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Staff Nurse Exam

Q.1 Which nursing action is most important when caring for a client after a cardiac catheterization?

  1. Provide for rest.
  2. Administer oxygen.
  3. Check a pulse distal to the insertion site.
  4. 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?

  1. Dysrhythmia
  2. Hypokalemia
  3. Anaphylactic shock
  4. 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?

  1. Stroke volume
  2. Venous pressure
  3. Coronary artery patency
  4. 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?

  1. A reduction of confusion
  2. An APPT twice the usual value
  3. An absence of ecchymotic areas
  4. 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?

  1. Nausea
  2. Epistaxis
  3. Chest pain
  4. 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?

  1. INR
  2. APTT
  3. Bleeding time
  4. 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?

  1. Diuretic therapy
  2. Sodium restriction
  3. Continuous dyspnoea
  4. 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?

  1. Syncope
  2. Headache
  3. Tachycardia
  4. 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?

  1. 3/4 to 1 inch
  2. 1/2 to 3/4 inch
  3. 1 to 1.5 inches
  4. 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?

  1. Restrict fluids.
  2. Elevate the legs.
  3. Apply elastic bandages.
  4. 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.