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Medsurg Exam 2 33, 34, 35, 36, 37 + ATI Questions and Answers 2023
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Medsurg Exam 2 33, 34, 35, 36, 37 + ATI Questions and Answers 2023
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Medsurg Exam 2 33, 34, 35, 36, 37 + ATIQuestions and Answers 2023
A nurse assesses a client who had a myocardial infarction and is
hypotensive. Which additional assessment finding should the nurse expect?
a.Heart rate of 120 beats/min
b.Cool, clammy skin
c.Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min - -ANS: A
When a client experiences hypotension, baroreceptors in the aortic arch
sense a pressure decrease in the vessels. The parasympathetic system
responds by lessening the inhibitory effect on the sinoatrial node. This
results in an increase in heart rate and respiratory rate. This tachycardia is
an early response and is seen even when blood pressure is not critically low.
An increased heart rate and respiratory rate will compensate for the low
blood pressure and maintain oxygen saturations and perfusion. The client
may not be able to compensate for long, and decreased oxygenation and
cool, clammy skin will occur later.
-A nurse assesses a client after administering a prescribed beta blocker.
Which assessment should the nurse expect to find?
a.Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg
b.Respiratory rate decreased from 25 breaths/min to 14 breaths/min
c.Oxygen saturation increased from 88% to 96%
d.Pulse decreased from 100 beats/min to 80 beats/min - -ANS: D
Beta blockers block the stimulation of beta1-adrenergic receptors. They
block the sympathetic (fight-or-flight) response and decrease the heart rate
(HR). The beta blocker will decrease HR and blood pressure, increasing
ventricular filling time. It usually does not have effects on beta2-adrenergic
receptor sites. Cardiac output will drop because of decreased HR.
-A nurse assesses clients on a medical-surgical unit. Which client should the
nurse identify as having the greatest risk for cardiovascular disease?
a.An 86-year-old man with a history of asthma
b.A 32-year-old Asian-American man with colorectal cancer
c.A 45-year-old American Indian woman with diabetes mellitus
d.A 53-year-old postmenopausal woman who is on hormone therapy - -ANS:
C
The incidence of coronary artery disease and hypertension is higher in
American Indians than in whites or Asian Americans. Diabetes mellitus
increases the risk for hypertension and coronary artery disease in people of
any race or ethnicity. Asthma, colorectal cancer, and hormone therapy do
not increase risk for cardiovascular disease.
, -A nurse assesses an older adult client who has multiple chronic diseases.
The client's heart rate is 48 beats/min. Which action should the nurse take
first?
a.Document the finding in the chart.
b.Initiate external pacing.
c.Assess the client's medications.
d.Administer 1 mg of atropine. - -ANS: C
Pacemaker cells in the conduction system decrease in number as a person
ages, resulting in bradycardia. The nurse should check the medication
reconciliation for medications that might cause such a drop in heart rate,
then should inform the health care provider. Documentation is important, but
it is not the priority action. The heart rate is not low enough for atropine or
an external pacemaker to be needed.
-An emergency room nurse obtains the health history of a client. Which
statement by the client should alert the nurse to the occurrence of heart
failure?
a." I get short of breath when I climb stairs."
b." I see halos floating around my head."
c." I have trouble remembering things."
d." I have lost weight over the past month." - -ANS: A
Dyspnea on exertion is an early manifestation of heart failure and is
associated with an activity such as stair climbing. The other findings are not
specific to early occurrence of heart failure.
-A nurse obtains the health history of a client who is newly admitted to the
medical unit. Which statement by the client should alert the nurse to the
presence of edema?
a." I wake up to go to the bathroom at night."
b." My shoes fit tighter by the end of the day."
c." I seem to be feeling more anxious lately."
d." I drink at least eight glasses of water a day." - -ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This
is known as edema. The nurse should note whether the client feels that his
or her shoes or rings are tight, and should observe, when present, an
indentation around the leg where the socks end. The other answers do not
describe edema.
-A nurse assesses an older adult client who is experiencing a myocardial
infarction. Which clinical manifestation should the nurse expect?
a.Excruciating pain on inspiration
b.Left lateral chest wall pain
c.Disorientation and confusion
d.Numbness and tingling of the arm - -ANS: C
In older adults, disorientation or confusion may be the major manifestation of
myocardial infarction caused by poor cardiac output. Pain manifestations and
,numbness and tingling of the arm could also be related to the myocardial
infarction. However, the nurse should be more concerned about the new
onset of disorientation or confusion caused by decreased perfusion
-A nurse assesses a client 2 hours after a cardiac angiography via the left
femoral artery. The nurse notes that the left pedal pulse is weak. Which
action should the nurse take?
a.Elevate the leg and apply a sandbag to the entrance site.
b.Increase the flow rate of intravenous fluids.
c.Assess the color and temperature of the left leg. d.Document the finding as
" left pedal pulse of +1/4." - -ANS: C
Loss of a pulse distal to an angiography entry site is serious, indicating a
possible arterial obstruction. The pulse may be faint because of edema. The
left pulse should be compared with the right, and pulses should be compared
with previous assessments, especially before the procedure. Assessing color
(pale, cyanosis) and temperature (cool, cold) will identify a decrease in
circulation. Once all peripheral and vascular assessment data are acquired,
the primary health care provider should be notified. Simply documenting the
findings is inappropriate. The leg should be positioned below the level of the
heart or dangling to increase blood flow to the distal portion of the leg.
Increasing intravenous fluids will not address the client's problem.
-A nurse assesses a client who is recovering after a left-sided cardiac
catheterization. Which assessment finding requires immediate intervention?
a.Urinary output less than intake
b.Bruising at the insertion site
c.Slurred speech and confusion
d.Discomfort in the left leg - -ANS: C
A left-sided cardiac catheterization specifically increases the risk for a
cerebral vascular accident. A change in neurologic status needs to be acted
on immediately. Discomfort and bruising are expected at the site. If intake
decreases, a client can become dehydrated because of dye excretion. The
second intervention would be to increase the client's fluid status. Neurologic
changes would take priority.
-A nurse assesses a client who is scheduled for a cardiac catheterization.
Which assessment should the nurse complete prior to this procedure?
a.Client's level of anxiety
b.Ability to turn self in bed
c.Cardiac rhythm and heart rate
d.Allergies to iodine-based agents - -ANS: D
Before the procedure, the nurse should ascertain whether the client has an
allergy to iodine-containing preparations, such as seafood or local
anesthetics. The contrast medium used during the procedure is iodine based.
This allergy can cause a life-threatening reaction, so it is a high priority.
, Second, it is important for the nurse to assess anxiety, mobility, and baseline
cardiac status.
-A nurse cares for a client who is prescribed magnetic resonance imaging
(MRI) of the heart. The client's health history includes a previous myocardial
infarction and pacemaker implantation. Which action should the nurse take?
a.Schedule an electrocardiogram just before the MRI. b.Notify the health care
provider before scheduling the MRI.
c.Call the physician and request a laboratory draw for cardiac enzymes.
d.Instruct the client to increase fluid intake the day before the MRI. - -ANS: B
The magnetic fields of the MRI can deactivate the pacemaker. The nurse
should call the health care provider and report that the client has a
pacemaker so the provider can order other diagnostic tests. The client does
not need an electrocardiogram, cardiac enzymes, or increased fluids.
-A nurse assesses a client who is recovering from a myocardial infarction.
The client's pulmonary artery pressure reading is 25/12 mm Hg. Which action
should the nurse take first?
a.Compare the results with previous pulmonary artery pressure readings.
b.Increase the intravenous fluid rate because these readings are low.
c.Immediately notify the health care provider of the elevated pressures.
d.Document the finding in the client's chart as the only action. - -ANS: A
Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic
and from 5 to 15 mm Hg for diastolic. Although this client's readings are
within normal limits, the nurse needs to assess any trends that may indicate
a need for medical treatment to prevent complications. There is no need to
increase intravenous fluids or notify the provider.
-A nurse cares for a client who has an 80% blockage of the right coronary
artery (RCA) and is scheduled for bypass surgery. Which intervention should
the nurse be prepared to implement while this client waits for surgery?
a.Administration of IV furosemide (Lasix)
b.Initiation of an external pacemaker
c.Assistance with endotracheal intubation
d.Placement of central venous access - -ANS: B
The RCA supplies the right atrium, the right ventricle, the inferior portion of
the left ventricle, and the atrioventricular (AV) node. It also supplies the
sinoatrial node in 50% of people. If the client totally occludes the RCA, the
AV node would not function and the client would go into heart block, so
emergency pacing should be available for the client. Furosemide, intubation,
and central venous access will not address the primary complication of RCA
occlusion, which is AV node malfunction.
-A nurse teaches a client with diabetes mellitus and a body mass index of 42
who is at high risk for coronary artery disease. Which statement related to
nutrition should the nurse include in this client's teaching?
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