2/16/2013 Prentice Hall Reviews & Rationales: Medical-Surgical Nursing - Second Edition Mary Ann Hogan, Joan Davenport,

Stacy Estridge, Dolores Zygmont Chapter 3: NCLEX RN Review PreTest

You got 3 out of 10 questions correct 1. The nurse is monitoring a client who has recently undergone pericardioce ntesis. Following the procedure, the nurse assesses the client and finds a decre ased blood pressure, distended neck veins, and clear lungs. The nurse suspects t hat the client has developed which of the following? You answered correctly: Cardiac tamponade Rationale: Cardiac tamponade occurs as a result of accumulation of fluid in the pericardial sac. This restricts filling of the cardiac chambers and thus reduces stroke volume, cardiac output, and blood pressure. Because the right atrium is also affected, jugular venous distention (JVD) occurs and the lungs are clear. I n heart failure (option 1), the cardiac chambers are dilated, and the increase i n volume and pressure is reflected back to the lungs causing crackles to develop as an early sign. Pericarditis (option 3) is one cause of cardiac tamponade. Si gns of pericarditis include a temperature elevation and chest pain. Cardiomyopat hy may cause heart failure with the development of crackles (option 4). Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Cardiovascular Strategy: Review the indications for a pericardiocentesis. Compare the indicatio ns to the constellation of symptoms presented in the stem with the indications. Alternatively, list the major symptoms for each distracter and compare them to t hose in the stem. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, pp. 1050-1051. 2. A 54-year-old male client was recently diagnosed with subacute bacterial endocarditis (SBE). The nurse determines that the client understands the discha rge teaching when he makes which statement? You answered incorrectly: "Can I take the antibiotics as a pill now? The correct answer was: "I have to call my doctor so I can get antibiotics befor e seeing the dentist." Rationale: Once a client is diagnosed with SBE, he or she is at risk for repeate d episodes. Taking prophylactic antibiotics prior to dental care is an important activity to prevent further infections. There is no routine sodium restriction with SBE unless heart failure develops (option 1). Antibiotic treatment for SBE is given by the IV route for the entire course (option 3). Although stopping smo king will decrease his risk factor for coronary artery disease, it does not affe ct the SBE (option 4). Cognitive Level: Application Client Need: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health: Cardiovascular Strategy: Differentiate the immediate damage to the valve that occurs as a resul t of SBE from heart failure and CAD. The appropriate route for the administratio n is determined by the timing in the course of the disease. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th

inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, pp. 1046-1047. 3. The nurse on a cardiac unit is caring for a client admitted with an acut e exacerbation of heart failure. The nurse concludes that the client's condition is worsening after noting which of the following with client assessment? You answered correctly: A cough develops with pink frothy sputum Rationale: Heart failure is the accumulation of fluid in the alveoli characteriz ed by increased crackles, tachypnea, tachycardia, pink frothy sputum, decreased SO2 and PO2. The amount and severity of symptoms indicates the severity of the d isease. The client in heart failure presents with acute restlessness and anxiety and is unable to fall asleep when acutely short of breath (option 4). The SNS s timulation not only causes the anxiety but also a tachycardia. As the SNS stimul ation decreases and heart failure resolves, the heart rate declines (option 1). Urine output is generally decreased in heart failure clients but is increased wh en treated with diuretic therapy (option 2). Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Analysis Content Area: Adult Health: Cardiovascular Strategy: The critical word in the question is worsening. Compare the expected f indings seen with heart failure with the findings indicated in the distracters. Then note the distracter that illustrates a worsening state and select it as the answer to the question. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, Inc. , pp. 1025-1027. 4. A client is scheduled for coronary angiography. In reviewing the client' s record, what significant finding would the nurse report to the healthcare prov ider before the diagnostic procedure? You answered correctly: Client reported an allergy to shrimp Rationale: The contrast medium or dye typically used for cardiac angiography is iodine based. The client with a known allergy to shellfish is at risk for anaphy laxis and requires the use of an alternate (hypoallergenic) contrast medium. Atr ial fibrillation (option 2) and chronic renal failure (option 4) are not contrai ndications to cardiac angiography. A value of 4.0 mEq/L is normal value for pota ssium (option 3). Cognitive Level: Application Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Strategy: The core issue of the question is knowledge of possible risks to a cli ent undergoing angiography. First, recall that any type of angiography involves the use of contrast medium and that standard contrast is iodine based. After eva luating each option, note that the option that links to risk of allergy is the o ne that mentions allergy to shellfish. The other distracters may be normal for o r unrelated to a client with heart disease and would not affect the performance of the test. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, pp. 943-945. 5. The nurse is implementing a discharge teaching plan for a client newly d iagnosed with heart failure. When discussing fluid status with the client, the n urse would explain the importance of doing which of the following?

You answered incorrectly: Taking a single extra dose of diuretic if there is dec reased urination for several days The correct answer was: Recording body weight every day before breakfast and rep ort a weight gain of 3 or more pounds in a week Rationale: Daily weight is the most sensitive indicator of changes in fluid stat us. It is more accurate for a client at home than urine output (option 4). A flu id restriction (option 1) may be recommended for a client with advanced heart fa ilure, but it is not a method of monitoring fluid status. The client should neve r adjust the dose of his or her medications independently (option 2). Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Strategy: To answer this question, imagine yourself as the client. Compare the d istracters to what a reasonable person would be able to do at home on a routine basis. Think of what is safe for a client to do. Adjusting medications is never recommended because something else may be occurring that needs investigation by the physician. The critical issue is knowledge of weight as an accurate and reli able gauge to fluid status. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, Inc. , p. 1038. 6. The nurse is caring for a client with complete heart block who is being prepared to have a temporary transvenous pacemaker inserted. In briefly explaini ng the blockage to the cardiac conduction system to the client, the nurse would point out which area on the diagram shown? Select the affected area. You answered incorrectly. Please click <a><url>HERE</url><href>D:\Content\Textfi les\pre_ch03q06-c.jpg</href></a> to see the correct answer. Rationale: Atrioventricular (AV) node heart block occurs because of conduction a bnormalities at AV node . First-degree block indicates a slowed AV nodal conduct ion (PR interval greater than 0.2 second duration). Second-degree indicates inte rmittent AV nodal block that can be either Mobitz Type 1 or Type 2. Third-degree block (complete heart block) indicates a complete dissociation between atrial a nd ventricular conduction fibers because of a loss of impulse transmission throu gh the AV node. The other areas are unaffected. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Content Area: Adult Health: Cardiovascular Strategy: Recall the components of the conduction system and the rhythms that or iginate within each segment. Use baseline nursing knowledge and the process of e limination to determine the area for selection. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, Inc. , p. 999. 7. A client is getting ready to go home after acute myocardial infarction ( AMI). The client is asking questions about the prescribed medications, and wants to know why metoprolol (Lopressor) was prescribed. The nurse's best response wo uld be which of the following? You answered incorrectly: "Your heart was beating too slowly, and metoprolol inc reases your heart rate." The correct answer was: "Lopressor slows your heart rate and decreases the amoun t of work it has to do so it can heal."

Rationale: Metoprolol (Lopressor) is a beta adrenergic blocker that slows the he art rate and decreases myocardial contractility (option 4). These actions reduce cardiac workload. Because of this, options 1 and 3 cannot be true. Nitroglyceri ne is a drug that dilates the coronary arteries (option 2). Cognitive Level: Application Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Content Area: Adult Health: Cardiovascular Strategy: To answer this question, integrate the normal cardiac physiology, chan ges that occur with and acute myocardial infarction, and the mechanism of action and side effects of beta blockers. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, p. 9 73. 8. A client is taking digoxin (Lanoxin) and furosemide (Lasix) for heart fa ilure. The nurse approves of which of the following client selections that is th e best menu choice for this client? You answered incorrectly: Ham and cheese omelet with low-cholesterol egg substit ute The correct answer was: Chicken with baked potato and cantaloupe Rationale: Furosemide is a loop diuretic that causes a loss of serum potassium. When taken concurrently with digoxin, it can potentiate digoxin toxicity. For cl ients who are taking a diuretic regularly, especially with concurrent digoxin, t hey should be instructed to eat foods high in potassium and low in sodium to pre vent additional fluid overload with heart failure and prevent excess potassium l oss. Chicken, potato, and cantaloupe are all potassium-rich foods (option 1), wh ile the foods in options 2, 3, and 4 are higher in sodium. Note that the foods i n options 3 and 4 are also higher in fat. Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process: Evaluation Content Area: Foundational Sciences: Nutrition Strategy: Knowledge of heart failure, digoxin, furosemide, and their connection to high-sodium foods is needed to answer this question. Review each diet selecti on with these content areas in mind to determine the best choice. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, Inc. , p. 989. 9. The nurse is caring for a newly admitted client with a diagnosis of rest rictive cardiomyopathy. When planning this client's care, which of the following would be the most appropriate nursing diagnosis? You answered incorrectly: Hopelessness related to lack of cure and debilitating symptoms The correct answer was: Activity intolerance related to decreased cardiac output Rationale: All clients with cardiomyopathy have some decrease in their cardiac o utput and corresponding activity intolerance (option 4). The experiences of fear (option 1), hopelessness (option 2), or deficient knowledge (option 3) are clie nt specific and must be evaluated on an individual basis. Any or all of these ma y be present, but more data would be needed to determine whether the other nursi ng diagnoses apply. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Analysis

Content Area: Adult Health: Cardiovascular Strategy: Understanding what is happening physiologically helps in the selection of the correct distracter. Focus selection of the best response in relation to the information given, which is a new onset diagnosis. Use Maslow's hierarchy of needs theory to determine that physiological needs must be addressed first. As the disease progresses or more information is learned by the client, the other d istracters may become relevant. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, p. 1 067. 10. The nurse working on a cardiac telemetry unit prepares to utilize an ext ernal pacemaker after noting that an assigned client has a blood pressure of 70/ 52 and has developed which of the following cardiac dysrhythmias? You answered incorrectly: Ventricular tachycardia The correct answer was: Second-degree heart block Rationale: The client with severe bradycardia, third-degree or complete heart bl ock, or second-degree heart block (which has a high potential to progress to com plete AV block) are those who are most likely to need an external pacemaker as a temporary therapy until definitive treatment can be given. Defibrillation is th e only effective and definitive treatment for a client who is in ventricular fib rillation (option 1). A client in rapid atrial fibrillation (option 2) and unsta ble ventricular tachycardia (option 3) may require synchronized cardioversion to terminate the abnormal rhythm. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Strategy: Think about the indications for an external pacemaker. Compare the ind ication to each of the distracters, noting that the term pacemaker implies tryin g to stimulate cardiac conduction. Reference: LeMone, P., & Burke, K. (2008). Medical-surgical nursing: Critical th inking in client care (4th ed.). Upper Saddle River, NJ: Pearson Education, p. 9 99.