Medical Surgical Comprehensive

8/22/2019 Medical Surgical Comprehensive

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MEDICAL-SURGICAL NURSING COMPREHENSIVE

1. A 60-year-old male client comes into the emergency department with complaints of crushing

substernal chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute

myocardial infraction (MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute,

blood work, a chest radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given

intravenously. The nurse should first:

a. Administer the morphine

b. Obtain a 12-lead ECG

c. Obtain the blood work

d. Order the chest radiograph

Ans: A although obtaining the ECG, chest radiograph, and blood work are all important, the nurses

priority action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is

priority action.

2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to

him that the purpose of the drug is to:

a. Help keep him well hydratedb. Dissolve clots that he may have

c. Prevent kidney failure

d. Treat potential cardiac dysrhythmias

Ans: B thrombolytic drugs are administered within the first 6 hours after of myocardial infarction to

lyse clots and reduce the extent of myocardial damage.

3. If the client who has admitted for MI develops cardiogenic shock, which characteristic signs

should the nurse expect to observe?

a. Oliguria

b. Bradycardia

c. Elevated blood pressured. Fever

Ans: A oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys.

Typically signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decrease urine

output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic

shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign

of cardiogenic shock.

4. The physician orders continuous intravenous nitroglycerin infusion for the client with MI.

essential nursing action include which of the following?

a. Obtaining an infusion pump for the medication

b. Monitoring blood pressure every 4 hours

c. Monitoring urine output hourly

d. Obtaining serum potassium levels daily

Ans: A intravenous nitroglycerin infusion requires an infusion pump for precise control of the

medication. Blood pressure monitoring would be done with a continuous system, and more frequently

than every 4 hours. Hourly urine outputs are not always required. Obtaining serum potassium levels is

not associated with nitroglycerin infusion.


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5. When teaching the client with MI, the nurse explains that the pain associated with MI is caused

by:

a. Left ventricular overload

b. Impending circulatory collapse

c. Extracellular electrolyte imbalances

d. Insufficient oxygen reaching the heart muscle

Ans: D an MI interferes with or blocks circulation to the heart muscle. Decreased blood supply to the

heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of

oxygen to the cardiac muscle results in ischemic pain or angina.

6. Aspirin is administered to the client experiencing an MI because of its:

a. Antipyretic action

b. Antithrombotic action

c. Antiplatelet action

d. Analgesic action

Ans: B aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason aspirin

is administered to the client experiencing an MI is its antithrombotic action. In clinical trials, the

antithrombotic action of aspirin has been thought to account for improved outcomes in clients with MI.

7. While caring for a client who has sustained an MI, the nurse notes eight PVCs in 1 minute on the

cardiac monitor. The client is receiving an intravenous infusion of 5% dextrose in water and oxygen at 2

L/minute. The nurses first course of action should be to:

a. Increase the intravenous infusion rate

b. Notify the physician promptly

c. Increase the oxygen concentration

d. Administer a prescribed analgesic

Ans: B 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 five or six per minute in the post-MI client, the physician should be notified immediately.More than six PVCs per minute is considered serious and usually calls for decreasing ventricular

irritability by administering medications such as lidocaine hydrochloride. Increasing the intravenous

infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not

be the nurses first course of action; rather, the nurse should notify the physician promptly.

Administering a prescribed analgesic would not decrease ventricular irritability.

8. Which of the following is an expected outcome for a client on the second day of hospitalization

after an MI? The client:

a. Has minimal chest pain

b. Can identify risk factors for MI

c. Agrees to participate in a cardiac rehabilitation program

d. Can perform personal self-care activities without pain

Ans: D by day 2 of hospitalization after an MI, clients are expected to be able to perform personal care

without chest pain. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors

for MI or to be able to agree to participate in a cardiac rehabilitation program.

9. When teaching a client about the expected outcomes after intravenous administration of

furosemide, the nurse would include which outcome?

a. Increased blood pressure


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b. Increased urine output

c. Decreased pain

d. Decreased PVCs

Ans: B furosemide is a loop diuretic acts to increase urine output. Furosemide does not increase blood

pressure, decrease pain, or decrease dysrhythmias.

10. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This

type of exercise is recommended primarily to help:

a. Prepare the client for ambulation

b. Promote urinary and intestinal elimination

c. Prevent thrombophlebitis and blood clot formation

d. Decrease the likelihood of decubitus ulcer formation

Ans: C although this type of exercise may decrease the likelihood of heel decubitus ulcer form

formation, it is taught to the MI client to prevent thrombophlebitis and blood clot formation. Movement

of the lower extremities provides muscular action and aids venous return. As a result, the activity helps

prevent stasis of blood, which predisposes the client to thrombophlebitis and blood clot formation. This

type of exercise is not associated with promoting urinary and intestinal elimination.

11. Which of the following reflects the principle on which a clients diet will most likely be based

during the acute phase of MI?

a. Liquids as desired

b. Small, easily digested meals

c. Three regular meals per day

d. Nothing by mouth

Ans: B recommended dietary principles in the acute phase of MI include avoiding large meals because

small, easily digested foods are better tolerated. Fluids are given according to the clients needs, and

sodium restrictions may be prescribed, especially for clients with manifestations of heart failure.

Cholesterol restrictions may be ordered as well. Clients are not prescribed diets of liquids only or

restricted to nothing by mouth unless their condition is very unstable.

12. Of the following controllable risk factors for coronary artery disease (CAD) appears most closely

linked to the development of the disease?

a. Age

b. Medication usage

c. High cholesterol levels

d. Gender

Ans: C high cholesterol levels are considered a controllable risk factor for CAD and appear most clearly

linked to the development of the disease. High cholesterol levels can be modified through diet, exercise,

and medication. Age and gender are uncontrollable risk factors for CAD. Medication usage is not

considered a risk factor for CAD.

13. Which of the following is an uncontrollable risk factor that has been linked to the development

of CAD?

a. Exercise

b. Obesity

c. Stress

d. Heredity


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Ans: D heredity has been linked to CAD and is an uncontrollable risk factor. Exercise, obesity, and

stress are controllable risk factor for CAD.

14. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated

fat, or leading a sedentary lifestyle, technique of behavior modification may be used to help the client

change behavior. The nurse can best reinforce new adaptive behaviors by:

a. Explaining how the old behavior leads to poor health

b. Withholding praise until the new behavior is well established

c. Rewarding the client whenever the acceptable behavior is performed

d. Instilling mild fear into the client to extinguish the behavior

Ans: C a basic principle of behavior modification is that behavior that is learned and continued is

behavior that has been rewarded. Other reinforcement techniques have not been found to be as

effective as reward.

15. Alteplase recombinant. Or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is

administered during the first 6 hours after onset of MI to:

a. Control chest pain

b. Reduce coronary artery vasospasmc. Control the dysrhythmias associated with MI

d. Revascularize the blocked coronary artery

Ans: D the thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary

artery. The drug is most effective when administered within the first 6 hours after onset.

16. After the administration of t-PA, the nurse understands that a nursing assessment priority is to:

a. Observe the client for chest pain

b. Monitor for fever

c. Monitor the 12-lead ECG every 4 hours

d. Monitor breath sounds

Ans: A although monitoring the 12-lead ECG and monitoring breath sounds are important, observingthe client for chest pain is the nursing assessment priority, because closure of the previously obstructed

coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the

artery after t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time

are essential to detect complications. Administration of t-PA should not cause fever.

17. When monitoring a client who is receiving t-PA, the nurse understands it is important to

monitor vital signs and have resuscitation equipment available because reperfusion of the cardiac tissue

can result in which of the following?

a. Cardiac dysrhythmias

b. Hypertension

c. Seizure

d. Hypothermia

Ans: A cardiac dysrhythmias are commonly observed with administration of t-PA. Cardiac

dysrhythmias associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with

administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the

cardiac tissue.

18. Contraindication to the administration of t-PA include which of the following?

a. Age greater than 60 years


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b. History of cerebral hemorrhage

c. History of heart failure

d. Cigarette smoking

Ans: B a past history of cerebral hemorrhage is a contraindication to administration of t-PA because

the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and

cigarette smoking are not contraindications.

19. A client has driven himself into the emergency room. He is 50 years old, has a history of

hypertension, and informs the nurse that his father died from 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 nasal cannula. The nurses 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

Ans: B advanced cardiac life support recommends that at least one or two intravenous lines be

inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest

radiograph, and drawing blood for the laboratory are important but secondary to starting theintravenous line.

20. Crackles heard on lung auscultation indicate which of the following?

a. Cyanosis

b. Bronchospasm

c. Airway narrowing

d. Fluid-filled alveoli

Ans: D crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not

have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with

wheezing sounds.

21. A 68-year-old female client on day 2 after hip surgery has no cardiac history but starts to

complain of chest heaviness. The first nursing action should be to:

a. Inquire about the onset, duration, severity, and precipitating factors of the heaviness

b. Administer oxygen via nasal cannula

c. Offer pain medication for the chest heaviness

d. Inform the physician of the chest heaviness

Ans: A further assessments is needed in this situation. It is premature to initiate other actions until

further data have been gathered. Inquiring about the onset, duration, location, severity, and

precipitating factors of the chest heaviness will provide pertinent information to convey to the

physician.

22. 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 damage


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Ans: D detection of myoglobin is one diagnostic tool to determine whether myocardial damage has

occurred. Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks

within 4 to 6 hours after physician.

23. An older, sedentary adult may not respond to emotional or physical stress as well as a younger

individual because of:

a. Left ventricular atrophy

b. Irregular heart beats

c. Peripheral vascular occlusion

d. Pacemaker placement

Ans: A in older adults who are less active and do not exercise the heart muscle, atrophy can result.

Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a

result, under sudden able to respond to the increased demands on the myocardial muscle. Decreased

cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may

develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are

generally not associated with an older sedentary adults lifestyle. Peripheral vascular occlusion of

pacemaker placement should not affect response to stress.

The Client With Heart Failure

24. A 69-year-old woman has a history of heart failure. She is admitted to the emergency

department with heart failure complicated by pulmonary edema. On admission of this client, which of

the following should be assessed first?

a. Blood pressure

b. Skin breakdown

c. Serum potassium

d. Urine output

Ans: A it is a priority to assess the blood pressure first, because people with pulmonary edema

typically experience severe hypertension that requires early intervention.

25. In which of the following should the nurse place a client with suspected heart failure?

a. Semi-sitting (Low Fowlers position)

b. Lying on the right side (Sims position)

c. Sitting almost upright (High Fowlers position)

d. Lying on the back with the head lowered (Trendelenburg position)

Ans: C sitting almost upright in bed with the feet and legs resting on the mattress decreases venous

return to the heart, thus reducing myocardial workload. Also, the sitting position allows maximum space

for lung expansion. Low Fowlers position would be used if the client could not tolerate high Fowlers

position for some reason. Lying on the right side would not be a good position for the client in heart

failure. The client in heart failure would not tolerate the Trendelenburg position.

26. Which of the following would be a priority nursing diagnosis for the client with heart failure and

pulmonary edema?

a. Risk for infection related to line placements

b. Impaired skin integrity related to pressure

c. Activity intolerance related to imbalance between oxygen supply and demand

d. Constipation related to immobility


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Ans: C activity intolerance is a primary problem for clients with heart failure and pulmonary edema.

The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients

frequently complain of dyspnea and fatigue. The client could be at risk for infection related to line

placements or impaired skin integrity related to pressure. However, these are not the priority nursing

diagnoses for the client with heart failure and pulmonary edema, nor is constipation related to

immobility.

27. The major goal of therapy for a client with heart failure and pulmonary edema would be to:

a. Increase cardiac output

b. Improve respiratory edema

c. Decrease peripheral edema

d. Enhance comfort

Ans: A increasing cardiac output is the main goal of therapy for the client with heart failure or

pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention.

Respiratory status and comfort will be improved when cardiac output increases to an acceptable level.

Peripheral edema is not typically associated with pulmonary edema.

28. Digoxin is administered intravenously to a client with heart failure, primarily because the drugacts to:

a. Dilate coronary arteries

b. Increase myocardial contractility

c. Decrease cardiac dysrhythmias

d. Decrease electrical conductivity in the heart

Ans: B digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes

increased strength of myocardial contractions and thereby increases output of blood from the left

ventricle. Digoxin does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias

and does decrease the electrical conductivity of the myocardium, this is not the primary reason for its

use in clients with heart failure and pulmonary edema.

29. Captopril, an antigiotensin-converting enzyme (ACE) inhibitor, may be administered to a client

with heart failure because it acts as a:

a. Vasopressor

b. Volume expander

c. Vasodilator

d. Potassium-sparing diuretic

Ans: C- ACE inhibitors have become the vasodilators of choice in the client with mild to severe

congestive heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve survival

in overt heart failure.

30. Furosemide is administered intravenously to a client with heart failure. How soon after

administration should the nurse begin to see evidence of the drugs desired effect?

a. 5 to 10 minutes

b. 30 to 60 minutes

c. 2 to 4 hours

d. 6 to 8 hours

Ans: A after intravenous injection of furosemide, diuresis normally begins in about 5 minutes and

reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours. When furosemide is


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given intramuscularly or orally, drug action begins more slowly and lasts longer than when it is given

intravenously.

31. The nurse teaches a client with heart failure to take oral Furosemide in the morning. The

primary reason for this is to help:

a. Prevent electrolyte imbalances

b. Retard rapid drug absorption

c. Excrete excessive fluids accumulated during the night

d. Prevent sleep disturbances during the night

Ans: D when diuretics are given early in the day, the client will void frequently during the daytime

hours and will not need to void frequently during the night. Therefore, the clients sleep will not be

disturbed. Taking furosemide in the morning has no effect on preventing electrolyte imbalances or

retarding rapid drug absorption. The client should not accumulate excessive fluids throughout the night.

32. Clients with heart failure are prone to atrial fibrillation. During physical assessment, the nurse

would suspect atrial fibrillation when palpation of the radial pulse reveals:

a. Two regular beats followed by one irregular

b. An irregular pulse rhythmc. Pulse rate below 60 bpm

d. A weak, thready pulse

Ans: B characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular

rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular

rate and should report it to the physician. A weak, thready pulse is characteristic of a client in shock.

33. When teaching the client about complications of atrial fibrillation, the nurse understands that

the complications can be caused by:

a. Stasis of blood in the atria

b. Increased cardiac output

c. Decreased pulse rated. Elevated blood pressure

Ans: Aatrial fibrillation occurs when the sinoatrial node no longer functions as the hearts pacemaker

and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed,

atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some

estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not

associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is

associated with an increased pulse rate.

34. The nurse should teach the client that signs of digitalis toxicity include which of the following?

a. Skin rash over the chest and back

b. Increased appetite

c. Visual disturbances such as seeing yellow spots

d. Elevated blood pressure

Ans: C colored vision and seeing yellow spots are symptoms of digitalis toxicity. Abdominal pain,

anorexia, nausea, and vomiting are other common symptoms of digitalis toxicity. Additional signs of

toxicity include dysrhythmias, such as atrial fibrillation or bradycardia. Skin rash, increased appetite, and

elevated blood pressure are not associated with digitalis toxicity.


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35. The nurse should be especially alert for signs and symptoms of digitalis toxicity if serum levels

indicate that the client has a:

a. Low sodium level

b. High glucose level

c. High calcium level

d. Low potassium level

Ans: D a low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity. Because

potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be

prone to increased cardiac excitability.

36. Which of the following foods should the nurse teach a client with heart failure to avoid or limit

when following a 2-g sodium diet?

a. Apples

b. Tomato juice

c. Whole wheat bread

d. Beef tenderloin

Ans: B canned foods and juices, such as tomato juice, are typically high in sodium and should be

avoided in a sodium-restricted diet, canned foods and juices in which sodium has been removed orlimited are available. The client should be taught to read labels carefully. Apples and whole wheat

breads are not high in sodium. Beef tenderloin would have less sodium than canned foods or tomato

juice.

37. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic

should be encouraged to eat such foods as bananas, orange juice, and,

a. Spinach

b. Skimmed milk

c. Baked chicken

d. Brown rice

Ans: A foods rich in potassium include bananas, orange juice, and green leafy vegetables such asspinach. Honeydew melon, cantaloupe, and watermelons are also rich in potassium. Other good sources

of potassium are grapefruit juice, nectarines, potatoes, dried prunes, raisins, and figs. Skimmed milk,

baked chicken, and brown rice are not considered high in potassium.

38. The nurse finds the apical impulses below the fifth intercostals space. The nurse suspects

a. Left atrial enlargement

b. Left ventricular enlargement

c. Right atrial enlargement

d. Right ventricular enlargement

Ans: B - a normal apical impulse is found over the apex of the heart and is typically located and

auscultated in the left fifth intercostals space in the midclavicular line. An apical impulse located or

auscultated below the fifth intercostals space or lateral to the midclavicular line may indicate left

ventricular enlargement.

39. The nurse is admitting a 69-year old man to the clinical unit. The client has a history of left

ventricular enlargement. During the assessment the nurse notes +3 pitting edema of the ankles

bilaterally. The client does not have chest pain. The nurse observes that the client does have dyspnea at

rest. The nurse infers that the client may have

a. Arteriosclerosis


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b. Congestive heart failure

c. Chronic bronchitis

d. Acute myocardial infarction

Ans: B peripheral edema is a symptom of congestive heart failure. Congestive heart failure results

when the heart chronically pumps against increased resistance or is unable to contract forcefully to

pump the blood out into the systemic circulation. As a result, the ventricles become overfilled and there

is an accumulation of volume within the closed system. The clients symptoms do not indicate

arteriosclerosis, chronic bronchitis, or acute MI.

40. The nurses discharge teaching plan for the client with congestive heart failure would stress the

significance of which of the following?

a. Maintaining a high-fiber diet

b. Walking 2 miles every day

c. Obtaining daily weights at the same time each day

d. Remaining sedentary for most of the day

Ans: C Congestive heart failure is a complex and chronic condition. Education should focus on health

promotion and preventive care in the home environment. Signs and symptoms can be monitored by the

client. Instructing the client to obtain daily weights at the same time each day is very important. Theclient should be told to call the physician if there has been a weight gain of 2 pounds or more. This may

indicate fluid overload, and treatment can be prescribed early and on an outpatient basis, rather than

waiting until the symptoms become life threatening. Following a high-fiber diet id beneficial, but it is not

relevant to the teaching needs of the client with congestive heart failure. Prescribing an exercise

program for the client, such as walking 2 miles everyday, would not be appropriate at discharge. The

clients exercise program would need to be planned in consultation with the physician and based on his

history and the physical condition of the client. The client may require exercise tolerance testing before

an exercise plan is laid out. Although the nurse does not pre-lifestyle should not be recommended.

41. A 70-year-old woman is scheduled to undergo mitral valve replacement for severe mitral

stenosis and mitral regurgitation. Although the diagnosis was made during childhood, she did not havesymptoms until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin

and furosemide. During the initial interview with the client, the nurse would most likely learn that the

clients childhood health history included:

a. Chicken pox

b. Poliomyelitis

c. Rheumatic fever

d. Meningitis

Ans: C Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis.

Chicken pox, poliomyelitis, and meningitis are not associated with mitral stenosis.

42. A client experiences some initial signs of excitation after having an intravenous infusion of

lidocaine hydrochloride started. The nurse would assess that the client is demonstrating a typical

adverse reaction to lidocaine hydrochloride when the client complains of:

a. Palpitations

b. Tinnitus

c. Urinary frequency

d. Lethargy

Ans: B Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision,

tremors, numbness and tingling of extremities, excessive perspiration, hypotension, convulsions, and


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finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary

frequency, and lethargy are not considered typical adverse reactions to lidocaine hydrochloride.

43. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter

inserted. The physician orders 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 concentrations in the blood

Ans: Cthe pulmonary artery pressures are used to assess the hearts ability to receive and pump

blood. The pulmonary capillary wedge pressure reflects the left ventricular end-diastolic pressure and

guides the physician in determining fluid management for the client. The degree of coronary artery

stenosis is assessed during a cardiac catheterization. The peripheral arterial pressure is assessed with an

arterial line. The oxygen and carbon dioxide concentrations in the arterial blood can be measured by an

arterial blood gas determination.

44. Which of the following signs and symptoms would most likely be found in a client with mitralregurgitation?

a. Exertional dyspnea

b. Confusion

c. Elevated creatine phosphokinase concentration

d. Chest pain

Ans: A weight gain due to fluid retention and worsening heart failure cause exertional dyspnea in

clients with mitral regurgitation. The rise in left atrial pressure that accompanies mitral valve disease is

transmitted backward to the pulmonary veins, capillaries, and arterioles and eventually to he right

ventricle. Signs and symptoms of pulmonary and systemic venous congestion follow. Confusion,

elevated creatine phosphokinase concentration, and chest pain are not typically associated with mitral

regurgitation.45. The nurse expects that a client with mitral stenosis would demonstrate symptoms associated

with congestion in the:

a. Aorta

b. Right atrium

c. Superior vena cava

d. Pulmonary circulation

Ans: D when mitral stenosis is present, the left atrium has difficulty emptying its contents into the left

ventricle. Hence, because there is no valve to prevent backward flow into the pulmonary vein, the

pulmonary circulation is under pressure. functioning of the aorta, right atrium, and superior vena cava is

not immediately influenced by mitral stenosis.

46. Because a client has mitral stenosis and is a prospective valve recipient, the nurse

preoperatively assesses the clients past compliance with medical regimens. Lack of compliance with

which of the following regimens would pose the greatest health hazard to this client?

a. Medication therapy

b. Diet modification

c. Activity restrictions

d. Dental care


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Ans: A preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart

disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with

bioprostheses are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage

schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism.

Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever.

Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper

respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and

dental care are important; however, they do not have as much significance postoperatively as

medication therapy does.

47. In preparing the client and the family for a postoperative stay in the intensive care unit after

open heart surgery, the nurse should explain that:

a. The client will remain in the intensive care unit for 5 days

b. The client will sleep most of the time while in the intensive care unit

c. Noise and activity within the intensive care unit are minimal

d. The client will receive medication to relieve pain

Ans: D management of postoperative pain is priority for the client after surgery, including valve

replacement surgery, according to the Agency for Health Care Policy and Research. The client and familyshould be informed that pain will be assessed by the nurse and medications will be given to relieve the

pain. The client will stay in the intensive care unit as long as monitoring and intensive care are needed.

Sensory deprivation and overload, high noise levels, and disrupted sleep and rest patterns are some

environmental factors that affect recovery from valve replacement surgery.

48. A client who has undergone a mitral valve replacement experiences persistent bleeding from

the surgical incision during the early postoperative period. Which of the following pharmaceutical

agents should the nurse be prepared to administer to this client?

a. Vitamin C

b. Protamine sulfate

c. Quinidine sulfated. Warfarin sodium (Coumadin)

Ans: B protamine sulfate is used to help combat persistent bleeding in a client who has had open heart

surgery. Vitamin C and quinidine sulfate do not influence blood clotting. Warfarin sodium is an

anticoagulant, as is heparin, and these two agents would tend to cause the client to bleed even more.

49. The most effective measure the nurse can use to prevent wound infection when changing a

clients dressing after coronary artery bypass surgery is to:

a. Observe careful handwashing procedures

b. Cleanse the incisional area with an antiseptic

c. Use prepackaged sterile dressings to cover the incision

d. Place soiled dressings in a waterproof bag before disposing of them

Ans: A many factors help prevent wound infections, including washing hands carefully, using the sterile

prepackaged supplies and equipment, cleansing the incisional area well, and disposing of soiled

dressings properly. However, most authorities say that the single most effective measure in preventing

wound infections is to wash the hands carefully before and after changing dressings. Careful

handwashing is also important in helping reduce other infections often acquired in hospitals, such as

urinary tract and respiratory system infections.


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50. For a client who excretes excessive amounts of calcium during the postoperative period after

open surgery, which of the following measures should the nurse institute to help prevent complications

associated with excessive calcium excretion?

a. Ensure a liberal fluid intake

b. Provide an alkaline-ash diet

c. Prevent constipation

d. Enrich the clients diet with dairy products

Ans: A in an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid.

When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi.

Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless

contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the

solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting

foods rich in calcium, such as dairy products, will help in preventing renal calculi.

51. The nurse teaches the client who is receiving warfarin sodium that:

a. Partial thromboplastin time values determine the dosage of warfarin sodium

b. Protamine sulfate is used to reverse the effects of warfarin sodium

c. The international normalized ration (INR) is used to assess effectivenessd. Warfarin sodium will facilitate clotting of the blood

Ans: C - the INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the

prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health

Organization was used for the plasma test. It is now the recommended method to monitor effectiveness

of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to

3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was

maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the

effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodiums

anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will

help to prevent blood clots.

52. Good dental care is an important measure in reducing risk of endocarditis. A teaching plan to

promote good dental care in a client with mitral stenosis should include demonstration of the proper

use of:

a. A manual toothbrush

b. An electric toothbrush

c. An irrigation device

d. Dental floss

Ans: Adaily dental care and frequent checkups by a dentist who is informed about the clients

condition are required to maintain good oral health. Use of an electric toothbrush, an irrigation device,

or dental floss may cause gums to bleed and allow bacteria to enter mucous membranes and the

bloodstream, increasing the risk of endocarditis.

53. Before a clients disease discharge after mitral valve replacement surgery, the nurse should

evaluate the clients understanding of postsurgery activity restrictions. Which of the following should

the client not engage in until after the 1-month-old postdischarge appointment with the surgeon?

a. Showering

b. Lifting anything heavier than 10 pounds

c. A program of gradually progressive walking

d. Light housework


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Ans: B most cardiac surgical clients have median sternotomy incisions, which take about 3 months to

heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning

exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well

approximated with no open areas or drainage. Activities should be gradually resumed on discharge.

54. Three days after mitral valve surgery, a 45-year-old woman comments that she hears a

clicking noise coming from her chest and her rather large chest incision. The nurses response should

reflect the understanding that the client may be experiencing which of the following?

a. Anxiety related to altered body image

b. Anxiety related to altered health status

c. Altered tissue perfusion

d. Lack of knowledge regarding the postoperative course

Ans: A verbalized concerns from the client may stem from her anxiety over the changes her body has

gone through after open heart surgery. Although the client may experience anxiety related to her

altered health status or may have a lack of knowledge regarding her postoperative course, she is

pointing out the changes in her body image. The client is not concerned about altered tissue perfusion.

The Client With Hypertension

55. An industrial health nurse at a large printing plant finds a male employees blood pressure to be

elevated on two occasions 1 month apart and refers him to his provide physician. The employee is about

25 pounds overweight and has smoked a pack of cigarettes daily for more than 20 years. The clients

physician prescribes atenolol for the hypertension. The nurse should instruct the client to:

a. Avoid sudden discontinuation of the drug

b. Monitor the blood pressure annually

c. Follow a 2-g sodium diet

d. Discontinue the medication if severe headaches develop

Ans: A -adrenergic antagonists indicated for management of hypertension. Sudden

discontinuation of this drug is dangerous because it may exacerbate symptoms. The medication shouldnot be discontinued without a doctors order. Blood pressure needs to be monitored more frequently

than annually in a client who is newly diagnosed and treated for hypertension. Clients are not usually

placed on a 2-g sodium diet for hypertension.

56. The nurse teaches her client, who has recently been diagnosed with hypertension, about his

dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections

would best meet the clients?

a. Mixed green salad with blue cheese dressing, crackers, and cold cuts

b. Ham sandwich on rye bread and an orange

c. Baked chicken, an apple, and a slice of white bread

d. Hot dogs, baked beans, and celery and carrot sticks

Ans: C processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both

and fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of

all types are complex and difficult to implement\ with clients who are basically asymptomatic.

57. A clients job involves working in a warm, dry room, frequently bending and crouching to check

the underside of a high-speed press, and wearing eye guards. Given this information, the nurse should

assess the client for which of the following?

a. Muscle aches


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b. Thirst

c. Lethargy

d. Postural hypotension

Ans: D possible dizziness from postural hypotension when rising a crouched or bent position increases

the clients risk of being injured by the equipment. The nurse should assess the clients blood pressure in

all three positions (lying, sitting, and standing) at all routine visits. The client may experience muscle

aches, or thirst from working in a warm, dry room, but these are not as potentially dangerous as

postural hypotension. The client should not be experiencing lethargy.

58. An exercise program is prescribed for the client with hypertension. Which intervention would

be most likely to assist the client in maintaining an exercise program?

a. Giving the client a written exercise program.

b. Explaining the exercise program to the clients spouse.

c. Reassuring the client that he or she can do the exercise program.

d. Tailoring a program to the clients needs and abilities.

Ans: D tailoring or individualizing a program to the clients lifestyle has been shown to be an effective

strategy for changing health behaviors. Providing a written program, explaining the program to the

clients spouse, and reassuring the client that he or she can do the program may be helpful but are notas likely to promote adherence as individualizing the program.

59. The client realizes the importance of quitting smoking, and the nurse develops a plan to help

the client achieve this goal. Which of the following nursing interventions should be the initial step in this

plan?

a. Review the negative effects of smoking on the body.

b. Discuss the effects of passive smoking on environmental pollution.

c. Established the clients smoking pattern.

d. Explain how smoking worsens high blood pressure.

Ans: C - a plan to reduce or stop smoking begins with establishing the clients personal daily smoking

pattern and activities associated with smoking. It is important that the client understands the associatedhealth and environmental risk, but this knowledge has not been shown to help clients change their

smoking behavior.

60. Essential Hypertension would be diagnosed in a 40-year-old man whose blood pressure

readings were consistently at or above which of the following?

a. 120/90 mmHg

b. 130/85 mmHg

c. 140/90 mmHg

d. 160/80 mmHg

Ans: C Heart Center of the Philippines standards define hypertension as a consistent systolic blood

pressure level greater than 140 mmHg and a consistent diastolic blood pressure level greater than 90

mmHg.

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Medical Surgical Comprehensive