NCMB 312

Medical Surgical Nursing

Correct Answer: A. Normal sinus rhythm
Measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively. Sinus rhythms originate in the SA node. The SA node is located in the right atrium and is the heart's natural pacemaker. The normal rate of the SA node is between 60 and 100. On ECG, sinus rhythm is represented by monomorphic P waves before each QRS complex and is regular.
Option B: Sinus bradycardia is a cardiac rhythm with appropriate cardiac muscle

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as:

A. Normal sinus rhythm
B. Sinus bradycardia
C. Sick sinus syndrome
D. First-degree heart block

Correct Answer: B. Tightly secured cable connections.
Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection. The artifacts produced by alternating current cause a "darkened reinforcement" in the ECG baseline, often making an analysis of rhythm difficult. This is due to lack of filters for alternating current systems or a poor operation of the device.

A nurse notices frequent artifacts on the ECG 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 following items is unlikely to be responsible for the artifact?

A. Frequent movement of the client.
B. Tightly secured cable connections.
C. Leads applied over hairy areas.
D. Leads applied to the limbs.

Correct Answer: B. Ventricular tachycardia
Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular. Ventricular tachycardia is characterized as a wide complex (QRS duration greater than 120 milliseconds) tachyarrhythmia at a heart rate greater than 100 beats per minute. It is classified by duration as non-sustained or sustained. Non-sustained ventricular tachycardia is defined as more than 3 beats of ventricular origin at a rate greater than 100 beats per minute that lasts less than 30 seconds in duration.

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing:

A. Premature ventricular contractions
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Sinus tachycardia

Correct Answer: C. Administer amiodarone (Cordarone) intravenously.
First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Procainamide will terminate between 50% and 80% of ventricular tachycardias, and it will slow the conduction of those that it does not terminate. Amiodarone will convert about 30% of patients to sinus rhythm but is very effective in reducing the reversion rate of refractory SMVT.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following?

A. Immediately defibrillate.
B. Prepare for pacemaker insertion.
C. Administer amiodarone (Cordarone) intravenously.
D. Administer epinephrine (Adrenaline) intravenously.

Correct Answer: B. Inhale deeply and cough forcefully every 1 to 3 seconds.
Cough Cardiopulmonary Resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented. A nurse or physician can instruct and coach the patients to cough forcefully every one to three seconds during the initial seconds of a sudden arrhythmia. But because it's not effective in all patients, it shouldn't delay definitive treatment.

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia?

A. Breathe deeply, regularly, and easily.
B. Inhale deeply and cough forcefully every 1 to 3 seconds.
C. Lie down flat in bed.
D. Remove any metal jewelry.

Correct Answer: A. Blood pressure and peripheral perfusion.
Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. Physical examination findings would reveal an irregular heart rhythm upon auscultation if the patient is experiencing PVCs during the examination. In some patients, cannon A waves may cause chest or neck discomfort. Otherwise, there would not be any direct physical examination findings. A prolonged run of PVCs can result in hypotension.

A client is having frequent premature ventricular contractions. A nurse would place a priority on the assessment of which of the following items?

A. Blood pressure and peripheral perfusion.
B. Sensation of palpitations.
C. Causative factors such as caffeine.
D. Precipitating factors such as infection.

Correct Answer: A. Hypotension and dizziness
The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute 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, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. A physical exam should always begin with the assessment of airway breathing and circulation as it is going to affect the decision making regarding management. On general physical examination, patients may have tachycardia with an irregularly irregular pulse.

A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse assesses the client for:

A. Hypotension and dizziness
B. Nausea and vomiting
C. Hypertension and headache
D. Flat neck veins

Correct Answer: B. Atrial fibrillation
Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled). Atrial fibrillation is the most common type of cardiac arrhythmia. It is the leading cardiac cause of stroke. Risk factors for atrial fibrillation include advanced age, high blood pressure, underlying heart and lung disease, congenital heart disease, and increased alcohol consumption.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as:

A. Sinus tachycardia
B. Atrial fibrillation
C. Ventricular tachycardia
D. Ventricular fibrillation

Correct Answer: A. Vagus nerve to slow the heart rate.
Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmias. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm. Vagal maneuvers are techniques used to increase vagal parasympathetic tone in an attempt to diagnose and treat various arrhythmias. They are often utilized first in an effort to abort episodes of stable supraventricular tachycardia (SVT) or differentiate SVT from ventricular tachycardias (VT).

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the:

A. Vagus nerve to slow the heart rate.
B. Vagus nerve to increase the heart rate; overdriving the rhythm.
C. Diaphragmatic nerve to slow the heart rate.
D. Diaphragmatic nerve to overdrive the rhythm.

Correct Answer: B. Ventricular fibrillation
Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. VF is a WCT caused by irregular electrical activity and characterized by a ventricular rate of usually greater than 300 with discrete QRS complexes on the electrocardiogram (ECG). QRS morphology in VF varies in shape, amplitude, and duration with a prominent irregular rhythm.

A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead, there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be:

A. Ventricular tachycardia
B. Ventricular fibrillation
C. Atrial fibrillation
D. Asystole

Correct Answer: B. Notify the physician promptly.
PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post-MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine.

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to:

A. Increase the IV infusion rate.
B. Notify the physician promptly.
C. Increase the oxygen concentration.
D. Administer a prescribed analgesic.

Correct Answer: D. Syncope and slow ventricular rate
In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result, there is decreased cerebral circulation, causing syncope. Patients with third-degree blocks can have varying clinical presentations. Rarely, patients are asymptomatic. Usually, they may present with generalized fatigue, tiredness, chest pain, shortness of breath, presyncope, or syncope. They may have significant hemodynamic instability and can be obtunded.

The adaptations of a client with complete heart block would most likely include:

A. Nausea and vertigo
B. Flushing and slurred speech
C. Cephalalgia and blurred vision
D. Syncope and slow ventricular rate

Correct Answer: D. Widening of QRS complexes to 0.12 second or greater.
Bundle branch block interferes with the conduction of impulses from the AV node to the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as evidenced by a widened QRS complex. Rhythm must be of supraventricular origin (EG: ventricular activation coming from atrial or AV nodal activation). Lead V1 should have either a QS or a small r wave with large S wave. Lead V6 should have a notched R wave and no Q wave.

A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe:

A. Sagging ST segments.
B. Absence of P wave configurations.
C. Inverted T waves following each QRS complex.
D. Widening of QRS complexes to 0.12 second or greater.

Correct Answer: B. Defibrillate the client
Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU. Pulseless VT and VF are both shockable rhythms, and once the staff identifies the rhythm as VF, patients should be shocked immediately with 120 to 200 joules on a biphasic defibrillator or 360 joules using a monophasic.

When ventricular fibrillation occurs in a CCU, the first person reaching the client should:

A. Administer oxygen.
B. Defibrillate the client.
C. Initiate CPR.
D. Administer sodium bicarbonate intravenously.

Correct Answers: A, B.
The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. Sinus arrhythmia is most typically present in young, healthy individuals. Studies have attempted to establish an increased prevalence in patients with underlying hypertension, obesity, and diabetes.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

A. The RR intervals are relatively consistent.
B. One P wave precedes each QRS complex.
C. Four to eight complexes occur in a 6-second strip.
D. The ST segment is higher than the PR interval.
E. The QRS complex ranges from 0.12 to 0.20 second.

Correct Answer: C. A continuous and totally unpredictable irregularity.
In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions. Due to its rhythm irregularity, blood flow through the heart becomes turbulent and has a high chance of forming a thrombus (blood clot), which can ultimately dislodge and cause a stroke. Atrial fibrillation is the leading cardiac cause of stroke.

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by:

A. The presence of occasional coupled beats.
B. Long pauses in an otherwise regular rhythm.
C. A continuous and totally unpredictable irregularity.
D. Slow but strong and regular beats.

Correct Answer: B. Plaques obstruct the artery
Atherosclerosis is a chronic inflammatory disease in which there is a build up of plaques inside arteries. These plaques are principally composed of lipids that induce an inflammatory reaction causing turbulent flow with atherosclerotic cardiovascular disease (ASCVD) as a result.

Atherosclerosis impedes coronary blood flow by which of the following mechanisms?

A. Plaques obstruct the vein.
B. Plaques obstruct the artery.
C. Blood clots form outside the vessel wall.
D. Hardened vessels dilate to allow blood to flow through.

Correct Answer: D. Pericardial tamponade
A paradoxical pulse (a palpable decrease in pulse amplitude on quiet inspiration) signals pericardial tamponade, a complication of CABG surgery. Cardiac tamponade is a medical or traumatic emergency that happens when enough fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock.

A paradoxical pulse occurs in a client who had a coronary artery bypass graft (CABG) surgery two (2) days ago. Which of the following surgical complications should the nurse suspect?

A. Left-sided heart failure
B. Aortic regurgitation
C. Complete heart block
D. Pericardial tamponade

Correct Answer: C. 95 mm Hg
The definition of mean arterial pressure (MAP) is the average arterial pressure throughout one cardiac cycle, systole, and diastole. MAP is influenced by cardiac output and systemic vascular resistance, each of which is under the influence of several variables.

After cardiac surgery, a client's blood pressure measures 126/80. The nurse determines that the mean arterial pressure (MAP) is which of the following?

A. 46 mm Hg
B. 80 mm Hg
C. 95 mm Hg
D. 90 mm Hg

Correct Answer: C. Pressure from fluid within the left ventricle.
The pulmonary artery pressures are used to assess the heart's ability to receive and pump blood. The pulmonary capillary wedge pressure reflects the left ventricle end-diastolic pressure and guides the physician in determining fluid management for the client. Pulmonary capillary wedge pressure (PCWP) is frequently used to assess left ventricular filling, represent left atrial pressure, and assess mitral valve function. It is measured by inserting a balloon-tipped, multi-lumen catheter (Swan-Ganz catheter) into a central vein, and advancing the catheter into a branch of the pulmonary artery.

A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted. The physician orders pulmonary artery pressure monitoring, including pulmonary capillary wedge pressures. The purpose of this is to help assess the:

A. Degree of coronary artery stenosis.
B. Peripheral arterial pressure.
C. Pressure from fluid within the left ventricle.
D. Oxygen and carbon dioxide concentration is the blood.

Correct Answer: A. Eggs
One of the microcytic, hypochromic anemias is iron-deficiency anemia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, whole-grain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes.

The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet?

A. Eggs
B. Lettuce
C. Citrus fruits
D. Cheese

Correct Answer: C. Meats and dairy products
Good sources of vitamin B12 include meats and dairy products. Dairy is a great source of vitamin B12. One cup of whole or full-fat yogurt provides up to 23% of the RDI, and one slice (28 grams) of Swiss cheese contains 16%. If looking for higher concentrations of vitamin B12, it's recommended to choose from low-fat cuts of meat. It's also better to grill or roast it instead of frying. This helps preserve the vitamin B12 content

The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12?

A. Whole grains
B. Green leafy vegetables
C. Meats and dairy products
D. Broccoli and Brussels sprouts

Correct Answer: D. Folate, 1.5 ng/mL
The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 leve

The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client's history on the specific drug or alcohol abuse?

A. Total bilirubin, 0.3 mg/dL
B. Serum creatinine, 0.5 mg/dL
C. Hemoglobin, 16 g/dL
D. Folate, 1.5 ng/mL

Correct Answer: B. Intrinsic factor, absent.
The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia.

The nurse understands that the client with pernicious anemia will have which of the following distinguishing laboratory findings?

A. Schilling's test elevated
B. Intrinsic factor, absent
C. Sedimentation rate, 16 mm/hour
D. RBCs 5.0 million

Correct Answer: B. Avoid exposure to others with acute infection.
Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance.

The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance?

A. Eat animal protein and dark leafy vegetables each day.
B. Avoid exposure to others with acute infection.
C. Practice yoga and meditation to decrease stress and anxiety.
D. Get 8 hours of sleep at night and take naps during the day.

Correct Answer: D. "I take a vitamin B12 tablet every day."
Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needs to be injected every month, because the ileum has been surgically removed.

A client comes into the health clinic 3 years after undergoing resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching?

A. "I have been drinking plenty of fluids."
B. "I have been gargling with warm salt water for my sore tongue."
C. "I have 3 to 4 loose stools per day."
D. "I take a vitamin B12 tablet every day."

Correct Answer: C. Drinks coffee or tea with meals
Coffee and tea increase gastrointestinal motility and inhibit the absorption of nonheme iron. It is advised that children restrict tea consumption, as a recent epidemiologic study found that regular intake of tea/coffee along with major meals led to a significantly increased odds ratio for iron deficiency anemia among schoolchildren from southern Kerala, India. The fact that iron absorption can be reduced by tea consumption has been recognized for many years with the inhibitory effects predominantly facilitated by the marked iron?binding properties of the phenolic compounds bearing catechol groups in tea

A vegetarian client was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client:

A. Adds dried fruit to cereal and baked goods.
B. Cooks tomato-based foods in iron pots.
C. Drinks coffee or tea with meals.
D. Adds vitamin C to all meals.

Correct Answer: A. "What activities were you able to do 6 months ago compared with the present?"
It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the client's activity tolerance by asking the client to compare activities 6 months ago and at the present. Assess manifestations of activity intolerance. Tell the patient to rate perceived exertion on a 0-10 scale.

A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the client's activity intolerance?

A. "What activities were you able to do 6 months ago compared to the present?"
B. "How long have you had this problem?"
C. "Have you been able to keep up with all your usual activities?"
D. "Are you more tired now than you used to be?

Correct Answer: C. Absorb vitamin B12
Pernicious anemia is caused by the body's inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schilling's test helps diagnose pernicious anemia by determining the client's ability to absorb vitamin B12. Patients presenting with signs and symptoms of cobalamin used to undergo this test. The most common features of vitamin-B12 deficiency include severe macrocytic anemia and variable neurologic abnormalities such as shuffling gait, with no improvement observed upon the administration of folic acid.

The primary purpose of the Schilling test is to measure the client's ability to:

A. Store vitamin B12
B. Digest vitamin B12
C. Absorb vitamin B12
D. Produce vitamin B12

Correct Answer: B. Starting a 24- to 48 hour urine specimen collection.
Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of non-radioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces.

The nurse implements which of the following for the client who is starting a Schilling test?

A. Administering methylcellulose (Citrucel).
B. Starting a 24- to 48 hour urine specimen collection.
C. Maintaining NPO status.
D. Starting a 72 hour stool specimen collection.

Correct Answer: B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."
Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. Intrinsic factor antibodies are immunoglobulin G isotype, and they can be either type 1 or type 2 antibodies. Type 1 operates against the cobalamin binding site, whereas type 2 directs its activity against the ileal mucosa receptor. B12 and intrinsic factor bind to receptors on the ileum, which allows for absorption.

A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurse's best response?

A. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid."
B. "The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor."
C. "The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction."
D. "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production."

Correct Answer: B. Respiratory rate decreased by 5 breaths/minute.
The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The respiratory system works in conjunction with the cardiovascular system. The pulmonary circuit receives almost all of the cardiac output. In response to the increased cardiac output, perfusion increases in the apex of each lung, increasing the available surface area for gas exchange (decreased alveolar dead space).

The nurse is assessing a client's activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response?

A. Pulse rate increased by 20 bpm immediately after the activity.
B. Respiratory rate decreased by 5 breaths/minute.
C. Diastolic blood pressure increased by 7 mm Hg.
D. Pulse rate within 6 bpm of resting phase after 3 minutes of rest.

Correct Answer: C. Continue to monitor vital signs.
The nurse should continue to monitor the client because this value reflects a normal physiologic response. Immediately after surgery, the client's hematocrit reflects a falsely high value related to the body's compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 days post-op. By the second to third day, this response decreases, and the client's hematocrit level is more reflective of the amount of RBCs in the plasma.

When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate?

A. Check the dressing and drains for frank bleeding.
B. Call the physician.
C. Continue to monitor vital signs.
D. Start oxygen at 2L/min per NC.

Correct Answer: A. Hematocrit
Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. Although epoetin alfa does not affect blood pressure directly, it may raise blood pressure in the early phase after administration when the hematocrit is increasing acutely. So, it should be used very carefully in patients with uncontrolled hypertension. Additionally, patients may require dosage adjustments of antihypertensive therapy after initiation of this medication.

A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection?

A. Hematocrit
B. Partial thromboplastin time
C. Hemoglobin concentration
D. Prothrombin time

Correct Answer: D. "Vitamin B12 is generally free of toxicity because it is water soluble."
Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the body's needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations.

A client states that she is afraid of receiving vitamin B12 injections because of the potential toxic reactions. What is the nurse's best response to relieve these fears?

A. "Vitamin B12 will cause ringing in the ears before a toxic level is reached."
B. "Vitamin B12 may cause a very mild skin rash initially."
C. "Vitamin B12 may cause mild nausea but nothing toxic."
D. "Vitamin B12 is generally free of toxicity because it is water soluble."

Correct Answer: B. Brown rice
Brown rice is a source of iron from plant sources (nonheme iron). Other sources of non-heme iron are whole-grain cereals and bread, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Brown rice is a highly nutritious food. It is a whole grain that is relatively low in calories (216 calories per cup), high in fiber, gluten-free, and can be incorporated into a variety of dishes. The USA Rice Federation notes that brown rice contains no trans-fat or cholesterol. It has only trace amounts of fat and sodium.

A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the client's nutritional needs and personal preferences?

A. Egg yolks
B. Brown rice
C. Vegetables
D. Tea

Correct Answer: B. Check for diminished sensations
Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. Vitamin B12 deficiency can lead to hematologic and neurological symptoms. Vitamin B12 is stored in excess in the liver, decreasing the likelihood of deficiency.

A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurse's first response?

A. Assess for potential abuse.
B. Check for diminished sensations.
C. Document the findings.
D. Clean and dress the area.

Correct Answer: A. Bleeding tendencies
Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A low platelet count or thrombocytopenia is caused by a bone marrow malfunction resulting from nutritional deficiencies, drugs, certain viral causes, or aplastic anemia. The risk for bleeding is increased as platelet count is decreased.

When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions?

A. Bleeding tendencies
B. Intake and output
C. Peripheral sensation
D. Bowel function

Correct Answer: A. Erythrocytes
Anemia is defined as a decreased number of erythrocytes (red blood cells). RBC are produced in the bone marrow and released into circulation. Approximately 1% of RBC are removed from circulation per day. Imbalance in production to removal or destruction of RBC leads to anemia.

Which of the following blood components is decreased in anemia?

A. Erythrocytes
B. Granulocytes
C. Leukocytes
D. Platelets

Correct Answer: C. Oxygen
Anemia stems from a decreased number of red blood cells and the resulting deficiency in oxygen and body tissues. Hemoglobin is an iron-rich protein that helps red blood cells carry oxygen from the lungs to the rest of the body. If the client has anemia, the body does not get enough oxygen-rich blood. This can cause him to feel tired or weak. He may also have shortness of breath, dizziness, headaches, or an irregular heartbeat.

A client with anemia may be tired due to a tissue deficiency of which of the following substances?

A. Carbon dioxide
B. Factor VIII
C. Oxygen
D. T-cell antibodies

Correct Answer: C. Stem cell
The precursor to the RBC is the stem cell. B cells, macrophages, and T cells, and lymphocytes, not RBC precursors. Precursor cells are known as the intermediate cell before they become differentiated after being a stem cell. Usually, a precursor cell is a stem cell with the capacity to differentiate into only one cell type. Sometimes, precursor cells are used as an alternative term for unipotent stem cells.

Which of the following cells is the precursor to the red blood cell (RBC)?

A. B cell
B. Macrophage
C. Stem cell
D. T cell

Correct Answer: A. None
Mild anemia usually has no clinical signs. Palpitations, SOB, and pallor are all associated with severe anemia. Whether or not a patient becomes symptomatic depends on the etiology of anemia, the acuity of onset, and the presence of other comorbidities, especially the presence of cardiovascular disease. Most patients experience some symptoms related to anemia when the hemoglobin drops below 7.0 g/dL.

Which of the following symptoms is expected with hemoglobin of 10 g/dl?

A. None
B. Pallor
C. Palpitations
D. Shortness of breath

Correct Answer: B. Decreased levels of white blood cells, red blood cells, and platelets
In aplastic anemia, the most likely diagnostic findings are decreased levels of all the cellular elements of the blood (pancytopenia). The moderate disease has less than 30% bone marrow cellularity; the severe disease has less than 25% cellularity or less than 50% cellularity containing fewer than 30% hematopoietic cells, and very severe meets severe criteria plus neutropenia less than 200/µL.

Which of the following diagnostic findings are most likely for a client with aplastic anemia?

A. Decreased production of T-helper cells.
B. Decreased levels of white blood cells, red blood cells, and platelets.
C. Increased levels of WBCs, RBCs, and platelets.
D. Reed-Sternberg cells and lymph node enlargement.

Correct Answer: D. "Take the medication on an empty stomach."
Preferably, ferrous gluconate should be taken on an empty stomach. For best absorption, the recommendation is to take iron at least 30 minutes before a meal or 2 hours before taking other medications. Oral iron replacement therapy is the most cost-effective and readily available for the general public as ferrous sulfate (20% elemental iron), ferrous gluconate (12% elemental iron), and ferrous fumarate (33% elemental iron).

A client with iron deficiency anemia is scheduled for discharge. Which instruction about prescribed ferrous gluconate therapy should the nurse include in the teaching plan?

A. "Take the medication with an antacid."
B. "Take the medication with a glass of milk."
C. "Take the medication with cereal."
D. "Take the medication on an empty stomach."

Correct Answer: C. Hemophilia A
Hemophilia A results from a deficiency of factor VIII. A hereditary hemorrhagic disorder resulting from congenital deficit or scarcity of factor VIII, hemophilia A, which is known as classical hemophilia, manifests as protracted and excessive bleeding either spontaneously or secondary to trauma. Hemophilia A's X-linked trait manifests as a congenital absence or decrease in plasma clotting Factor VIII, a pro-coagulation cofactor and robust initiator of thrombin that is essential for the generation of adequate amounts of fibrin to form a platelet-fibrin plug at sites of endothelial disruption.

Which of the following disorders results from a deficiency of factor VIII?

A. Sickle cell disease
B. Christmas disease
C. Hemophilia A
D. Hemophilia B

Correct Answer: D. "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."
Sickle cell disease is an inherited disease that is present at birth. However, 60% to 80% of a newborn's hemoglobin is fetal hemoglobin, which has a structure different from that of hemoglobin S or hemoglobin A. Sickle cell symptoms usually occur about 4 months after birth, when hemoglobin S begins to replace the fetal hemoglobin.

The mothers asks the nurse why her child's hemoglobin was normal at birth but now the child has S hemoglobin. Which of the following responses by the nurse is most appropriate?

A. "The placenta bars passage of the hemoglobin S from the mother to the fetus."
B. "The red bone marrow does not begin to produce hemoglobin S until several months after birth."
C. "Antibodies transmitted from you to the fetus provide the newborn with temporary immunity."
D. "The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."

Correct Answer: B. Children with iron deficiency anemia are more susceptible to infection than are other children.
Children with iron-deficiency anemia are more susceptible to infection because of marked decreases in bone marrow functioning with microcytosis. Iron deficiency may, apart from leading to anemia, increase the susceptibility to infection by suppressing the immunological response to pathogens. Anemia is a global public health problem, especially affecting young children with prevalence up to 70% in some populations (World Health Organisation, 2005).

A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?

A. Little is known about iron-deficiency anemia and its relationship to infection in children.
B. Children with iron deficiency anemia are more susceptible to infection than are other children.
C. Children with iron-deficiency anemia are less susceptible to infection than are other children.
D. Children with iron-deficient anemia are equally as susceptible to infection as are other children.

Correct Answers: A & B
Toddlers should have between 2 and 3 cups of milk per day and 8 ounces of juice per day. If they have more than that, then they are probably not eating enough other foods, including iron-rich foods that have the needed nutrients.

Which statements by the mother of a toddler would lead the nurse to suspect that the child has iron-deficiency anemia? Select all that apply.

A. "He drinks over 3 cups of milk per day."
B. "I can't keep enough apple juice in the house; he must drink over 10 ounces per day."
C. "He refuses to eat more than 2 different kinds of vegetables."
D. "He doesn't like meat, but he will eat small amounts of it."
E. "He sleeps 12 hours every night and takes a 2-hour nap."

Correct Answer: B. Potato, peas, and chicken
Potato, peas, chicken, green vegetables, and rice cereal contain significant amounts of iron and therefore would be recommended. Meat and poultry contain large amounts of heme iron, which is easy for the body to digest. Beef, organ meats, and liver in particular have a lot of iron. A 3-ounce serving of beef liver, for example, contains 5 mg of iron.

Which of the following foods would the nurse encourage the mother to offer to her child with iron deficiency anemia?

A. Rice cereal, whole milk, and yellow vegetables
B. Potato, peas, and chicken
C. Macaroni, cheese, and ham
D. Pudding, green vegetables, and rice

Correct Answer: D. Red blood cells that are microcytic and hypochromic.
The results of a CBC in children with iron deficiency anemia will show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The CBC documents the severity of the anemia. In chronic iron deficiency anemia, the cellular indices show a microcytic and hypochromic erythropoiesis—that is, both the mean corpuscular volume (MCV) and the mean corpuscular hemoglobin concentration (MCHC) have values below the normal range for the laboratory performing the test.

Laboratory studies are performed for a child suspected of having iron deficiency anemia. The nurse reviews the laboratory results, knowing which of the following results would indicate this type of anemia?

A. An elevated hemoglobin level.
B. A decreased reticulocyte count.
C. An elevated RBC count.
D. Red blood cells that are microcytic and hypochromic.

Correct Answer: A. Normal because of increased blood flow through the leg
An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Aortoiliac occlusive disease can contribute to lower extremity ischemic symptoms necessitating intervention. Symptoms of patients with aortoiliac occlusive disease may include claudication, rest pain of the lower extremities, or ischemic ulcer formation on lower extremities due to inadequate blood flow.

A nurse is assessing the neurovascular of a client who has returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:

A. Normal because of increased blood flow through the leg.
B. Slightly deteriorating and should be monitored for another hour.
C. Moderately impaired, and the surgeon should be called.
D. Adequate from an arterial approach, but venous complications are arising.

Correct Answer: A. Increase the cardiac output.
Temperatures of 102*F or greater lead to an increased metabolism and cardiac workload. Myocardial infarction following cardiac surgery is classified as type 5 myocardial infarction according to the universal classification of myocardial infarction. The incidence is between 5% to 10%. Diagnosing postoperative myocardial infarction is challenging since cardiac enzymes are routinely elevated due to manipulation during operation and symptoms are influenced by postoperative status.

After open-heart surgery, a client develops a temperature of 102°F. The nurse notifies the physician because elevated temperatures:

A. Increase the cardiac output.
B. May indicate cerebral edema.
C. May be a forerunner of hemorrhage.
D. Are related to diaphoresis and possible chilling.

Correct Answer: C. The samples of blood all contain about the same amount of oxygen
Blood samples from the right atrium, right ventricle, and pulmonary artery would all be about the same with regard to oxygen concentration. Such blood contains slightly less oxygen than does systemic arterial blood.

During a cardiac catheterization blood samples from the right atrium, right ventricle, and pulmonary artery are analyzed for their oxygen content. Normally:

A. All contain less CO2 than does pulmonary vein blood.
B. All contain more oxygen than does pulmonary vein blood.
C. The samples of blood all contain about the same amount of oxygen.
D. Pulmonary artery blood contains more oxygen than the other samples.

Correct Answer: D. Left ventricular functioning
The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Pulmonary artery catheterization remains an excellent tool for the assessment of patients with pulmonary hypertension, cardiogenic shock, or unexplained dyspnea. It can be used to assess right-sided cardiac chamber filling pressures, to estimate cardiac output, to evaluate intracardiac shunts, to evaluate cardiac valves, or to assess vascular resistance.

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:

A. Stroke volume
B. Cardiac output
C. Venous pressure
D. Left ventricular functioning

Correct Answer: D. Some increase in edema in the leg used for the donor graft when activity increases
The client is up more at home, so dependent edema usually increases. Serosanguineous drainage may persist after discharge. After surgery, it takes 4 to 6 weeks to completely heal and start feeling better. It is normal to have swelling in the leg that the vein graft was taken from.

When preparing a client for discharge after surgery for a CABG, the nurse should teach the client that there will be:

A. No further drainage from the incisions after hospitalizations.
B. A mild fever and extreme fatigue for several weeks after surgery.
C. Little incisional pain and tenderness after 3 to 4 weeks after surgery.
D. Some increase in edema in the leg used for the donor graft when activity increases.

Correct Answer: B. Deflate the balloon as soon as the PCWP is measured.
While the balloon must be inflated to measure the capillary wedge pressure, leaving the balloon inflated will interfere with blood flow to the lung. Once the catheter is advanced into the pulmonary artery to the point where the waveform changes into a wedge form, the balloon should be deflated. The catheter will then show the PA pressures. After obtaining the appropriate PA pressures, a PCWP/pulmonary artery occlusion pressure can now be measured.

What is the most important nursing action when measuring a pulmonary capillary wedge pressure (PCWP)?

A. Have the client bear down when measuring the PCWP.
B. Deflate the balloon as soon as the PCWP is measured.
C. Place the client in a supine position before measuring the PCWP.
D. Flush the catheter with heparin solution after the PCWP is determined.

Correct Answer: C. Capillary refill time
Checking capillary refill provides data about the current perfusion of the extremity. Vascular surgery is considered a high-risk procedure and most procedures carry a >5% risk of an acute cardiac event. Direct reconstruction of aorta iliofemoral disease is associated with a 2.8% perioperative mortality while extra-anatomic bypass confers an 8.8% mortality.

The most important assessment for the nurse to make after a client has had a femoropopliteal bypass for peripheral vascular disease would be:

A. Incisional pain
B. Pedal pulse rate
C. Capillary refill time
D. Degree of hair growth

Correct Answers: A, C, & D
Cardiac tamponade is a medical or traumatic emergency that happens when enough fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock. The diagnosis of cardiac tamponade is a clinical diagnosis that requires prompt recognition and treatment to prevent cardiovascular collapse and cardiac arrest.

Which signs cause the nurse to suspect cardiac tamponade after a client has cardiac surgery? Select all that apply.

A. Tachycardia
B. Hypertension
C. Increased CVP
D. Decreased urine output
E. Jugular vein distention

Correct Answer: B. Cardiac tamponade
All of the client's symptoms are found in both cardiac tamponade and hypovolemic shock EXCEPT the increase in urinary output. Cardiac tamponade is a medical or traumatic emergency that happens when enough fluid accumulates in the pericardial sac compressing the heart and leading to a decrease in cardiac output and shock. The diagnosis of cardiac tamponade is a clinical diagnosis that requires prompt recognition and treatment to prevent cardiovascular collapse and cardiac arrest.

A 35-year-old male was knifed in the street fight, admitted through the ER, and is now in the ICU. An assessment of his condition reveals the following symptoms: respirations shallow and rapid, CVP 15 cm H2O, BP 90 mm Hg systolic, skin cold and pale, urinary output 60-100 mL/hr for the last 2 hours. Analyzing these symptoms, the nurse will base a nursing diagnosis on the conclusion that the client has which of the following conditions?

A. Hypovolemic shock
B. Cardiac tamponade
C. Wound dehiscence
D. Atelectasis

Correct Answer: D. Allergy to iodine or shellfish
This procedure requires an informed consent because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. Allergic reactions can be related to the use of local anesthetic, contrast agents, heparin or other medications used during the procedure. Reactions to the contrast agents can occur in up to 1% of the patients, and people with prior reactions are pretreated with corticosteroids and antihistamines.

A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure?

A. Intake and output
B. Baseline peripheral pulse rates
C. Height and weight
D. Allergy to iodine or shellfish

Correct Answer: C. "Does the pain get worse when you breathe in?"
Chest pain is assessed by using the standard pain assessment parameters. It is very important to find out what makes the pain worse. Is there an exertional component, is it associated with eating or breathing? Is there a positional component? Don't forget to ask about new workout routines, sports, and lifting. Ask what medications they have tried.

A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem?

A. "Have you ever had this pain before?"
B. "Can you describe the pain to me?"
C. "Does the pain get worse when you breathe in?"
D. "Can you rate the pain on a scale of 1-10, with ten (10) being the worst?"

Correct Answer: B. Bathroom privileges and self-care activities
On transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet). A patient on telemetry should be visualized hourly. With every ECG alarm, the patient should be visualized and assessed (refer to Nursing Assessment Clinical Guideline). It is the responsibility of nursing staff to know the whereabouts of their patient at all times - toilet doors should not be locked - however, laminated signs may be used on doors instead

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities?

A. Strict bed rest for 24 hours after transfer.
B. Bathroom privileges and self-care activities.
C. Unsupervised hallway ambulation with distances under 200 feet.
D. Ad lib activities because the client is monitored.

Correct Answer: A. Review the intake and output records for the last 2 days.
Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Monitor intake and output. Note decreased urinary output and positive fluid balance on 24-hour calculations. Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decreased urinary output and edema formation.

A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next?

A. Review the intake and output records for the last two (2) days.
B. Change the time of diuretic administration from morning to evening.
C. Request a sodium restriction of one (1) g/day from the physician.
D. Order daily weight starting the following morning.

Correct Answer: A. Check the client status and lead placement.
Sudden loss of electrocardiogram complexes indicates ventricular asystole or possible electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. Unlike invasive procedures, no preparation is needed, but the patient should be advised to keep the monitor away from other electrical devices while wearing the device. Physicians should recommend not to put lotion or moisturizer on the chest as it will affect the attachment of leads.

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:

A. Check the client status and lead placement.
B. Press the recorder button on the electrocardiogram console.
C. Call the physician.
D. Call a code blue.

Correct Answer: D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.
BP should be taken with the client seated with the arm bared, positioned with support, and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding the measurement. First, the patient should be questioned regarding recent caffeine consumption, exercise, or smoking. If any of these activities have occurred within the last 30 minutes, blood pressure measurement should be postponed until this period has passed.

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following?

A. Seating the client with arm bared, supported, and at heart level.
B. Measuring the blood pressure after the client has been seated quietly for 5 minutes.
C. Using a cuff with a rubber bladder that encircles at least 80% of the limb.
D. Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

Correct Answer: D. Protamine sulfate
The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur. Protamine is a medication used to reverse and neutralize the anticoagulant effects of heparin. Protamine is the specific antagonist that neutralizes heparin-induced anticoagulation. Protamine is a strongly alkaline (nearly two-thirds of the amino acid composition is arginine) polycationic low-molecular-weight protein found in salmon sperm that is also currently available in a recombinant form.

IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available in the nursing unit?

A. Vitamin K
B. Aminocaproic acid
C. Potassium chloride
D. Protamine sulfate

Correct Answer: C. Within the therapeutic range.
The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range. PT measures the time, in seconds, for plasma to clot after adding thromboplastin, (a mixture of tissue factor, calcium, and phospholipid) to a patient's plasma sample.

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is:

A. The same as the client's own baseline level.
B. Lower than the needed therapeutic level.
C. Within the therapeutic range.
D. Higher than the therapeutic range.

Correct Answer: B. Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect.
Warfarin works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. Because of the delay in factor II (prothrombin) suppression, heparin is administered concurrently for four to five days to prevent thrombus propagation. Loading doses of warfarin are not warranted and may result in bleeding complications.

A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin:

A. Stimulates the breakdown of specific clotting factors by the liver, and it takes two (2)- three (3) days for this to exert an anticoagulant effect.
B Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect.
C. Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for this to begin.
D. Has the same mechanism of action as Heparin, and the crossover time is needed for the serum level of warfarin to be therapeutic.

Correct Answer: A. Administer the morphine.
Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse's priority action would be to relieve the crushing chest pain. Opioids may be used for pain control in addition to sublingual nitroglycerin if the blood pressure is adequate. All patients with STEMI and NSTEMI require immediately chewed aspirin 160 mg to 325 mg. Furthermore, the patient should have intravenous access and oxygen supplementation if oxygen saturation is less than 91%.

A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest X-ray, an ECG, and two (2) mg of morphine given intravenously. The nurse should first:

A. Administer the morphine.
B. Obtain a 12-lead ECG.
C. Obtain the lab work.
D. Order the chest x-ray.

Correct Answer: B. Dissolve clots he may have.
Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and reduce the extent of myocardial damage. Thrombolytics or fibrinolytics are a group of medications used in the management and treatment of dissolving intravascular clots. They are in the plasminogen activator class of drugs.

When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to:

A. Help keep him well hydrated.
B. Dissolve clots he may have.
C. Prevent kidney failure.
D. Treat potential cardiac arrhythmias.

Correct Answer: A, C, E
In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply.

A. Reflects electrical impulse beginning at the SA node.
B. Indicated electrical impulse beginning at the AV node.
C. Reflects atrial muscle depolarization.
D. Identifies ventricular muscle depolarization.
E. Has a duration of normally 0.11 seconds or less.

Correct Answer: B. Start an intravenous line.
Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in one or both of the antecubital spaces. Reperfusion therapy is indicated in all patients with symptoms of ischemia of less than 12-hours duration and persistent ST-segment elevation. Primary percutaneous coronary intervention (PCI) is preferred to fibrinolysis if the procedure can be performed

A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse's next action would be to:

A. Call for the doctor.
B. Start an intravenous line.
C. Obtain a portable chest radiograph.
D. Draw blood for laboratory studies.

Correct Answer: D. Myocardial infarction
Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred. Myoglobin is generally detected about one hour after a heart attack is experienced and peaks within four (4) to six (6) hours after infarction (Remember, less than 90 mg/L is normal). Myoglobin is a heme protein found in skeletal and cardiac muscle that has attracted considerable interest as an early marker of MI. Its low molecular weight accounts for its early release profile: myoglobin typically rises 2-4 hours after onset of infarction, peaks at 6-12 hours, and returns to normal within 24-36 hours.

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?

A. Cancer
B. Hypertension
C. Liver disease
D. Myocardial infarction

Correct Answer: A. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction.
Propranolol hydrochloride is a beta-adrenergic blocking agent. Actions of propranolol hydrochloride include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol can be used to ameliorate the sympathetic response in angina, tachyarrhythmias, prevention of acute ischemic attacks, migraine prophylaxis, and restless leg syndrome. Propranolol can be used in almost all cases if the desired result is to slow contractility and decrease a patient's heart rate.

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride:

A. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and Conduction.
B. Increases norepinephrine secretion and thus decreases blood pressure and heart rate.
C. Is a potent arterial and venous vasodilator that reduces peripheral vascular resistance and lowers blood pressure.
D. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.

Correct Answer: C. Make a commitment to long-term therapy
Compliance is the most critical element of hypertensive therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management and weight management are important components of hypertension therapy, but the priority goal is related to compliance. Response to drug therapy (usually consisting of several drugs, including diuretics, angiotensin-converting enzyme [ACE] inhibitors, vascular smooth muscle relaxants, beta and calcium channel blockers) is dependent on both the individual as well as the synergistic effects of the drugs.

The most important long-term goal for a client with hypertension would be to:

A. Learn how to avoid stress.
B. Explore a job change or early retirement.
C. Make a commitment to long-term therapy.
D. Control high blood pressure.

Correct Answer: A. Cerebrovascular accident
Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, hypertension may go undetected. CVA's can be related to long-term hypertension. Large-scale meta-analyses have also shown the rising CVD and vascular disease risk with a rise in systolic and diastolic blood pressures, with almost doubling the risk of death from heart disease and stroke with rising SBP of as much as 20 and DBP of 10mmHg.

Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of:

A. Cerebrovascular accident
B. Liver disease
C. Myocardial infarction
D. Pulmonary disease

Correct Answer: C. Take a nitroglycerin tablet before climbing the stairs.
Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain-free. Nitrates relax vascular smooth muscle leading to dilation of veins primarily; this decreases cardiac preload and, in turn, decreases myocardial oxygen demand providing relief in anginal symptoms.

During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting an invalid friend twice a week and now cannot walk up the second flight of steps to the friend's apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem?

A. Visit her friend earlier in the day.
B. Rest for at least an hour before climbing the stairs.
C. Take a nitroglycerin tablet before climbing the stairs.
D. Lie down once she reaches the friend's apartment.

Correct Answer: A. A change in the pattern of her pain
The client should report a change in the pattern of chest pain. It may indicate an increasing severity of CAD. This is important to note as these differences may indicate impending myocardial infarction, and ST-elevation myocardial infarction (STEMI) and should be evaluated expeditiously as the risk of morbidity and mortality are higher in this scenario versus stable angina.

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?

A. A change in the pattern of her pain.
B. Pain during sex.
C. Pain during an argument with her husband.
D. Pain during or after an activity such as lawn mowing.

Correct Answer: B. Assess the extent of arterial blockage
Cardiac catheterization is done in clients with angina primarily to assess the extent and severity of the coronary artery blockage, A decision about medical management, angioplasty, or coronary artery bypass surgery will be based on the catheterization results. Cardiac catheterization is performed for both diagnostic and therapeutic purposes. Despite significant advancement in non-invasive cardiac imaging, it remains the standard for the measurement of cardiac hemodynamics.

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:

A. Open and dilate the blocked coronary arteries.
B. Assess the extent of arterial blockage.
C. Bypass obstructed vessels.
D. Assess the functional adequacy of the valves and heart muscle.

Correct Answer: C. Vasodilation of peripheral vasculature
Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin is a vasodilatory drug used primarily to provide relief from anginal chest pain. It is currently FDA approved for the acute relief of an attack or acute prophylaxis of angina pectoris secondary to coronary artery disease.

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug's principal effects are produced by:

A. Antispasmodic effect on the pericardium.
B. Causing an increased myocardial oxygen demand.
C. Vasodilation of peripheral vasculature.
D. Improved conductivity in the myocardium.

Correct Answer: A. Headache
Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or sit down to avoid fainting. Headaches can be severe, throbbing, and persistent and may occur immediately after use. Nitro does not cause shortness of breath or stomach cramps.

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including:

A. Headache
B. High blood pressure
C. Shortness of breath
D. Stomach cramps

Correct Answer: C. Take one (1) tablet, then an additional tablet every five (5) minutes for a total of three (3) tablets. Call the physician if pain persists after three tablets.
The correct protocol for nitroglycerin used involves immediate administration, with subsequent doses taken at 5-minute intervals as needed, for a total dose of three (3) tablets. Sublingual nitroglycerin appears in the bloodstream within two (2) to three (3) minutes and is metabolized within about 10 minutes.

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?

A. Take one (1) tablet every two (2) to five (5) minutes until the pain stops.
B. Take one (1) tablet and rest for ten (10) minutes. Call the physician if pain persists after ten (10) minutes.
C. Take one (1) tablet, then an additional tablet every 5 minutes for a total of three (3) tablets. Call the physician if pain persists after three (3) tablets.
D. Take one (1) tablet. If pain persists after five (5) minutes, take two (2) tablets. If pain persists five (5) minutes later, call the physician.

Correct Answer: C. Left anterior descending artery
The left anterior descending artery is the primary source of blood flow for the anterior wall of the heart. The left anterior descending artery (LAD) supplies the anterior two-thirds of the septum.[2] The LAD is one of two major branches of the LMCA, with the other being the left circumflex (LCx) coronary arteries. Combined, these two supply blood to the left atrium and left ventricle.

Which of the following arteries primarily feeds the anterior wall of the heart?

A. Circumflex artery
B. Internal mammary artery
C. Left anterior descending artery
D. Right coronary artery

Correct Answer: B. During diastolic
Although the coronary arteries may receive a minute portion of blood during systole, most of the blood flow to coronary arteries is supplied during diastole. Breathing patterns are irrelevant to blood flow. The RCA and LMCA extend from the aortic root to supply different regions of the heart. The RCA gives rise to the sinoatrial nodal branch of the right coronary artery, posterior descending artery branch of the RCA, and the marginal branch.

When do coronary arteries primarily receive blood flow?

A. During inspiration
B. During diastolic
C. During expiration
D. During systole

Correct Answer: C. Inferior
The right coronary artery supplies the right ventricle or the inferior portion of the heart. Therefore, prolonged occlusion could produce an infarction in that area. The RCA emerges from the anterior ascending aorta and supplies blood primarily to the right atrium, right ventricle. The sinoatrial nodal artery is a branch of the RCA that supplies the SA node.

Prolonged occlusion of the right coronary artery produces an infarction in which of the following areas of the heart?

A. Anterior
B. Apical
C. Inferior
D. Lateral

Correct Answer: C. Pulmonic
Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. The murmur has a crescendo-decrescendo configuration. There is a strong tendency for the murmur to peak later in systole as stenosis becomes more severe. The murmur is best heard over the second intercostal space at the left sternal border and does not radiate.

A murmur is heard at the second left intercostal space along the left sternal border. Which valve is this?

A. Aortic
B. Mitral
C. Pulmonic
D. Tricuspid

Correct Answer: A. Troponin I
Troponin I levels rise rapidly and are detectable within 1 hour of myocardial injury. Troponin levels aren't detectable in people without cardiac injury. Anything that causes damage to cardiac muscle can cause troponin to spill into the circulation. The most common cause of injury is oxygen supply and demand mismatch, which is seen in acute myocardial infarction.

Which of the following blood tests is most indicative of cardiac damage?

A. Troponin I
B. Complete blood count (CBC)
C. Creatine kinase (CK)
D. Lactate dehydrogenase

Correct Answer: D. Electrocardiogram (ECG)
The ECG is the quickest, most accurate, and most widely used tool to determine the location of myocardial infarction. ECG is an effective tool to distinguish between acute MI and the myocardial ischemia that usually precedes it, as not all patients with myocardial ischemia will develop MI. Transitioning from ischemia to infarction results in precise sequential electrical abnormalities captured on ECG.

Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage?

A. Cardiac catheterization
B. Cardiac enzymes
C. Echocardiogram
D. Electrocardiogram (ECG)

Correct Answer: D. Tightness
The pain of angina usually ranges from a vague feeling of tightness to heavy, intense pain. Pain impulses originate in the most visceral muscles and may move to such areas as the chest, neck, and arms. Angina is chest pain or discomfort caused when the heart muscle doesn't get enough oxygen-rich blood. It may feel like pressure or squeezing in the chest. The discomfort also can occur in the shoulders, arms, neck, jaw, or back. Angina pain may even feel like indigestion.

Which of the following types of pain is most characteristic of angina?

A. Knifelike
B. Sharp
C. Shooting
D. Tightness

Correct Answer: D. Vascular resistance
Vascular resistance is the impedance of blood flow by the arterioles that most predominantly affects the diastolic pressure. Vascular resistance is used to maintain organ perfusion. In certain disease states, such as congestive heart failure, there is a hyper-adrenergic response, causing an increase in peripheral vascular resistance. Prolonged increases in blood pressure affect several organs throughout the body.

Which of the following parameters is the major determinant of diastolic blood pressure?

A. Baroreceptors
B. Cardiac output
C. Renal function
D. Vascular resistance

Correct Answer: C. Kidneys' excretion of sodium and water
The kidneys respond to a rise in blood pressure by excreting sodium and excess water. This response ultimately affects systolic pressure by regulating blood volume. The renin-angiotensin-aldosterone system is an essential regulator of arterial blood pressure. The system relies on several hormones that act to increase blood volume and peripheral resistance.

Which of the following factors can cause blood pressure to drop to normal levels?

A. Kidneys' excretion of sodium only.
B. Kidneys' retention of sodium and water.
C. Kidneys' excretion of sodium and water.
D. Kidneys' retention of sodium and excretion of water

Correct Answer: A. Changes in blood pressure.
Baroreceptors located in the carotid arteries and aorta sense pulsatile pressure. Baroreceptors are a type of mechanoreceptor allowing for the relay of information derived from blood pressure within the autonomic nervous system. Information is then passed in rapid sequence to alter the total peripheral resistance and cardiac output maintaining blood pressure within a preset, normalized range.

Baroreceptors in the carotid artery walls and aorta respond to which of the following conditions?

A. Changes in blood pressure.
B. Changes in arterial oxygen tension.
C. Changes in arterial carbon dioxide tension.
D. Changes in heart rate.

Correct Answer: A. Afterload
Afterload refers to the resistance normally maintained by the aortic and pulmonic valves, the condition and tone of the aorta, and the resistance offered by the systemic and pulmonary arterioles. The afterload of any contracting muscle is defined as the total force that opposes sarcomere shortening minus the stretching force that existed before contraction. Applying this definition to the heart, afterload can be most easily described as the "load" against which the heart ejects blood.

Which of the following terms describes the force against which the ventricle must expel blood?

A. Afterload
B. Cardiac output
C. Overload
D. Preload

Correct Answer: D. Preload
Preload is the amount of stretch of the cardiac muscle fibers at the end of diastole. The volume of blood in the ventricle at the end of the diastole determines the preload. Also termed left ventricular end-diastolic pressure (LVEDP), preload is a measure of the degree of the ventricular stretch when the heart is at the end of diastole. Preload, in addition to afterload and contractility, is one of the three main factors that directly influence stroke volume (SV), the amount of blood pumped out of the heart in one cardiac cycle.

Which of the following terms is used to describe the amount of stretch on the myocardium at the end of diastole?

A. Afterload
B. Cardiac index
C. Cardiac output
D. Preload

Correct Answer: C. Question the physician about the order.
Propranolol and other beta-adrenergic blockers are contraindicated in a client with asthma, so the nurse should question the physician before giving the dose. Propranolol is also contraindicated in those with any lung pathologies, such as COPD, asthma, or emphysema. The pathophysiology of this mechanism is solely due to the effects that beta-2 receptors have on lung function. Normally, activation of beta-2 receptors vasodilates the smooth muscle in the lungs. When using agents like propranolol in patients with underlying lung issues, the blockage of beta-2 causes vasoconstriction of smooth muscle, worsening respiratory function.

A 57-year-old client with a history of asthma is prescribed propranolol (Inderal) to control hypertension. Before administered propranolol, which of the following actions should the nurse take first?

A. Monitor the apical pulse rate.
B. Instruct the client to take medication with food.
C. Question the physician about the order.
D. Caution the client to rise slowly when standing.

Correct Answer: C. Hypokalemia
Furosemide is a potassium-depleting diuretic that can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia. Hypokalemia can result in a variety of cardiac dysrhythmias. Although cardiac dysrhythmias or ECG changes are more likely to be associated with moderate to severe hypokalemia, there is a high degree of individual variability and can occur with even mild decreases in serum levels.

One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect?

A. Hypocalcemia
B. Hypermagnesemia
C. Hypokalemia
D. Hypernatremia

Correct Answer: D. "Avoid salt substitutes."
Because Spironolactone is a potassium-sparing diuretic, the client should avoid salt substitutes because of their high potassium content. Spironolactone specifically works by competitively blocking aldosterone receptor-mediated action. The effect of the blockade is that sodium reabsorption with water retention does not occur, and there is increased potassium retention.

A client is receiving spironolactone to treat hypertension. Which of the following instructions should the nurse provide?

A. "Eat foods high in potassium."
B. "Take daily potassium supplements."
C. "Discontinue sodium restrictions."
D. "Avoid salt substitutes."

Correct Answer: D. Impulse to travel to the ventricles.
The P-R interval is measured on the ECG strip from the beginning of the P wave to the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle. The PR interval represents the time between atrial depolarization and ventricular depolarization. Abnormalities in the timing of the PR segment can indicate pathology. A PR interval of under 120 milliseconds (ms) may indicate that electrical impulses are traveling between the atria and ventricles too quickly.

When assessing an ECG, the nurse knows that the P-R interval represents the time it takes for the:

A. Impulse to begin atrial contraction.
B. Impulse to transverse the atria to the AV node.
C. SA node to discharge the impulse to begin atrial depolarization.
D. Impulse to travel to the ventricles.

Correct Answer: A. "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities."
Such a response does not have false hope to the client but is positive and realistic. The answer tells the client what cardiac rehabilitation is and does not dwell on his negativity about it. Cardiac rehabilitation programs aim to limit the psychological and physiological stresses associated with cardiovascular disease, reduce the risk of associated mortality, and improve cardiovascular function to help patients optimize their quality of life.

Following a treadmill test and cardiac catheterization, the client is found to have coronary artery disease, which is inoperative. He is referred to the cardiac rehabilitation unit. During his first visit to the unit he says that he doesn't understand why he needs to be there because there is nothing that can be done to make him better. The best nursing response is:

A. "Cardiac rehabilitation is not a cure but can help restore you to many of your former activities."
B. "Here we teach you to gradually change your lifestyle to accommodate your heart disease."
C. "You are probably right but we can gradually increase your activities so that you can live a more active life."
D. "Do you feel that you will have to make some changes in your life now?"

Correct Answer: C. Distal to the catheter insertion
Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong. Assess limb for color, warmth, CRT, pulse strength, sensation, movement and pain. The affected limb will appear pale and cool and have diminished or absent pulses distal to the insertion site; additionally there may be decreased sensation and delayed CRT due to lack of supply of arterial blood. The nurse may notice a limb with decreased perfusion; assess pressure dressing to ensure it is not too tight. For accurate assessment of the pulse, mark the pulse position with a pen. A Doppler ultrasound can be utilized if a pulse is not palpable.

To evaluate a client's condition following cardiac catheterization, the nurse will palpate the pulse:

A. In all extremities
B. At the insertion site
C. Distal to the catheter insertion
D. Above the catheter insertion