Exam 1 Cardiac
The nurse is providing teaching to a client newly diagnosed with Raynaud’s disease. Which statement by the client indicates a need for further teaching?
A. “I will avoid exposure to cold temperatures.”
B. “I will stop smoking.”
C. “I should wear gloves when outside in cold weather.”
D. “I will use nicotine patches to help reduce stress.”
D.
Nicotine causes vasoconstriction which worsens Raynaud's symptoms
A client with peptic ulcer disease reports black, tarry stools. What is the nurse’s priority interpretation?
A. Iron deficiency
B. GI bleeding
C. Infection
D. Constipation
Answer: B
B.
Black tarry stools indicated bleeding in upper GI tract.
Which assessment finding is most consistent with acute kidney injury (AKI)?
A. Generalized swelling in the lower extremities
B. Decreased urine output
C. Blood pressure 90/66 mmHg
D. Heart rate 55 bpm
B.
Decreased filtration leads to decreased urine output.
Which symptom is most commonly seen in Bell’s palsy?
A. One-sided facial drooping
B. Paralysis of both legs
C. Memory loss
D. Loss of hearing
A.
Bell's Pasley affects facial nerve (VII) causing drooping.
A client is prescribed nitroglycerin for chest pain. What is the most common side effect?
A. Headache
B. Constipation
C. Rash
D. Feve
A.
Vasoconstriction leads to headache.
A nurse is providing teaching to a client prescribed nitroglycerin for chronic stable angina. Which statement by the client indicates correct understanding of the medication?
A. “I should take this medication only after the chest pain becomes severe.”
B. “I should sit down before taking this medication.”
C. “I can take this medication with sildenafil if my chest pain continues.”
D. “I should swallow the tablet quickly with water.”
B.
Nitroglycerin causes vasodilation which lower BP. Can causes dizziness, lightheadedness, and fainting.
The nurse is caring for a client with cirrhosis. Which laboratory value should the nurse monitor to assess for hepatic encephalopathy?
A. Potassium
B. Albumin
C. Ammonia
D. Creatinine
C.
Ammonia build up causes confusion and altered LOC.
The nurse is caring for a client with an arteriovenous (AV) fistula for hemodialysis. Which nursing action is appropriate?
A. Measure blood pressure in the affected arm
B. Check the fistula site for a thrill or bruit
C. Apply a tight bandage over the fistula
D. Draw blood from the fistula site
B.
Bruit and thrill indicate proper blood flow.
The nurse is caring for a client with myasthenia gravis. Which symptom is most expected?
A. Muscle weakness that worsens with activity
B. High fever
C. Increased appetite
D. Severe headache
A.
A patient with MG muscles become weaker with repeated use.
The nurse is reviewing laboratory results for a client taking warfarin (Coumadin). Which laboratory value indicates the medication is working therapeutically?
A. INR 2.5
B. WBC 7,000
C. Potassium 4.0
D. Hemoglobin 13
A.
IRN indicates clotting time
A nurse is caring for a client 4 hours after a cardiac catheterization performed through the femoral artery. Which assessment finding requires immediate intervention?
A. Blood pressure 128/76
B. Small amount of bruising at insertion site
C. Client reports back pain and swelling at insertion site
D. Heart rate 82
C.
Back pain and swelling at insertion site may indicate bleed.
The nurse is caring for a client admitted with acute pancreatitis. Which provider order should the nurse implement first?
A. Administer IV opioid pain medication
B. Begin a low-fat diet
C. Keep the client NPO
D. Encourage oral fluids
C.
Allows pancreas to rest and prevents further damage
The nurse is caring for a client with kidney stones. Which nursing intervention is most important to include in the plan of care?
A. Encourage increased fluid intake
B. Restrict physical activity
C. Encourage a high sodium diet
D. Limit all movemen
A.
Increased fluids will flush kidney to help pass easier.
Which assessment finding is most concerning in a client with Guillain-Barré syndrome?
A. Difficulty breathing
B. Tingling in the toes
C. Hypotension
D. Headache
A.
GB causes ascending paralysis eventually affecting lungs.
The nurse is caring for a client receiving Heparin therapy. Which medication should the nurse anticipate administering if signs of bleeding occur?
A. Protamine sulfate
B. Vitamin K
C. Naloxone
D. Atropine
A.
Reversal agent for Heparin
The nurse is reviewing the cardiac monitor of a client and notes a rhythm consistent with ventricular tachycardia. The client is unresponsive and has no pulse. What is the nurse’s priority action?
A. Administer atropine
B. Begin chest compressions
C. Prepare to administer a beta blocker
D. Obtain a 12-lead ECG
B.
No pulse= compressions
V-Fib = Defib AFTER compressions
The nurse is reviewing laboratory results for a client with suspected liver disease. Which assessment finding is most consistent with an elevated bilirubin level?
A. Yellow discoloration of the skin and sclera
B. Decreased urine output
C. Increased appetite
D. Muscle weakness
A.
Bilirubin is produced by RBC breakdown which causes jaundice.
The nurse is assessing a client diagnosed with glomerulonephritis. Which finding is most expected?
A. Tea-colored urine
B. Bright red blood in stool
C. Yellow discoloration of skin
D. Productive cough
A.
Glomerulonephritis causes inflammation allowing blood to leak into urine
The nurse is caring for a client receiving palliative care. Which statement best describes the goal of palliative treatment?
A. Cure the disease completely
B. Improve quality of life and manage symptoms
C. Provide care only during the last 48 hours of life
D. Stop all medications immediately
B.
Palliative care focuses on comfort and quality of life.
The nurse is preparing to administer Hydralazine to a client. Which assessment finding indicates the medication is having the desired therapeutic effect?
A. Decreased blood pressure
B. Increased respiratory rate
C. Increased blood glucose
D. Decreased urine output
A.
Vasodilator to lower blood pressure by relaxing blood vessels
A nurse is assessing a client with peripheral artery disease (PAD). Which symptoms is most expected?
A. Leg pain that improves with walking
B. Leg pain that occurs with activity and improves with rest
C. Warm, red extremities
D. Bounding pedal pulses
B.
PAD causes decreased arterial blood flow intermittent claudication. Pain resolves with rest.
The nurse is caring for a client with acute pancreatitis. Which finding indicates the client may be experiencing third spacing?
A. Increased urine output
B. Blood pressure 86/54 mmHg
C. Warm, flushed skin
D. Weight loss of 2 lb
B.
Fluid shift from blood to other tissues or abdominal cavity.
The nurse is caring for a client with chronic kidney disease who is scheduled for a CT scan with contrast dye. Which intervention is most appropriate to help reduce the risk of kidney injury?
A. Administer an IV fluid bolus prior to the procedure
B. Restrict fluid intake for 12 hours before the procedure
C. Administer potassium supplements
D. Encourage high sodium intake before the procedur
A.
Contrast can be harmful to kidneys a bolus dilutes die and promotes elimination.
The nurse is caring for a client experiencing a sickle cell crisis. Which intervention is the nurse’s priority?
A. Administer oxygen
B. Encourage high protein foods
C. Limit fluid intake
D. Restrict activity for 1 week
A.
Oxygen reduces sickling of RBC
The nurse is preparing to administer Atropine to a client experiencing symptomatic bradycardia. Which assessment finding indicates the medication is having the desired effect?
A. Heart rate increases
B. Blood pressure decreases
C. Respiratory rate decreases
D. Urinary output decreases
A.
Atropine speeds up
Adenosine slows down