need for further teachin"

1. #: will sit up slowly before standin each mornin.#

$. #: will take my medication every mornin with breakfast.#

&. #: need to drink lots of coffee and tea to keep myself healthy.#

(. #: will call my doctor if my ankles swell or my rins et tiht.#

?. & +ationale, Tea and coffee are stimulants and mild diuretics. These are a poor choice for hydration.

Takin the medication at the same time each day improves compliance. 8ecause furosemide is a diuretic*

the mornin is the best time to take the medication so as not to interrupt sleep. Notification of the healthcare provider is appropriate if edema is noticed in the hands* feet* or face or if the client is short of breath.

ittin up slowly prevents postural hypotension.

Test-Takin tratey, 2se the process of elimination* notin the strateic words need for further teachin.

These words indicate a neative event !uery and ask you to select an option that is an incorrect statement.

+ecallin that tea and coffee are stimulants and that diuretics potentially can worsen dehydration will

direct you to option &. :n addition* coffee and tea are not healthy items to consume. +eview client

teachin points related to this medication if you had difficulty with this !uestion.

E. A client who has developed severe pulmonary edema would most likely exhibit which of the

followin"

1. 7ild anxiety

$. liht anxiety

&. ;xtreme anxiety

(. 7oderate anxiety

E. & +ationale, 0ulmonary edema causes the client to be extremely aitated and anxious. The client may

complain of a sense of drownin* suffocation* or smotherin.

Test-Takin tratey 2se the process of elimination. Notin the strateic word severe will direct you to

option &. +eview the clinical manifestations associated with severe pulmonary edema if you had difficulty

with this !uestion.


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E. A nurse is carin for a client receivin a heparin intravenous :9 infusion. The nurse anticipates that

which laboratory study will be prescribed to monitor the therapeutic effect of heparin"

1. %ematocrit

$. %emolobin

&. 0rothrombin time

(. Activated partial thromboplastin time

E. ( +ationale, The prothrombin time will assess for the therapeutic effect of warfarin sodium

Coumadin* and the activated partial thromboplastin time a0TT will assess the therapeutic effect of

heparin. %ematocrit and hemolobin values assess red blood cell concentrations. 8aseline assessment*

includin an a0TT value* should be completed* as well as onoin daily a0TT values while the client istakin heparin. %eparin doses are determined based on the result of the a0TT.

Test-Takin tratey, 2se the process of elimination. ;liminate options 1 and $ because they are

comparative or alike and are unrelated to heparin therapy. Brom the remainin options* recall the

relationship between the prothrombin time and warfarin and the a0TT and heparin. +eview care of a

client on heparin infusion if you had difficulty with this !uestion.

1). A client with pulmonary edema has been on diuretic therapy. The client has an order for additional

furosemide 5asix in the amount of () m intravenous push. @nowin that the client will also be started

on dioxin 5anoxin* the nurse should review which laboratory result"

1. odium level

$. 'ioxin level

&. Creatinine level

(. 0otassium level

1). ( +ationale, The serum potassium level is measured in the client receivin dioxin and furosemide.%eihtened dioxin effect leadin to dioxin toxicity can occur in the client with hypokalemia.

%ypokalemia also predisposes the client to ventricular dysrhythmias.

Test-Takin tratey 2se the process of elimination. ;liminate option $ because the client will 3ust be

beinnin dioxin therapy. No data indicate the presence of renal insufficiencyF therefore* eliminate

option &. Burosemide therapy can cause hyponatremia and hypokalemia* but remember that the risk of


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hypokalemia has more severe conse!uences in this situation. +eview the nursin considerations related to

administerin furosemide if you had difficulty with this !uestion.

11. A home health nurse instructs a client about the use of a nitrate patch. The nurse tells the client that

which of the followin will prevent client tolerance to nitrates"

1. #'o not remove the patches.#

$. #%ave a 1$-hour no-nitrate time.#

&. #%ave a $(-hour no-nitrate time.#

(. #@eep nitrates on $( hours* then off $( hours.#

11. $ +ationale, To help prevent tolerance* clients need a 1$-hour #no-nitrate# time* sometimes referred to

as a pharmacoloical vacation away from the medication. /ptions 1* &* and ( are incorrect.

Test-Takin tratey, 2se the process of elimination* focusin on the sub3ect* preventin tolerance to

nitrates. This sub3ect and knowlede reardin administerin this medication will direct you to option $.

+eview the administration of nitrate patches if you had difficulty with this !uestion.

1$. A client is admitted to a medical unit with nausea and bradycardia. The family hands a nurse a small

white envelope labeled #heart pill.# The envelope is sent to the pharmacy and it is found to be dioxin

5anoxin. A family member states* #That doctor doesnt know how to take care of my family.# Which of

the followin statements would convey a therapeutic response by the nurse"

1. #'ont worry about this. :ll take care of everythin.#

$. #Gou are concerned your loved one receives the best care.#

&. #Goure rihtH :ve never seen a doctor put pills in an envelope.#

(. #: think youre wron. That physician has been in practice over &) years.#

1$. $ +ationale, This is a therapeutic* non3udmental response. The statement reflects the familys

concern but remains non3udmental. /ption 1 dismisses the familys concerns and disempowers the

family. /ption & creates doubt about the physicians practice without actually knowin the circumstances.

/ption ( is arumentative and nontherapeutic.

Test-Takin tratey, 2se therapeutic communication techni!ues. +eflection of the clients or familys

concerns is the most therapeutic. +eview these techni!ues if you had difficulty with this !uestion.


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1$. A nurse assesses the sternotomy incision of a client on the third day after cardiac surery. The incision

shows some sliht #puffiness# alon the edes and is nonreddened* with no apparent drainae.

Temperature is EEI B orally. The white blood cell count is D


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1(. A nurse is preparin to ambulate a client on the third day after cardiac surery. The nurse would plan

to do which of the followin to enable the client to best tolerate the ambulation"

1. +emove telemetry e!uipment.

$. 0rovide the client with a walker.

&. 0remedicate the client with an analesic.

(. ;ncourae the client to couh and deep breathe.

1(. & +ationale, The nurse should encourae reular use of pain medication for the first (? to D$ hours

after cardiac surery because analesia will promote rest* decrease myocardial oxyen consumption

resultin from pain* and allow better participation in activities such as couhin* deep breathin* and

ambulation. /ptions $ and ( will not help in toleratin ambulation. +emoval of telemetry e!uipment is

contraindicated unless prescribed.

Test Takin tratey 2se the process of elimination. Bocus on the sub3ect* how best to tolerate the

ambulation. Couhin and deep breathin will not actively help endurance* so eliminate option (.

+emoval of telemetry e!uipment is contraindicated unless ordered. Brom the remainin options* focusin

on the sub3ect will direct you to option &. +eview comfort measures for the client followin cardiac

surery if you had difficulty with this !uestion.

1D. A client has developed paroxysmal nocturnal dyspnea. Which of the followin medications does a

nurse anticipate will be prescribed by the physician"

1. 0ropranolol :nderal

$. 8umetanide 8umex

&. 5idocaine 6ylocaine

(. treptokinase treptase

1D. $ +ationale, 8umetanide 8umex is a diuretic. The paroxysmal nocturnal dyspnea may be due to

increased venous return when the client is lyin in bed* and the client needs diuresis. 0ropranolol is a b-

blocker* lidocaine is an antiarrhythmic* and streptokinase is a thrombolytic.

Test-Takin tratey, 2se the process of elimination. @nowlede of each medication type and that a

diuretic will increase urine output will direct you to option $. +eview the actions of the medications

identified in the options* if you had difficulty with this !uestion.


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1?. A nurse notices fre!uent artifact on the electrocardioraphic monitor for a client whose leads are

connected by cable to a console at the bedside. The nurse examines the client to determine the cause.

Which of the followin items is unlikely to be responsible for the artifact"

1. Bre!uent movement of the client

$. Tihtly secured cable connections

&. 5eads applied over hairy areas

(. 5eads applied to the limbs

1?. $ +ationale, 7otion artifact* or #noise*# can be caused by fre!uent client movement* electrode

placement on limbs* and insufficient adhesion to the skin* such as placin electrodes over hairy areas of

the skin. ;lectrode placement over bony prominences also should be avoided. inal interference also can

occur with electrode removal and cable disconnection.

Test-Takin tratey 2se the process of elimination* focusin on the sub3ect* artifact and note the

strateic word unlikely. +ecallin the causes of artifact will direct you to option $. +eview these causes if


$). A client has fre!uent bursts of ventricular tachycardia on the cardiac monitor. Why should the nurse

be most concerned about with this dysrhythmia"

1. :t can develop into ventricular fibrillation at any time.

$. :t is almost impossible to convert to a normal rhythm.

&. :t is uncomfortable for the client* ivin a sense of impendin doom.

(. :t produces a hih cardiac output that !uickly leads to cerebral and myocardial ischemia.

$). 1 +ationale, 9entricular tachycardia is a life-threatenin dysrhythmia that results from an irritable

ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead

!uickly to cerebral and myocardial ischemia. Clients fre!uently experience a feelin of impendin doom.

9entricular tachycardia is treated with antidysrhythmic medications* cardioversion client awake* or

defibrillation loss of consciousness. 9entricular tachycardia can deteriorate into ventricular fibrillation atany time.

Test-Takin tratey 2se the process of elimination and note the strateic words most concerned. /ption

$ is incorrect and is eliminated first. Brom the remainin options* focusin on the strateic words will

direct you to option 1 because this option identifies the life-threatenin condition. +eview the concerns

associated with ventricular tachycardia if you had difficulty with this !uestion.


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$1. A client is at risk for pulmonary embolism and is on anticoaulant therapy with warfarin sodium

Coumadin. The clients prothrombin time is $) seconds* with a control of 11 seconds. %ow would the

nurse interpret these results"

1. Client needs to have test repeated.

$. Client results are within the therapeutic rane.

&. Client results are hiher than the therapeutic rane.

(. Client results are lower than the needed therapeutic level.

$1. $ +ationale, The therapeutic rane for prothrombin time is 1.< to $ times the control for clients at hih

risk for thrombus. 8ased on the clients control value* the therapeutic rane for this individual would be

1.< to $$ seconds. Therefore the result is within the therapeutic rane.

Test-Takin tratey, 2se the process of elimination. 5ook at the control value. +ememberin that the

purpose of anticoaulant therapy is to prolon clottin times will assist in eliminatin options & and (.

;liminate option 1* because there is no basis for repeatin the test. 8ecause the prothrombin value

identified in the !uestion is not even double the control* select option $ from the remainin options.

+eview the therapeutic prothrombin level for a client at risk for pulmonary embolism if you had difficulty

with this !uestion.

$1. A nurse is carin for a client with unstable ventricular tachycardia. The nurse instructs the client to do

which of the followin* if prescribed* durin an episode of ventricular tachycardia"

1. 5ie down flat in bed.

$. +emove any metal 3ewelry.

&. 8reathe deeply* reularly* and easily.

(. :nhale deeply and couh forcefully every 1 to & seconds.

$1. ( +ationale, Couh cardiopulmonary resuscitation C0+ sometimes is used in the client withunstable ventricular tachycardia. The nurse tells the client to use couh C0+* if prescribed* by inhalin

deeply and couhin forcefully every 1 to & seconds. Couh C0+ may terminate the dysrhythmia or

sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

/ptions 1* $* and & will not assist in terminatin the dysrhythmia.

Test-Takin tratey To answer this !uestion* you must be familiar with the treatment for unstable


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ventricular tachycardia. +emember that couh C0+ sometimes is used in the client with unstable

ventricular tachycardia. +eview the concept of couh C0+ if you are not familiar with it.

$$. A client is havin fre!uent premature ventricular contractions. A nurse would place priority on

assessment of which of the followin"

1. ensation of palpitations

$. Causative factors* such as caffeine

&. 0recipitatin factors* such as infection

(. 8lood pressure and oxyen saturation

$$. ( +ationale, 0remature ventricular contractions can cause hemodynamic compromise. The shortened

ventricular fillin time with the ectopic beat leads to decreased stroke volume and* if fre!uent enouh* to

decreased cardiac output. The client may be asymptomatic or may feel palpitations. 0remature ventricular

contractions can be caused by cardiac disorders* states of hypoxemia or by any number of physioloical

stressors* such as infection* illness* surery* or trauma* and by intake of caffeine* nicotine* or alcohol.

Test-Takin tratey Note the strateic words priority on assessment. 2se the A8CsJairway* breathin*

and circulationJto direct you to option (. +eview the effects of premature ventricular contractions if you

had difficulty with this !uestion.

$&. A client has developed atrial fibrillation* with a ventricular rate of 1


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correlate with a tachycardic state. Brom the remainin options* think of the conse!uences of fallin

cardiac output to direct you to option &. +eview the effects of atrial fibrillation if you had difficulty with

this !uestion.

$&. A client is on enalapril 9asotec for the treatment of hypertension. The nurse teaches the client that he

should seek emerent care if he experiences which adverse effect"

1. Nausea

$. :nsomnia

&. 'ry couh

(. wellin of the tonue

$&. ( +ationale, ;nalapril 9asotec is an aniotensin-convertin en=yme inhibitor. Anioedema is an

adverse effect. wellin of the tonue and lips can result in airway occlusion. Nausea* insomnia* and a

couh can occur as side not adverse effects of the medication.

Test-Takin tratey, Note the strateic word adverse. 2se the A8CsJairway* breathin* and circulation

Jto direct you to option (. +eview the adverse effects of this medication if you had difficulty with this

!uestion.

$(. Which of the followin would be an expected outcome of nesiritide Natrecor administration"

1. Client will have an increase in urine output.

$. Client will have an absence of dysrhythmias.

&. Client will have an increase in blood pressure.

(. Client will have an increase in pulmonary capillary wede pressure.

$(. 1 +ationale, Nesiritide is a recombinant version of human 8-type natriuretic peptide* which

vasodilates arteries and veins. :t is used for the treatment of decompensated heart failure* increases renal

lomerular filtration* and increases urine output. /ptions $* &* and ( are incorrect.

Test-Takin tratey, 2se the process of elimination. Nesiritide does not have antidysrhythmic properties.

'ysrhythmias may be a side effect of the medication* so option $ should be eliminated. ;liminate option

& because the medication is a vasodilator and causes a decrease in blood pressure. ;liminate option (

because the medication decreases pulmonary capillary wede pressure 0CW0. +eview the effects of this

medication if you had difficulty with this !uestion.


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$


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Test-Takin tratey @nowlede of anatomy and physioloy alone may be sufficient to answer this

!uestion. ;liminate options & and ( because a rapid rate dysrhythmia would need to be slowed. +ecallin

the functions of the vaus nerve and the diaphramatic nerve will direct you to option 1. The vaus nerve

affects heart rate. The diaphramatic nerve affects respiration. :f you are unfamiliar with the functions of

these nerves* review this content.

$D. A nurse is preparin to defibrillate a client in ventricular fibrillation. After placin the paddles on the

clients chest and before discharin them* which of the followin should be done"

1. ;nsure that the client has been intubated.

$. et the defibrillator to the #synchroni=e# mode.

&. Administer lidocaine hydrochloride 6ylocaine.

(. Confirm that the rhythm is actually ventricular fibrillation.

$D. ( +ationale, 2ntil the defibrillator is attached and chared* the client is resuscitated by usin

cardiopulmonary resuscitation. /nce the defibrillator has been attached* the electrocardioram is checked

to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. 5eads also are

checked for any loose connections. A nitrolycerin patch* if present* is removed. The client does not have

to be intubated to be defibrillated. 5idocaine may be iven subse!uently but is not re!uired before

defibrillation. The machine is not set to the synchronous mode because there is no underlyin rhythm

with which to synchroni=e.

Test-Takin tratey 2se the process of elimination* focusin on the sub3ect* ventricular fibrillation. Notethat option ( directly addresses this sub3ect and also addresses assessment of the client. +eview the

procedure for defibrillation if you had difficulty with this !uestion.

&). A nurse is evaluatin a clients response to cardioversion. Which of the followin observations would

be of hihest priority to the nurse"

1. 8lood pressure

$. tatus of airway

&. /xyen flow rate

(. 5evel of consciousness

&). $ +ationale, Nursin responsibilities after cardioversion include maintenance first of a patent airway*

and then oxyen administration* assessment of vital sins and level of consciousness* and dysrhythmia


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detection.

Test Takin tratey 2se the process of elimination* notin the strateic words hihest priority. 2se the

A8CsJairway* breathin* and circulationJto direct you to option $. +eview care of the client followin

cardioversion if you had difficulty with this !uestion.

&1. A nurse is performin cardiopulmonary resuscitation on a client who has had a cardiac arrest. An

automatic external defibrillator is available to treat the client. Which of the followin activities will allow

the nurse to assess the clients cardiac rhythm"

1. %old the defibrillator paddles firmly aainst the chest.

$. Apply adhesive patch electrodes to the chest and move away from the client.

&. Apply standard electrocardioraphic monitorin leads to the client and observe the rhythm.

(. Connect standard electrocardioraphic electrodes to a transtelephonic monitorin device.

&1. $ +ationale, The nurse or rescuer puts two lare adhesive patch electrodes on the clients chest in the

usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the

client to move away and not touch the client. The defibrillator then analy=es the rhythm* which may take

up to &) seconds. The machine then indicates if defibrillation is necessary.

Test-Takin tratey 2se the process of elimination. :f you are not familiar with this piece of e!uipment*

look first at the word automatic in the name. This implies that a person is not as involved in the process as

with a conventional defibrillator and will help eliminate option 1. 8ecause standard electrocardiorammonitorin leads do not play an active role once resuscitation is underway options & and (* you can

eliminate these comparative or alike options. +eview the procedure related to the use of an automatic

external defibrillator if you had difficulty with this !uestion.

&$. A nurse employed in a cardiac unit determines that which of the followin clients is the least likely to

have implantation of an automatic internal cardioverter-defibrillator A:C'"

1. A client with syncopal episodes related to ventricular tachycardia

$. A client with ventricular dysrhythmias despite medication therapy

&. A client with an episode of cardiac arrest related to myocardial infarction

(. A client with three episodes of cardiac arrest unrelated to myocardial infarction


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&$. & +ationale, An automatic internal cardioverter-defibrillator A:C' detects and delivers an electrical

shock to terminate life-threatenin episodes of ventricular tachycardia and ventricular fibrillation. These

devices are implanted in clients who are considered hih risk* includin those who have survived sudden

cardiac death unrelated to myocardial infarction* those who are refractive to medication therapy* and those

who have syncopal episodes related to ventricular tachycardia.

Test-Takin tratey 2se the process of elimination and note the strateic words least likely. 9entricular

dysrhythmias that induce syncope or occur while the client is on medication are likely to be true

indications for the A:C'* so eliminate options 1 and $ first. Brom the remainin options* the main

difference is whether or not the cardiac arrest was related to myocardial infarction. /f these two* the one

most likely to be responsive to A:C' would be the client without myocardial infarction because those

dysrhythmias are spontaneous. +eview the indications for the use of an A:C'* if you had difficulty with

this !uestion.

&&. A nurse is carin for a client who has 3ust had implantation of an automatic internal cardioverter-defibrillator. The nurse immediately would assess which of the followin items based on priority"

1. Anxiety level of the client and family

$. 0resence of a 7edic-Alert card for the client to carry

&. @nowlede of restrictions of postdischare physical activity

(. Activation status of the device* heart rate cutoff* and number of shocks it is prorammed to deliver

&&. ( +ationale, The nurse who is carin for the client after insertion of an automatic internalcardioverter-defibrillator needs to assess device settins* similar to after insertion of a permanent

pacemaker. pecifically* the nurse needs to know whether the device is activated* the heart rate cutoff

above which it will fire* and the number of shocks it is prorammed to deliver. /ptions 1* $* and & are

also nursin interventions but are not the priority.

Test-Takin tratey 2se 7aslows %ierarchy of Needs theory. /ption ( is the option that identifies the

physioloical need. +eview care to the client followin insertion of an automatic internal cardioverter-

defibrillator if you had difficulty with this !uestion.

&(. A nurse is carin for a client immediately after insertion of a permanent demand pacemaker via the

riht subclavian vein. Which of the followin activities will assist with preventin dislodement of the

pacin catheter"

1. 5imitin movement and abduction of the left arm

$. 5imitin movement and abduction of the riht arm


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&. Assistin the client to et out of bed and ambulate with a walker

(. %avin the physical therapist do active rane-of-motion exercises to the riht arm

&(. $ +ationale, :n the first several hours after insertion of a permanent or a temporary pacemaker* the

most common complication is pacin electrode dislodment. The nurse helps prevent this complication

by limitin the clients activities of the arm on the side of the insertion site.

Test-Takin tratey 2se the process of elimination. Note that the pacemaker was inserted on the riht

side. Therefore* to prevent pacin electrode dislodment* motion must be limited on that side. /ptions &

and ( involve movement of the riht arm and are eliminated first. 5imitin the movement of the left arm

option 1 is of no benefit to the client. Thus* option $ is the correct option. +eview care of the client

followin insertion of a pacemaker if you had difficulty with this !uestion.

&


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$. #The vein is tied off at the upper end to prevent stasis from occurrin.#

&. #The vein is tied off at the lower end to prevent stasis from occurrin.#

(. #An aent is in3ected into the vein to damae the vein wall and close the vein off.#

&. ( +ationale, clerotherapy is the in3ection of a sclerosin aent into a varicosity. The aent damaes

the vessel and causes aseptic thrombosis* which results in vein closure. With no blood flow throuh the

vessel* there is no distention. The surical procedure for varicose veins is vein liation and strippin. This

procedure involves tyin off the varicose vein and lare tributaries and then removin the vein with hook

and wires via multiple small incisions in the le.

Test-Takin tratey 2se the process of elimination and note the name of the procedure* sclerotherapy. A

vessel that is sclerosed is blocked. This will direct you to option (. +eview this procedure if you had


&D. A client is havin a follow-up physician office visit after vein liation and strippin. The client

describes a sensation of #pins and needles# in the affected le. Which of the followin would be an

appropriate action by the nurse based on evaluation of the clients comment"

1. :nstruct the client to apply warm packs.

$. +eport the complaint to the physician.

&. +eassure the client that this is only temporary.

(. Advise the client to take acetaminophen Tylenol until it is one.

&D. $ +ationale, %ypersensitivity or a sensation of #pins and needles# in the surical limb may indicate

temporary or permanent nerve in3ury followin surery. The saphenous vein and saphenous nerve run

close toether in the distal third of the le. 8ecause complications from this surery are relatively rare*

this symptom should be reported.

Test-Takin tratey 2se the process of elimination. 0ins and needles sensations usually indicate nerve

irritation or damae. :f you know this* you can eliminate options 1 and (. +eassurin the client about

somethin bein #only temporary# is often not an appropriate action* unless this is known to be absolutelytrue. +eview the complications associated with vein liation and strippin if you had difficulty with this

!uestion.

&?. 0ostoperatively* a nurse is carin for a client who had a percutaneous insertion of an inferior vena

cava filter and was on heparin therapy before surery. The nurse would inspect the surical site most


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closely for evidence of which of the followin"

1. 8leedin and infection

$. Thrombosis and infection

&. 8leedin and wound dehiscence

(. Wound dehiscence and evisceration

&?. 1 +ationale, After inferior vena cava filter insertion* the nurse inspects the surical site for bleedin

and sins and symptoms of infection. /therwise* care is the same as for any other postoperative client.

Test-Takin tratey 2se the process of elimination. 8ecause inferior vena cava filters are inserted

percutaneously throuh a deep vein* options & and ( are eliminated because no abdominal incision is

made. Brom the remainin options* notin that the client has been on anticoaulant therapy before surery

because of the hih risk of pulmonary embolism will direct you to option 1. +eview care of the clientfollowin insertion of an inferior vena cava filter if you had difficulty with this !uestion.

(). A client is scheduled for a cardiac catheteri=ation usin a radiopa!ue dye. Which of the followin

assessments is most critical before the procedure"

1. :ntake and output

$. %eiht and weiht

&. Allery to iodine or shellfish

(. 8aseline peripheral pulse rates

(). & +ationale, A cardiac catheteri=ation re!uires an informed consent because it involves in3ection of a

radiopa!ue dye into the blood vessel. The risk of alleric reaction and possible anaphylaxis is a concern

and the presence of alleries must be assessed before the procedure. Althouh options 1* $* and ( are

accurate* they are not the most critical preprocedure assessments.

Test-Takin tratey 2se the process of elimination and note the strateic words most critical. +ecallin

the concern related to allery to the dye and the risk of anaphylaxis makes option & correct. +eviewpreprocedure interventions for a cardiac catheteri=ation if you had difficulty with this !uestion.

(1. A nurse is assessin the neurovascular status of a client who returned to the surical nursin unit (

hours ao after underoin aortoiliac bypass raft. The affected le is warm* and the nurse notes redness

and edema. The pedal pulse is palpable and unchaned from admission. %ow would the nurse correctly


21/40

interpret the clients neurovascular status"

1. The neurovascular status is normal because of increased blood flow throuh the le.

$. The neurovascular status is moderately impaired* and the sureon should be called.

&. The neurovascular status is slihtly deterioratin and should be monitored for another hour.

(. The neurovascular status is ade!uate from an arterial approach* but venous complications are arisin.

(1. 1 +ationale, An expected outcome of surery is warmth* redness* and edema in the surical extremity

because of increased blood flow. Therefore* options $* &* and ( are incorrect interpretations.

Test-Takin tratey 2se the process of elimination. /ption $ can be eliminated because the pedal pulse

is unchaned from admission. 9enous complications from immobili=ation resultin from surery would

not be apparent within ( hours* so eliminate option (. Brom the remainin options* think about the effects

of sudden reperfusion in an ischemic limb. There would be redness from new blood flow and edema fromthe sudden chane in pressure in the blood vessels. +eview the expected assessment findins followin

this surical procedure if you had difficulty with this !uestion.

($. A nurse is evaluatin the condition of a client after pericardiocentesis performed to treat cardiac

tamponade. Which of the followin observations would indicate that the procedure was unsuccessful"

1. +isin blood pressure

$. Clearly audible heart sounds

&. Client expressions of relief

(. +isin central venous pressure

($. ( +ationale, Bollowin pericardiocentesis* a rise in blood pressure and a fall in central venous

pressure are expected. The client usually expresses immediate relief. %eart sounds are no loner muffled

or distant.

Test-Takin tratey 2se the process of elimination and note the strateic word unsuccessful. uccessful

therapy is measured by the disappearance of the oriinal sins and symptoms of cardiac tamponade.Therefore* look for the option that identifies a sin consistent with continued tamponade. +eview sins of

cardiac tamponade and the expected effects of pericardiocentesis if you had difficulty with this !uestion.

(&. A nurse is assessin a client with an abdominal aortic aneurysm. Which of the followin assessment

findins by the nurse is probably unrelated to the aneurysm"


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1. 0ulsatile abdominal mass

$. %yperactive bowel sounds in the area

&. ystolic bruit over the area of the mass

(. ub3ective sensation of #heart beatin# in the abdomen

(&. $ +ationale, Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may

describe a feelin of the #heart beatin# in the abdomen when supine or bein able to feel the mass

throbbin. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be

auscultated over the mass. %yperactive bowel sounds are not related specifically to an abdominal aortic

aneurysm.

Test-Takin tratey 2se the process of elimination and note the strateic word unrelated. Note that

options 1* &* and ( are comparative or alike in that they identify a circulatory component. +eview thesins of abdominal aortic aneurysm if you had difficulty with this !uestion.

(


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chanes are most consistent with which of the followin complications"

1. Cardioenic shock

$. Cardiac tamponade

&. 0ulmonary embolism

(. 'issectin thoracic aortic aneurysm

E$. 1

+ationale,

Cardioenic shock occurs with severe damae more than ()K to the left ventricle. Classic sins include

hypotension* a rapid pulse that becomes weaker* decreased urine output* and cool* clammy skin.

+espiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade isaccompanied by distant* muffled heart sounds and prominent neck vessels. 0ulmonary embolism presents

suddenly with severe dyspnea accompanyin the chest pain. 'issectin aortic aneurysms usually are

accompanied by back pain.

Test-Takin tratey,

2se the process of elimination. +ecallin that the early serious complications of myocardial infarction

include dysrhythmias* cardioenic shock* and sudden death will direct you to option 1. No information in

the !uestion is associated with options $* &* or (. +eview the complications of myocardial infarction if


E&. A client admitted to the hospital with chest pain and history of type $ diabetes mellitus is scheduled

for cardiac catheteri=ation. Which of the followin medications would need to be withheld for (? hours

before and after the procedure"

1. +eular insulin

$. Llipi=ide Llucotrol

&. +epalinide 0randin

(. 7etformin Llucophae

E&. (

+ationale,


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7etformin Llucophae needs to be withheld (? hours before and after cardiac catheteri=ation because

of the in3ection of contrast medium durin the procedure. :f the contrast medium affects kidney function*

with metformin in the system* the client would be at increased risk for lactic acidosis. The medications in

options 1* $* and & do not need to be withheld (? hours before or after cardiac catheteri=ation.

Test-Takin tratey,

2se the process of elimination. ;liminate options $ and & first. Althouh these medications may be

withheld on the mornin of the procedure because of the clients N0/ status* there is no indication for

withholdin the medication the day prior to and the day postprocedure. +eular insulin may be

administered if elevated blood lucose levels from infused intravenous solutions occur on the day of the

procedure. +eview preprocedure and postprocedure interventions if you had difficulty with this !uestion.

E(. A client is in sinus bradycardia with a heart rate of (< beats4min* complains of di==iness* and has a

blood pressure of ?$4) mm %. Which of the followin should the nurse anticipate will be prescribed"

1. 'efibrillate the client.

$. Administer dioxin 5anoxin.

&. Continue to monitor the client.

(. 0repare for transcutaneous pacin.

E(. (

+ationale,

%ypotension and di==iness are sins of decreased cardiac output. Transcutaneous pacin provides a

temporary measure to increase the heart rate and thus perfusion in the symptomatic client. 'ioxin will

further decrease the clients heart rate. 'efibrillation is used for treatment of pulseless ventricular

tachycardia and ventricular fibrillation. Continuin to monitor the client delays necessary intervention.

Test-Takin tratey,

2se the process of elimination. ;liminate option & because the client is symptomatic and re!uires

intervention. /ption $ is eliminated because dioxin will further decrease the clients heart rate.

'efibrillation is used for treatment of pulseless ventricular tachycardia and ventricular fibrillationF

therefore eliminate option 1. +eview the indications for transcutaneous pacin if you had difficulty with

this !uestion.


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E. A client with myocardial infarction suddenly becomes tachycardic* shows sins of air huner* and

beins couhin frothy* pink-tined sputum. Which of the followin would the nurse anticipate when

auscultatin the clients breath sounds"

1. tridor

$. Crackles

&. cattered rhonchi

(. 'iminished breath sounds

E. $

+ationale,

0ulmonary edema is characteri=ed by extreme breathlessness* dyspnea* air huner* and the production offrothy* pink-tined sputum. Auscultation of the luns reveals crackles. +honchi and diminished breath

sounds are not associated with pulmonary edema. tridor is a crowin sound associated with

larynospasm or edema of the upper airway.

Test-Takin tratey,

2se the process of elimination. +ecallin that fluid produces sounds that are called crackles will assist

you in eliminatin options 1* &* and (. :f you had difficulty with this !uestion* review the manifestations

found in pulmonary edema.

ED. A client with myocardial infarction is developin cardioenic shock. 8ecause of the risk of

myocardial ischemia* for which of the followin should the nurse carefully assess the client"

1. 8radycardia

$. 9entricular dysrhythmias

&. +isin diastolic blood pressure

(. Ballin central venous pressure

ED. $

+ationale,

Classic sins of cardioenic shock as they relate to this !uestion include low blood pressure and

tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular


26/40

failure became apparent. 'ysrhythmias commonly occur as a result of decreased oxyenation and severe

damae to reater than ()K of the myocardium.

Test-Takin tratey,

2se the process of elimination and focus on the strateic words myocardial ischemia. +ecall that ischemiamakes the myocardium irritable* producin dysrhythmias. Also* knowlede of the classic sins of shock

helps eliminate the incorrect options. +eview the clinical manifestations associated with cardioenic

shock if you had difficulty with this !uestion.

E?. A client who had cardiac surery $( hours ao has a urine output averain $) m54hr for $ hours.

The client received a sinle bolus of


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nurse"

1. Call a code blue.

$. Call the physician.

&. Check the client status and lead placement.

(. 0ress the recorder button on the electrocardioram console.

D)). &

+ationale,

udden loss of electrocardioraphic complexes indicates ventricular asystole or possibly electrode

displacement. Accurate assessment of the client and e!uipment is necessary to determine the cause and

identify the appropriate intervention. /ptions 1* $* and ( are unnecessary.

Test-Takin tratey,

2se the steps of the nursin process. Always assess the client directly before takin any action. /ption &

is the only option that addresses assessment. +eview care of the client on a cardiac monitor if you had


D)$. A client has fre!uent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse

be most concerned about with this dysrhythmia"

1. :t can develop into ventricular fibrillation at any time.

$. :t is almost impossible to convert to a normal rhythm.

&. :t is uncomfortable for the client* ivin a sense of impendin doom.

(. :t produces a hih cardiac output that !uickly leads to cerebral and myocardial ischemia.

D)$. 1

+ationale,

9entricular tachycardia is a life-threatenin dysrhythmia that results from an irritable ectopic focus that

takes over as the pacemaker for the heart. The low cardiac output that results can lead !uickly to cerebral

and myocardial ischemia. Clients fre!uently experience a feelin of impendin doom. 9entricular

tachycardia is treated with antidysrhythmic medications* cardioversion client awake* or defibrillation

loss of consciousness. 9entricular tachycardia can deteriorate into ventricular fibrillation at any time.


28/40

Test-Takin tratey,

2se the process of elimination and note the strateic words most concerned. /ption $ is incorrect and is

eliminated first. Brom the remainin options* focusin on the strateic words will direct you to option 1

because this option identifies the life-threatenin condition. +eview the concerns associated withventricular tachycardia if you had difficulty with this !uestion.

D)&. A client is havin fre!uent premature ventricular contractions. A nurse would place priority on

assessment of which of the followin"

1. ensation of palpitations

$. Causative factors* such as caffeine

&. 0recipitatin factors* such as infection

(. 8lood pressure and oxyen saturation

(

+ationale,

0remature ventricular contractions can cause hemodynamic compromise. The shortened ventricular fillin

time with the ectopic beat leads to decreased stroke volume and* if fre!uent enouh* to decreased cardiac

output. The client may be asymptomatic or may feel palpitations. 0remature ventricular contractions canbe caused by cardiac disorders* states of hypoxemia* or by any number of physioloical stressors* such as

infection* illness* surery* or trauma* and by intake of caffeine* nicotine* or alcohol.

Test-Takin tratey,

Note the strateic words priority on assessment. 2se the A8CsJairway* breathin* and circulationJto

direct you to option (. +eview the effects of premature ventricular contractions if you had difficulty with

this !uestion.

D)(. A client has developed atrial fibrillation* with a ventricular rate of 1


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&. %ypotension and di==iness

(. %ypertension and headache

D)(. &

+ationale,

The client with uncontrolled atrial fibrillation with a ventricular rate more than 1)) beats4min is at risk for

low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations* chest pain

or discomfort* hypotension* pulse deficit* fatiue* weakness* di==iness* syncope* shortness of breath* and

distended neck veins.

Test-Takin tratey,

2se the process of elimination. Blat neck veins are normal or indicate hypovolemia* so eliminate option 1.

Nausea and vomitin option $ are associated with vaus nerve activity and do not correlate with atachycardic state. Brom the remainin options* think of the conse!uences of fallin cardiac output to

direct you to option &. +eview the effects of atrial fibrillation if you had difficulty with this !uestion.

D1$. A nurse is assessin the neurovascular status of a client who returned to the surical nursin unit (

hours ao after underoin aortoiliac bypass raft. The affected le is warm* and the nurse notes redness

and edema. The pedal pulse is palpable and unchaned from admission. %ow would the nurse correctly

interpret the clients neurovascular status"

1. The neurovascular status is normal because of increased blood flow throuh the le.

$. The neurovascular status is moderately impaired* and the sureon should be called.

&. The neurovascular status is slihtly deterioratin and should be monitored for another hour.

(. The neurovascular status is ade!uate from an arterial approach* but venous complications are arisin.

D1$. 1

+ationale,

An expected outcome of aortoiliac bypass raft surery is warmth* redness* and edema in the surical

extremity because of increased blood flow. Therefore options $* &* and ( are incorrect interpretations.

Test-Takin tratey,

2se the process of elimination. /ption $ can be eliminated because the pedal pulse is unchaned from

admission. 9enous complications from immobili=ation resultin from surery would not be apparent


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within ( hours* so eliminate option (. Brom the remainin options* think about the effects of sudden

reperfusion in an ischemic limb. There would be redness from new blood flow and edema from the

sudden chane in pressure in the blood vessels. +eview the expected assessment findins followin this

surical procedure if you had difficulty with this !uestion.

D1(. A nurse is carin for a client who had a resection of an abdominal aortic aneurysm yesterday. The

client has an intravenous infusion with a rate of 1


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$. 9ariant anina

&. 2nstable anina

(. Nonaninal pain

D1


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accumulated blood. /xyen is always prescribed* and the client is placed in a hih Bowlers position to

ease the work of breathin. Burosemide* a rapid-actin diuretic* will eliminate accumulated fluid. A Boley

catheter is inserted to measure output accurately. :ntravenously administered morphine sulfate reduces

venous return preload* decreases anxiety* and also reduces the work of breathin. Transportin the client

to the coronary care unit is not a priority intervention. :n fact* this may not be necessary at all if the

clients response to treatment is successful.

Test-Takin tratey,

Note the strateic words priority interventions and focus on the clients dianosis. +ecall the

pathophysioloy associated with pulmonary edema and use the A8CsJairway* breathin* and circulation

Jto help determine priority interventions. +eview priority interventions for the client with pulmonary

edema if you had difficulty with this !uestion.

D1D. A client with atrial fibrillation is receivin a continuous heparin infusion at 1))) units4hr. The nursewould determine that the client is receivin the therapeutic effect based on which of the followin results"

1. 0rothrombin time of 1$.< seconds

$. Activated partial thromboplastin time of ) seconds

&. Activated partial thromboplastin time of $? seconds

(. Activated partial thromboplastin time loner than 1$) seconds

D1D. $

+ationale,

Common laboratory ranes for activated partial thromboplastin time are $) to & seconds. 8ecause the

activated partial thromboplastin time should be 1.< to $.< times the normal value* the clients activated

partial thromboplastin time would be considered therapeutic if it was ) seconds.

Test-Takin tratey,

2se the process of elimination. /ption 1 is eliminated because the prothrombin time assesses response to

warfarin Coumadin therapy. ;liminate option & because at $? seconds the client is receivin no

therapeutic effect from the continuous heparin infusion. ;liminate option ( because this value is beyond

the therapeutic rane and the client is at risk for bleedin. +eview laboratory tests to monitor the

effectiveness of heparin therapy if you had difficulty with this !uestion.


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D1?. A nurse provides dischare instructions to a postoperative client who is takin warfarin sodium

Coumadin. Which statement* if made by the client* reflects the need for further teachin"

1. #: will take my pills every day at the same time.#

$. #: will avoid alcohol consumption.#

&. #: have already called my family to pick up a 7edic-Alert bracelet.#

(. #: will take ;cotrin enteric-coated aspirin for my headaches because it is coated.#

D1?. (

+ationale,

;cotrin is an aspirin-containin product and should be avoided. Alcohol consumption should be avoided

by a client takin warfarin sodium. Takin prescribed medication at the same time each day increasesclient compliance. The 7edic-Alert bracelet provides health care personnel emerency information.

Test-Takin tratey,

2se the process of elimination and note the strateic words need for further teachin. These words

indicate a neative event !uery and ask you to select an option that is an incorrect statement. +ecallin

that warfarin Coumadin is an anticoaulant and that ;cotrin is an aspirin-containin product will direct

you to option (. +eview client teachin points related to warfarin if you had difficulty with this !uestion.

D$1. A nurse is monitorin a client who is takin propranolol :nderal. Which assessment data would

indicate a potential serious complication associated with propranolol"

1. The development of complaints of insomnia

$. The development of audible expiratory whee=es

&. A baseline blood pressure of 1


34/40

induce this reaction* particularly in clients with chronic obstructive pulmonary disease or asthma. Normal

decreases in blood pressure and heart rate are expected. :nsomnia is a fre!uent mild side effect and should

be monitored.

Test-Takin tratey,

2se the process of elimination* eliminatin options & and ( because these are expected effects from the

medication. Note the strateic words potential serious complication. These strateic words will direct you

to option $. +eview the adverse effects of this medication if you had difficulty with this !uestion.

D$&. A client is dianosed with an acute myocardial infarction and is receivin tissue plasminoen

activator* alteplase Activase* t0A. Which of the followin is a priority nursin intervention"

1. 7onitor for renal failure.

$. 7onitor psychosocial status.

&. 7onitor for sins of bleedin.

(. %ave heparin sodium available.

D$&. &

+ationale,

Tissue plasminoen activator is a thrombolytic. %emorrhae is a complication of any type ofthrombolytic medication. The client is monitored for bleedin. 7onitorin for renal failure and

monitorin the clients psychosocial status are important but are not the most critical interventions.

%eparin is iven after thrombolytic therapy* but the !uestion is not askin about follow-up medications.

Test-Takin tratey,

2se the process of elimination and note the strateic word priority. +emember* bleedin is a priority.

+eview care of the client on tissue plasminoen activator if you had difficulty with this !uestion.

D$(. A nurse is plannin to administer hydrochlorothia=ide %ydro':2+:5 to a client. The nurse

understands that which of the followin are concerns related to the administration of this medication"

1. %ypouricemia* hyperkalemia

$. :ncreased risk of osteoporosis


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&. %ypokalemia* hyperlycemia* sulfa allery

(. %yperkalemia* hypolycemia* penicillin allery

D$(. &

+ationale,

Thia=ide diuretics such as hydrochlorothia=ide are sulfa-based medications* and a client with a sulfa

allery is at risk for an alleric reaction. Also* clients are at risk for hypokalemia* hyperlycemia*

hypercalcemia* hyperlipidemia* and hyperuricemia.

Test-Takin tratey,

2se the process of elimination. +ecallin that thia=ide diuretics carry a sulfa rin will direct you to option

&. +eview the nursin considerations related to administerin this medication if you had difficulty with

this !uestion.

D$


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+ememberin that over-the-counter medications should be avoided when a client is takin a prescription

medication will direct you to option (. +eview client teachin points related to this medication if you had


D$. A client is on nicotinic acid niacin for hyperlipidemia and the nurse provides instructions to the

client about the medication. Which statement by the client would indicate an understandin of the

instructions"

1. #:t is not necessary to avoid the use of alcohol.#

$. #The medication should be taken with meals to decrease flushin.#

&. #Clay-colored stools are a common side effect and should not be of concern.#

(. #:buprofen 7otrin taken &) minutes before the nicotinic acid should decrease the flushin.#

D$. (

+ationale,

Blushin is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory dru can be taken

&) minutes prior to takin the medication to decrease flushin. Alcohol consumption needs to be avoided

because it will enhance this side effect. The medication should be taken with meals but this will decrease

astrointestinal upsetF takin the medication with meals has no effect on the flushin. Clay-colored stools

are a sin of hepatic dysfunction and should be immediately reported to the physician.

Test-Takin tratey,

2se the process of elimination. /ption 1 can be eliminated because alcohol must be abstained from.

/ption $ can be eliminated because takin the medication with meals helps decrease the astrointestinal

symptoms. The clay-colored stools in option & is a sin of hepatic dysfunction and should be immediately

reported to the physician. +eview the client teachin points related to this medication if you had difficulty

with this !uestion.

D$D. A -year-old client complainin of not feelin well is seen in a clinic. The client is takin severalmedications for the control of heart disease and hypertension. These medications include atenolol

Tenormin* dioxin 5anoxin* and chlorothia=ide 'iuril. A tentative dianosis of dioxin toxicity is

made. Which of the followin assessment data would support this dianosis"

1. 'yspnea* edema* and palpitations

$. Chest pain* hypotension* and paresthesia


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&. 'ouble vision* loss of appetite* and nausea

(. Constipation* dry mouth* and sleep disorder

D$D. &

+ationale,

'ouble vision* loss of appetite* and nausea are early sins of dioxin toxicity. Additional sins of dioxin

toxicity include bradycardia* difficulty readin* other visual alterations such as reen and yellow vision or

seein spots or halos* confusion* vomitin* diarrhea* decreased libido* and impotence.

Test-Takin tratey,

2se the process of elimination. +ecallin that astrointestinal and visual disturbances occur with dioxin

toxicity will direct you to option &. :f you had difficulty with this !uestion* review the sins of dioxintoxicity.

D$E. :ntravenous heparin therapy is prescribed for a client. While implementin this prescription* a nurse

ensures that which of the followin medications is available on the nursin unit"

1. 0rotamine sulfate

$. 0otassium chloride

&. Aminocaproic acid Amicar

(. 9itamin @ A!ua7;0%GT/N

D$E. 1

+ationale,

The antidote to heparin is protamine sulfateF it should be readily available for use if excessive bleedin or

hemorrhae should occur. 9itamin @ is an antidote for warfarin sodium. Aminocaproic acid is the

antidote for thrombolytic therapy. 0otassium chloride is administered for a potassium deficit.

Test-Takin tratey,

@nowlede reardin the various antidotes is needed to answer this !uestion. +emember the antidote to

heparin is protamine sulfate. 5earn these antidotes if you had difficulty with this !uestion.


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D&). A client is receivin thrombolytic therapy with a continuous infusion of streptokinase treptase.

The client suddenly becomes extremely anxious and complains of itchin. A nurse hears stridor and on

examination of the client notes enerali=ed urticaria and hypotension. Which of the followin should be

the priority action of the nurse"

1. Administer oxyen and protamine sulfate.

$. top the infusion and call the physician.

&. Cut the infusion rate in half and sit the client up in bed.

(. Administer diphenhydramine

D&). $

+ationale,

The client is experiencin an anaphylactic reaction to streptokinase* which is allerenic. The infusion

should be stopped* the physician notified* and the client treated with epinephrine* antihistamines* and

corticosteroids.

Test-Takin tratey,

+ecall that an alleric reaction and possible anaphylaxis are risks associated with streptokinase therapy.

Also* focusin on the sins and symptoms in the !uestion will assist in answerin the !uestion. When a

severe alleric reaction occurs* the offendin substance should be stopped* and lifesavin treatment

should bein. +eview the adverse effects of this medication if you had difficulty with this !uestion.

D&1. A client is admitted with pulmonary embolism and is to be treated with streptokinase treptase. A

nurse would report which of the followin assessments to the physician before initiatin this therapy"

1. Adventitious breath sounds

$. Temperature of EE.(I B orally

&. 8lood pressure of 1E?411) mm %

(. +espiratory rate of $? breaths4min

D&1. &

+ationale,

Thrombolytic therapy is contraindicated in a number of preexistin conditions in which there is a risk of


39/40

uncontrolled bleedin* similar to the case in anticoaulant therapy. Thrombolytic therapy also is

contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhae. Therefore

the nurse would report the results of the blood pressure to the physician before initiatin therapy.

Test-Takin tratey,

2se the process of elimination and focus on the clients dianosis. /ptions 1* $* and ( may be present in

the client with pulmonary embolism but are not necessarily sins that warrant reportin before this

therapy is initiated. +eview the contraindications associated with the administration of this medication if


D&$. The nurse is monitorin a client who is takin dioxin 5anoxin for adverse effects. Which findins

are characteristic of dioxin toxicity. elect all that apply.

1. Tremors

$. 'iarrhea

&. :rritability

(. 8lurred vision


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A client with coronary artery disease complains of substernal chest pain. After assessin the clients heart

rate and blood pressure* a nurse administers nitrolycerin* ).( m* sublinually. After < minutes* the client

states* #7y chest still hurts.# elect the appropriate actions that the nurse should take. elect all that

apply.

1. Call a Code 8lue.

$. Contact the physician.

&. Contact the clients family.

(. Assess the clients pain level.

FLASHCARD Cardiovascular

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