a nurse assesses a client who had a myocardial inf
a nurse assesses a client after administering a pr
a nurse assesses clients on a medical surgical uni
a nurse assesses an older ad
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Excelsior College
NURSING 211
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Nursing 211 Exam 1
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
A
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
D
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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
C
,A nurse assesses an older adult client who has multiple chronic diseases. The clients 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 clients medications.
d. Administer 1 mg of atropine
C
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.
A
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.
B
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
C
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.
C
,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
C
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment
should the nurse complete prior to this procedure?
a. Clients level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents
D
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The
clients 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.
B
A nurse assesses a client who is recovering from a myocardial infarction. The clients 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 clients chart as the only action.
A
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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
B
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
clients teaching?
a. The best way to lose weight is a high-protein, low-carbohydrate diet.
b. You should balance weight loss with consuming necessary nutrients.
c. A nutritionist will provide you with information about your new diet.
d. If you exercise more frequently, you wont need to change your diet.
B
A nurse cares for a client who has advanced cardiac disease and states, I am having trouble
sleeping at night. How should the nurse respond?
a. I will consult the provider to prescribe a sleep study to determine the problem.
b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help.
c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at
night.
d. Use pillows to elevate your head and chest while you are sleeping.
D
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will
need to stop eating so much chili to keep that indigestion pain from returning. How should the
nurse respond?
a. Chili is high in fat and calories; it would be a good idea to stop eating it.
b. The provider has prescribed an antacid for you to take every morning.
c. What do you understand about what happened to you?
d. When did you start experiencing this indigestion?
C
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I
might die. How should the nurse respond?
a. This is a routine surgery and the risk of death is very low.
b. Would you like to speak with a chaplain prior to surgery?
c. Tell me more about your concerns about the surgery.
d. What support systems do you have to assist you?
C
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