NSG 3037 - Med-Surg Practice Test Cardio p2 (Answers & Rationales-pg.14
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NSG 3037, South University
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NSG 3037, South University
Congestive Heart Failure
1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive
heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing
this client?
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white...
nsg 3037 med surg practice test cardio p2 answers amp rationales pg14
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Congestive Heart Failure
1. The client is admitted to the telemetry unit diagnosed with acute exacerbation of congestive
heart failure (CHF). Which signs/symptoms would the nurse expect to find when assessing
this client?
1. Apical pulse rate of 110 and 4+ pitting edema of feet.
2. Thick white sputum and crackles that clear with cough.
3. The client sleeping with no pillow and eupnea.
4. Radial pulse rate of 90 and CRT less than three (3) seconds.
2. The nurse is developing a nursing care plan for a client diagnosed with congestive heart
failure. A nursing diagnosis of “decreased cardiac output related to inability of the heart to
pump effectively” is written. Which short-term goal would be best for the client?
1. The client will be able to ambulate in the hall by date of discharge.
2. The client will have an audible S1 and S2 with no S3 heard by end of shift.
3. The client will turn, cough, and deep breathe every two (2) hours.
4. The client will have a SaO2 reading of 98% by day two (2) of care.
3. The nurse is developing a discharge-teaching plan for the client diagnosed with congestive
heart failure. Which interventions should be included in the plan? Select all that apply.
1. Notify the health-care provider of a weight gain of more than one (1) pound in a week.
2. Teach the client how to count the radial pulse when taking digoxin, a cardiac glycoside.
3. Instruct the client to remove the saltshaker from the dinner table.
4. Encourage the client to monitor urine output for change in color to become dark.
5. Discuss the importance of taking the loop diuretic furosemide at bedtime.
4. The nurse enters the room of the client diagnosed with congestive heart failure. The client is
lying in bed gasping for breath, is cool and clammy, and has buccal cyanosis. Which
intervention would the nurse implement first?
1. Sponge the client’s forehead.
2. Obtain a pulse oximetry reading.
3. Take the client’s vital signs.
4. Assist the client to a sitting position.
5. The nurse is assessing the client diagnosed with congestive heart failure. Which
signs/symptoms would indicate that the medical treatment has been effective?
1. The client’s peripheral pitting edema has gone from 3+ to 4+.
2. The client is able to take the radial pulse accurately.
3. The client is able to perform ADLs without dyspnea.
4. The client has minimal jugular vein distention.
6. The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory
data would indicate that the client is in severe congestive heart failure?
1. An elevated B-type natriuretic peptide (BNP).
2. An elevated creatine kinase (CK-MB).
3. A positive D-dimer.
4. A positive ventilation/perfusion (V/Q) scan.
, 7. The health-care provider has ordered an angiotensin-converting enzyme (ACE) inhibitor for
the client diagnosed with congestive heart failure. Which discharge instructions should the
nurse include?
1. Instruct the client to take a cough suppressant if a cough develops.
2. Teach the client how to prevent orthostatic hypotension.
3. Encourage the client to eat bananas to increase potassium level.
4. Explain the importance of taking the medication with food.
8. The nurse on the telemetry unit has just received the a.m. shift report. Which client should
the nurse assess first?
1. The client diagnosed with myocardial infarction who has an audible S3 heart sound.
2. The client diagnosed with congestive heart failure who has 4+ sacral pitting edema.
3. The client diagnosed with pneumonia who has a pulse oximeter reading of 94%.
4. The client with chronic renal failure who has an elevated creatinine level.
9. The nurse and an unlicensed assistive personnel (UAP) are caring for four clients on a
telemetry unit. Which nursing task would be best for the nurse to delegate to the UAP?
1. Assist the client to go down to the smoking area for a cigarette.
2. Transport the client to the intensive care unit (ICU) via a stretcher.
3. Provide the client going home discharge-teaching instructions.
4. Help position the client who is having a portable x-ray done.
10. The charge nurse is making shift assignments for the medical floor. Which client should be
assigned to the most experienced registered nurse?
1. The client diagnosed with congestive heart failure who is being discharged in the
morning.
2. The client who is having frequent incontinent liquid bowel movements and vomiting.
3. The client with an apical pulse rate of 116, a respiratory rate of 26, and a blood pressure
of 94/62.
4. The client who is complaining of chest pain on inspiration and a nonproductive cough.
11. The client diagnosed with congestive heart failure is complaining of leg cramps at night.
Which nursing interventions should be implemented?
1. Check the client for peripheral edema and make sure the client takes a diuretic early in
the day.
2. Monitor the client’s potassium level and assess the client’s intake of bananas and orange
juice.
3. Determine if the client has gained weight and instruct the client to keep the legs elevated.
4. Instruct the client to ambulate frequently and perform calf-muscle stretching exercises
daily.
12. The nurse has written an outcome goal “demonstrates tolerance for increased activity” for a
client diagnosed with congestive heart failure. Which intervention should the nurse
implement to assist the client to achieve this outcome?
1. Measure intake and output.
2. Provide two (2)g sodium diet.
3. Weigh the client daily.
4. Plan for frequent rest periods.
Angina/Myocardial Infarction
,13. Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a
myocardial infarction (MI)?
1. Creatine kinase (CK-MB).
2. Lactate dehydrogenase (LDH).
3. Troponin.
4. White blood cells (WBCs).
14. Along with persistent, crushing chest pain, which signs/symptoms would make the nurse
suspect that the client is experiencing a myocardial infarction?
1. Midepigastric pain and pyrosis.
2. Diaphoresis and cool, clammy skin.
3. Intermittent claudication and pallor.
4. Jugular vein distention and dependent edema.
15. The client diagnosed with rule-out myocardial infarction is experiencing chest pain while
walking to the bathroom. Which action should the nurse implement first?
1. Administer sublingual nitroglycerin.
2. Obtain a STAT electrocardiogram (ECG).
3. Have the client sit down immediately.
4. Assess the client’s vital signs.
16. The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing
chest pain. Which interventions should the nurse implement? Select all that apply.
1. Administer morphine intramuscularly.
2. Administer an aspirin orally.
3. Apply oxygen via a nasal cannula.
4. Place the client in a supine position.
5. Administer nitroglycerin subcutaneously.
17. The client who has had a myocardial infarction is admitted to the telemetry unit from
intensive care. Which referral would be most appropriatefor the client?
1. Social worker.
2. Physical therapy.
3. Cardiac rehabilitation.
4. Occupational therapy.
18. The client is one (1) day postoperative coronary artery bypass surgery. The client complains
of chest pain. Which intervention should the nurse implement first?
1. Medicate the client with intravenous morphine.
2. Assess the client’s chest dressing and vital signs.
3. Encourage the client to turn from side to side.
4. Check the client’s telemetry monitor.
19. The client diagnosed with a myocardial infarction is six (6) hours post–right femoral
percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery.
Which assessment data would require immediate intervention by the nurse?
1. The client is keeping the affected extremity straight.
2. The pressure dressing to the right femoral area is intact.
3. The client is complaining of numbness in the right foot.
4. The client’s right pedal pulse is 3+ and bounding.
, 20. The intensive care department nurse is assessing the client who is 12 hours post–myocardial
infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse
implement?
1. Notify the health-care provider immediately.
2. Elevate the head of the client’s bed.
3. Document this as a normal and expected finding.
4. Administer morphine intravenously.
21. The nurse is administering a calcium channel blocker to the client diagnosed with a
myocardial infarction. Which assessment data would cause the nurse
to question administering this medication?
1. The client’s apical pulse is 64.
2. The client’s calcium level is elevated.
3. The client’s telemetry shows occasional PVCs.
4. The client’s blood pressure is 90/58.
22. The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive
personnel (UAP) is encouraging the client to move the legs. Which action should the nurse
implement?
1. Instruct the UAP to stop encouraging the leg movements.
2. Report this behavior to the charge nurse as soon as possible.
3. Praise the UAP for encouraging the client to move the legs.
4. Take no action concerning the UAP’s behavior.
23. The client diagnosed with a myocardial infarction asks the nurse, “Why do I have to rest
and take it easy? My chest doesn’t hurt anymore.” Which statement would be the
nurse’s best response?
1. “Your heart is damaged and needs about four (4) to six (6) weeks to heal.”
2. “There is necrotic myocardial tissue that puts you at risk for dysrhythmias.”
3. “Your doctor has ordered bedrest. Therefore, you must stay in the bed.”
4. “Just because your chest doesn’t hurt anymore doesn’t mean you are out of danger.”
24. The client has just returned from a cardiac catheterization. Which assessment data would
warrant immediate intervention from the nurse?
1. The client’s BP is 110/70 and pulse is 90.
2. The client’s groin dressing is dry and intact.
3. The client refuses to keep the leg straight.
4. The client denies any numbness and tingling.
Coronary Artery Disease
25. The male client is diagnosed with coronary artery disease (CAD) and is prescribed
sublingual nitroglycerin. Which statement indicates the client needs more teaching?
1. “I should keep the tablets in the dark-colored bottle they came in.”
2. “If the tablets do not burn under my tongue, they are not effective.”
3. “I should keep the bottle with me in my pocket at all times.”
4. “If my chest pain is not gone with one tablet, I will go to the ER.”
26. The client with coronary artery disease asks the nurse, “Why do I get chest pain?” Which
statement would be the most appropriate response by the nurse?
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