Q.1 Which nursing action is most important when caring for a client after a cardiac catheterization?
- Provide for rest.
- Administer oxygen.
- Check a pulse distal to the insertion site.
- Assess the electrocardiogram every fifteen minutes.
The Correct Answer is C. Check a pulse distal to the insertion site.
Rationale
- The pulse should be assessed because the trauma at the insertion site may interfere with blood flow distal to the site.
- There is also danger of bleeding.
- Rest is not a priority, although the extremity in which the catheter was inserted usually is immobilized for a period of time to prevent bleeding at the insertion site.
- This is determined on an individual basis; it is not routine. The client will be on a cardiac monitor, which will allow for continuous monitoring.
Q.2 For which common complication of myocardial infarction should the nurse monitor clients in the coronary care unit?
- Dysrhythmia
- Hypokalemia
- Anaphylactic shock
- Cardiac enlargement
The Correct Answer is A. Dysrhythmia
Rationale
- Myocardial infarction (MI) may cause increased irritability of tissue or interruption of normal transmission of impulses.
- Dysrhythmias occur in about 90% of clients after an MI.
- Hypokalemia may result when clients are taking cardiac glycosides and diuretics; this is a complication associated with therapy, not a pathologic entity related to the MI itself.
- Anaphylactic shock is caused by an allergic reaction, not by an MI.
- Cardiac enlargement is a slow process, so it will not be evident in the coronary care unit.
Q.3 A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure?
- Stroke volume
- Venous pressure
- Coronary artery patency
- Left ventricular functioning
The Correct Answer is D. Left ventricular functioning
Rationale
- The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated.
- Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Although a central venous pressure reading can be obtained with the pulmonary catheter, it is not as specific as a pulmonary wedge pressure, which reflects pressure in the left side of the heart.
- The patency of the coronary arteries usually is evaluated by cardiac catheterization.
Q.4 An older adult with cerebral arteriosclerosis is admitted with atrial fibrillation and is started on a continuous heparin infusion. What clinical finding enables the nurse to conclude that the anticoagulant therapy is effective?
- A reduction of confusion
- An APPT twice the usual value
- An absence of ecchymotic areas
- A decreased viscosity of the blood
The Correct Answer is B. An APPT twice the usual value
Rationale
- Desired anticoagulant effect is achieved when the activated partial thromboplastin time is 1.5 to 2 times normal.
- While anticoagulants help prevent thrombi that could block cerebral circulation, they do not increase cerebral perfusion, and so will not affect existing confusion.
- Although absence of bleeding suggests that the drug has not reached toxic levels, it does not indicate its effectiveness.
- This medication does not affect the viscosity of blood.
Q.5 What specifically should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel?
- Nausea
- Epistaxis
- Chest pain
- Elevated temperature
The Correct Answer is B. Epistaxis
Rationale
- The high vascularity of the nose, combined with its susceptibility to trauma (e.g., sneezing, nose blowing), makes it a frequent site of hemorrhage.
- This response usually is not associated with anticoagulant therapy.
Q.6 A client is receiving warfarin (Coumadin). Which test result should the nurse use to determine if the daily dose of this anticoagulant is therapeutic?
- INR
- APTT
- Bleeding time
- Sedimentation rate
The Correct Answer is A. INR
Rationale
- Warfarin (Coumadin) initially is prescribed day by day, based on international normalized ratio (INR) blood test results.
- This test provides a standard system to interpret prothrombin times.
- APTT (accelerated partial thromboplastin time) is used to evaluate the effects of heparin, which acts on the intrinsic pathway.
- Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation.
- Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.
Q.7 A nurse identifies signs of electrolyte depletion in a client with heart failure who is receiving bumetanide and digoxin. What does the nurse determine is the cause of the depletion?
- Diuretic therapy
- Sodium restriction
- Continuous dyspnoea
- Inadequate oral intake
The Correct Answer is A. Diuretic therapy
Rationale
- Diuretic therapy that affects the loop of Henle generally involves the use of drugs (e.g., bumetanide) that directly or indirectly increase urinary sodium, chloride, and potassium excretion.
- Sodium restriction does not necessarily accompany administration of bumetanide.
- Dyspnoea does not directly result in a depletion of electrolytes.
- Unless otherwise ordered, oral intake is unaffected.
Q.8 What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?
- Syncope
- Headache
- Tachycardia
- Hemiparesis
The Correct Answer is A. Syncope
Rationale
- With 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.
- Headache is not related to heart block.
- The heart rate usually is slow because the ventricular rhythm is not initiated by the SA node.
- Hemiparesis is not related to heart block unless decreased cerebral perfusion causes a brain attack.
Q.9 A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?
- 3/4 to 1 inch
- 1/2 to 3/4 inch
- 1 to 1.5 inches
- 2 to 2.5 inches
The Correct Answer is D. 2 to 2.5 inches
Rationale
The sternum must be depressed at least 2 inches to compress the heart adequately between the sternum and vertebrae and to simulate cardiac pumping action.
Q.10. A client admitted to the hospital has oedematous ankles. What should the nurse do to best reduce edema of the lower extremities?
- Restrict fluids.
- Elevate the legs.
- Apply elastic bandages.
- Do range-of-motion exercises.
The Correct Answer is B. Elevate the legs.
Rationale
- Elevation of extremities promotes venous and lymphatic drainage by gravity.
- Options A and C – This is a dependent function of the nurse.
- Option D – This procedure may have little effect on edema.