Deck 37: Circulation Perfusion

Question 1

A client diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the client?
1)Blood pressure (BP) will be lower than 135/85 mm Hg on all occasions.
2)BP will be normal after 2 to 3 weeks on medication.
3)Client will not experience dizziness on rising.
4)Urine output will increase to at least 50 mL/hr.

Answer 1

1

Question 2

A client with heart failure has BP 120/60 mm Hg, heart rate (HR) 64 beats/min, respiratory rate (RR) 18 breaths/min, temperature (T) 97.6°F, coarse crackles bilaterally, and 3+ edema to the lower extremities. An appropriate nursing diagnosis for this client is:
1)Impaired Gas Exchange
2)Excess Fluid Volume
3)Ineffective Tissue Perfusion
4)Deficient Knowledge

Answer 2

2

Question 3

The nurse is reviewing the results of the client's laboratory findings and notes an elevated C-reactive protein (CRP) level. What does this indicate?
1)The client had a myocardial infarction.
2)The client has inflammation in the body.
3)The client has reduced cardiac output.
4)The client's diet is high in cholesterol.

Answer 3

2

Question 4

The nurse is preparing the nursing care plan for a middle-aged client admitted to the intensive care unit for acute myocardial infarction. The client's symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate?
1)Decreased Cardiac Output
2)Impaired Tissue Perfusion
3)Impaired Cardiac Contractility
4)Impaired Activity Tolerance

Question 5

The nurse is providing teaching for a weight loss group on the cardiac dangers of obesity. Which statement, if made by the nurse, would be incorrect?
1)"Obesity increases the risk of atherosclerosis."
2)"Obesity increases the risk of hypertension."
3)"Obesity can reduce pumping action of the heart."
4)"Obesity can diminish tissue perfusion."

Question 6

The nurse is assessing an adult client diagnosed with chronic heart failure 10 years ago. Which finding would indicate poor perfusion to the tissues?
1)Blood pressure reading of 102/64 mm Hg
2)Absence of hair on the lower legs and feet
3)Pulse rate of 104 beats/min
4)Shortness of breath when supine

Question 7

The nurse is planning care for an elderly client diagnosed with end-stage heart failure and a nursing diagnosis of Decreased Cardiac Output secondary to ineffective left ventricular function. What outcome would the nurse plan for this client to measure improvement in cardiac output?
1)Brisk capillary refill in feet bilaterally
2)Heart rate within expected range
3)Breath sounds clear with no shortness of breath
4)Regular pulse rhythm

Question 8

The nurse administers sublingual nitroglycerine to a client diagnosed with angina. When the client's chest pain is not relieved, the nurse prepares to give another nitroglycerine tablet. What is the nurse's priority action prior to administering the next dose of medication?
1)Notify the physician.
2)Elevate the head of the bed.
3)Measure the client's blood pressure.
4)Place the client on a cardiorespiratory monitor.

Question 9

The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the client comprehends the teaching when she makes the following statement:
1)"I may need to drink more fluids to make more oxygen."
2)"I may need to take an iron supplement so that I am not anemic."
3)"I will need a multivitamin supplement for several months."
4)"I will need to eat more fruits and vegetables."

Question 10

The nurse is assessing a client and asks if they have any chronic stress. The client wants to know how chronic stress affects the body. The nurse responds that when the body is under stress, it releases a chemical that increases the heart rate and the tendency of the blood to clot. Which of the following chemicals is the nurse discussing?
1)Histamine
2)Catecholamines
3)Cortisol
4)Protease

Question 11

For which client might the nurse use the nursing diagnosis Risk for Ineffective Renal Tissue Perfusion?
1)The client with hypertension who is noncompliant with medication administration
2)The client with angina who takes nitroglycerine when experiencing chest pain
3)The client diagnosed with pneumonia, becoming short of breath with activity
4)The client with a hemorrhagic stroke secondary to head trauma

Question 12

The nurse administers a beta-adrenergic agent to a client with congestive heart failure. What assessment findings would indicate that the drug is working?
1)Heart rate changes from 92 beats/min to 76 beats/min.
2)Cardiac monitor shows narrowing of the QRS segment.
3)Statements of tingling in the fingers and toes.
4)Urine output has increased to equal input.

Question 13

The nurse is providing care to the client who complains of chest pains after a large meal and after strenuous exercise. What is the most appropriate nursing intervention with this client's pain?
1)Immediately administer a vasodilator at the onset of the chest pain.
2)Have the client recognize triggers and keep a log of any symptoms.
3)Obtain CRP and a venogram to rule out myocardial infarction.
4)Prepare the client for emergency cardiac catheterization.

Question 14

The client diagnosed with inadequate closure of the mitral valve is scheduled for surgery and asks the nurse, "Why does it matter if my valve leaks?" What is the nurse's best response to explain why this mitral valve needs to be repaired?
1)"Blood backflows from the left ventricle to the left atrium, reducing available blood flowing to the body."
2)"Blood backflows from the right ventricle to the right atrium, reducing available blood flow to the lungs."
3)"Blood backflows from the aorta into the left ventricle, reducing blood pressure and causing dizziness."
4)"Blood backflows from the pulmonary artery into the right ventricle, reducing blood flow to the lungs."

Question 15

The nurse analyzes the client's electrocardiogram (ECG) and compares it with a baseline ECG recorded before the client began having chest pain. What finding indicates a problem with the ventricle?
1)Prolonged QRS segment
2)Elevated P wave
3)Absence of T wave
4)Prolonged P-R interval

Question 16

A nurse is performing CPR on an infant. When performing chest compressions, the nurse understands that the compression rate should be at least:
1)60 times a minute
2)80 times a minute
3)100 times a minute
4)120 times a minute

Question 17

The nurse is caring for a client with reduced perfusion to the extremities. The nurse evaluates the client and finds the response to therapy is not optimal. What lifestyle change does the nurse suspect is contributing to the lack of response?
1)Following a vegetarian diet
2)Taking daily brisk walks
3)Ingesting 1,500 mL of fluid per day
4)Smoking cessation when the diagnosis was received

Question 18

The nurse is assessing a client who is complaining of chest pain, clutching his chest, and short of breath. Which assessment question would be appropriate for the nurse to ask?
1)"Please describe your pain, its location, and what you've done to treat it."
2)"Does the pain radiate to your arm, jaw, or shoulder?"
3)"What are your current medications, including supplements or vitamins?"
4)"What is your medical history, beginning with most recent?"

Question 19

The nurse is providing care to the client who is 3 days status post cardiac bypass grafting. The client has incisions to his right leg from the graft harvest of the veins. The client complains of warmth and tenderness to their right calf. The nurse notes a 3-cm periwound, with erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the client has what kind of complication?
1)Deep vein thrombosis (DVT)
2)Dehiscence of the wound
3)Internal bleeding
4)Infection at the incisional site

Question 20

The nurse plans to maintain hydration for the client at risk for thrombus formation. What evaluation finding is an indicator that the intervention is successful?
1)The client denies pain in the lower legs.
2)The client denies chest pain or difficulty breathing.
3)Urine output exceeds 1,500 mL per 24-hour period.
4)There is a weight gain of 5 pounds within 24 hours.

Question 21

As the nurse caring for a client who has suffered myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Select all that apply.
1)Decreased heart rate
2)Increased heart rate
3)Decreased cardiac output
4)Decreased strength of ventricular contractions
5)Increased peripheral edema

Question 22

The nurse is assessing a healthy older client who has comes to the health clinic because she reports not feeling like herself. The client complains of increased fatigue when walking up stairs and performing normal household activities. What are normal physiological changes in the cardiovascular system that occur with aging? Select all that apply.
1)Cardiac contractile strength is reduced.
2)Heart valves become more rigid.
3)Peripheral vessels lose elasticity.
4)Heart responds to increased oxygen demands.
5)Sympathetic nervous system decreases.

Question 23

The nurse is preparing client teaching for a client diagnosed with peripheral edema secondary to right-sided heart failure. What intervention will promote circulation and reduce edema in the lower extremities?
1)Encourage frequent ambulation.
2)Administer antihypertensive medications.
3)Encourage vigorous exercise for 30 minutes a day.
4)Administer oxygen when the client is short of breath.

Question 24

The nurse is assessing a young adult client in the allergy clinic. The nurse recognizes that an allergic reaction will cause which of the following cardiac events? Select all that apply.
1)Erythema of the affected areas
2)Rhinitis and runny eyes
3)Swelling of the area
4)Pruritus and hives
5)Bradycardia

Question 25

Which of the following medications would the nurse expect to be included in the treatment of a client with congestive heart failure (CHF)? Select all that apply.
1)Nitrates
2)Beta-adrenergic agents
3)Anticoagulants
4)Diuretics
5)Statins

Question 26

The nurse is assessing the client's home medication and note that although the client denies hypertension, there are several antihypertensive medications. Which of the following medications lower blood pressure? Select all that apply.
1)Atenolol
2)Digoxin
3)Lisinopril
4)Nifedipine
5)Warfarin