1. :Question -50
Postoperatively, a nurse is caring for a client
who had a percutaneous insertion of an
inferior vena cava filter and was on heparin
therapy before surgery. The nurse would
inspect the surgical site most closely for
?evidence of which of the following
:Options
Bleeding and infection . 1
Thrombosis and infection . 2
Bleeding and wound dehiscence . 3
Wound dehiscence and evisceration . 4
:Answer
. 1
:Rationale
After inferior vena cava filter insertion, the
nurse inspects the surgical site for bleeding
and signs and symptoms of infection.
Otherwise, care is the same as for any other
.postoperative client
:Question -51
A client with angina has a 12- lead
electrocardiogram taken during an episode of
chest pain . A nurse examines the tracing for
which electrocardiographic change caused by
:myocardial ischemia? Options
Tall peaked T waves . 1
Prolonged PR interval . 2
Widened QRS complex . 3
ST segment elevation or depression . 4
:Answer
. 4

2. :Rationale
An electrocardiogram taken during a chest
pain episode captures ischemic changes,
which include ST segment elevation or
depression. Tall, peaked T waves may
indicate hyperkalemia. A prolonged PR
interval indicates first-degree heart block. A
widened QRS complex indicates delay in
intraventricular conduction, such as a bundle
.branch block
:Question -52
A client is scheduled for a dipyridamole
(Persantine) thallium -201 scan . A nurse
would assess to make sure that the client
avoided which of the following before the
?procedure
:Options
Caffeine . 1
Fatty meal . 2
Excess sugar . 3
Milk products . 4
:Answer
. 1
:Rationale
This test is an alternative to the exercise
thallium -201 scan . Dipyridamole
(Persantine) dilates the coronary arteries as
exercise would. Before the procedure, any
form of caffeine should be withheld, as
should bronchodilators such as theophylline.
Theophylline may decrease the effects of
dipyridamole. The client does not have to

3. avoid the items identified in options 2 , 3 ,
. and 4
:Question -53
A nurse is assessing the neurovascular status
of a client who returned to the surgical
nursing unit 4 hours ago after undergoing
aortoiliac bypass graft. The affected leg is
warm, and the nurse notes redness and
edema. The pedal pulse is palpable and
unchanged from admission. How would the
nurse correctly interpret the client ’s
?neurovascular status
:Options
The neurovascular status is normal . 1
because of increased blood flow through the
.leg
The neurovascular status is moderately . 2
.impaired, and the surgeon should be called
The neurovascular status is slightly . 3
deteriorating and should be monitored for
.another hour
The neurovascular status is adequate . 4
from an arterial approach, but venous
.complications are arising
:Answer
. 1
:Rationale
An expected outcome of surgery is warmth,
redness, and edema in the surgical extremity
because of increased blood flow . Therefore ,
options 2 , 3 , and 4 are incorrect
. interpretations

4. :Question -54
A nurse is assessing the neurovascular status
of a client who returned to the surgical
nursing unit 4 hours ago after undergoing
aortoiliac bypass graft. The affected leg is
warm, and the nurse notes redness and
edema. The pedal pulse is palpable and
unchanged from admission. How would the
nurse correctly interpret the client ’s
?neurovascular status
:Options
The neurovascular status is normal . 1
because of increased blood flow through the
.leg
The neurovascular status is moderately . 2
.impaired, and the surgeon should be called
The neurovascular status is slightly . 3
deteriorating and should be monitored for
another hour. 4 . The neurovascular status is
adequate from an arterial approach, but
.venous complications are arising
:Answer
. 1
:Rationale
An expected outcome of surgery is warmth,
redness, and edema in the surgical extremity
because of increased blood flow . Therefore ,
options 2 , 3 , and 4 are incorrect
. interpretations
:Question -55
A nurse is evaluating the condition of a client
after pericardiocentesis performed to treat

5. cardiac tamponade. Which of the following
observations would indicate that the
:procedure was unsuccessful? Options
Rising blood pressure . 1
Clearly audible heart sounds . 2
Client expressions of relief . 3
Rising central venous pressure . 4
:Answer
. 4
:Rationale
Following pericardiocentesis, a rise in blood
pressure and a fall in central venous pressure
are expected. The client usually expresses
immediate relief. Heart sounds are no longer
.muffled or distant
:Question -56
A nurse is assessing a client with an
abdominal aortic aneurysm. Which of the
following assessment findings by the nurse is
?probably unrelated to the aneurysm
:Options
Pulsatile abdominal mass . 1
Hyperactive bowel sounds in the area . 2
Systolic bruit over the area of the mass . 3
Subjective sensation of “heart beating . 4
”in the abdomen
:Answer
. 2
:Rationale
Not all clients with abdominal aortic
aneurysm exhibit symptoms. Those who do
may describe a feeling of the “heart beating

6. ”in the abdomen when supine or being able to
feel the mass throbbing. A pulsatile mass may
be palpated in the middle and upper abdomen.
A systolic bruit may be auscultated over the
mass. Hyperactive bowel sounds are not
related specifically to an abdominal aortic
.aneurysm
:Question -57
A nurse is caring for a client who had a
resection of an abdominal aortic aneurysm
yesterday. The client has an intravenous
infusion with a rate of 150 mL/hr, unchanged
for the last 10 hours . The client ’s urine
output for the last 3 hours was 90 , 50 , and
28 mL (28 mL most recent). The client ’s
blood urea nitrogen level is 35 mg/dL and
serum creatinine level is 1.8 mg/dL ,
measured this morning . Which of the
?following actions should the nurse take next
:Options
.Call the physician . 1
.Check the urine specific gravity . 2
Check to see if the client had a sample . 3
.for serum albumin level drawn
Put the intravenous line on a pump so . 4
.that the infusion rate is sure to stay stable
:Answer
. 1
:Rationale
Following abdominal aortic aneurysm
resection or repair, the nurse monitors the

7. client for signs of renal failure. Renal failure
can occur because often much blood is lost
during the surgery and, depending on the
aneurysm location, the renal arteries may be
hypoperfused for a short period during
surgery. The nurse monitors hourly intake
and output and notes the results of daily
blood urea nitrogen and creatinine levels .
Urine output lower than 30 to 50 mL/hr is
. reported to the physician
:Question -58
A client is admitted to the hospital with a
venous stasis leg ulcer. Which of the
following characteristics would be an
?expected finding of this type of ulcer
:Options
Pale-colored base . 1
Deep, with even edges . 2
Has little granulation tissue . 3
Has brown pigmentation surrounding it . 4
:Answer
. 4
:Rationale
Venous leg ulcers, also called stasis ulcers,
tend to be more superficial than arterial
ulcers, and the ulcer bed is pink. The edges
of the ulcer are uneven, and granulation
tissue is evident. The skin has a brown
pigmentation from accumulation of metabolic
waste products resulting from venous stasis.
.The client also exhibits peripheral edema
:Question -59

8. A home care nurse is making a routine visit
to a client receiving digoxin (Lanoxin) in the
treatment of heart failure. The nurse would
particularly assess the client for which of the
?following
:Options
Diarrhea and hypotension . 1
Fatigue and muscle twitching . 2
Thrombocytopenia and weight gain . 3
Anorexia, nausea, and visual . 4
disturbances
:Answer
. 4
:Rationale
The first signs and symptoms of digoxin
toxicity in adults include abdominal pain,
nausea, vomiting, visual disturbances
(blurred, yellow, or green vision, halos
around lights), bradycardia, and other
dysrhythmias . Options 1 , 2 , and 3 are
. unrelated to digoxin therapy
:Question -60
Cardiac magnetic resonance imaging (MRI) is
prescribed for a client. The nurse identifies
that which of the following is a
contraindication for performance of this
?diagnostic study
:Options
.Client has a pacemaker . 1
.Client is allergic to iodine . 2
.Client has diabetes mellitus . 3
.Client has a biological porcine valve . 4

9. :Answer
. 1
:Rationale
The magnetic fields used for magnetic
resonance imaging (MRI) can deactivate the
pacemaker. Options 2 , 3 , and 4 are not
. contraindications for an MRI
:Question -61
A client with angina complains that the
anginal pain is prolonged and severe and
occurs at the same time each day, most often
at rest in the absence of precipitating
factors. How would the nurse best describe
?this type of anginal pain
:Options
Stable angina . 1
Variant angina . 2
Unstable angina . 3
Nonanginal pain . 4
:Answer
. 2
:Rationale
Variant angina, or Prinzmetal ’s angina, is
prolonged and severe and occurs at the same
time each day, most often at rest. Stable
angina is induced by exercise and relieved by
rest or nitroglycerin tablets. Unstable angina
occurs at lower and lower levels of activity
or at rest, is less predictable, and is often a
.precursor of myocardial infarction
:Question -62
Intravenous heparin therapy is ordered for a

10. client. While implementing this order, a nurse
ensures that which of the following
?medications is available on the nursing unit
:Options
Protamine sulfate . 1
Potassium chloride . 2
(Aminocaproic acid (Amicar . 3
(Vitamin K (AquaMEPHYTON . 4
:Answer
. 1
:Rationale
The antidote to heparin is protamine sulfate;
it should be readily available for use if
excessive bleeding or hemorrhage should
occur. Vitamin K is an antidote for warfarin
sodium. Aminocaproic acid is the antidote for
thrombolytic therapy. Potassium chloride is
.administered for a potassium deficit
:Question -63
A client is at risk for pulmonary embolism
and is on anticoagulant therapy with warfarin
sodium (Coumadin). The client ’s prothrombin
time is 20 seconds , with a control of 11
seconds . How would the nurse interpret
?these results
:Options
.Client needs to have test repeated . 1
Client results are within the therapeutic . 2
.range
Client results are higher than the . 3
.therapeutic range
Client results are lower than the needed . 4

11. .therapeutic level
:Answer
. 2
:Rationale
The therapeutic range for prothrombin time is
1.5 to 2 times the control for clients at high
risk for thrombus . Based on the client ’s
control value , the therapeutic range for this
individual would be 16.5 to 22 seconds .
Therefore the result is within the therapeutic
. range
:Question -64
A client who has been receiving heparin
therapy also is started on warfarin sodium
(Coumadin). The client asks a nurse why both
medications are being administered. Which of
the following statements reflects appropriate
?teaching by the nurse
:Options
Warfarin sodium stimulates production of . 1
the body ’s own thrombolytic substances , but
.it takes 2 to 4 days for this to begin
Warfarin sodium stimulates breakdown of . 2
specific clotting factors by the liver, and it
takes 2 to 3 days for this to exert an
.anticoagulant effect
Warfarin sodium inhibits synthesis of . 3
specific clotting factors in the liver, and it
takes 3 to 4 days for this medication to exert
.an anticoagulant effect
Warfarin sodium has the same mechanism . 4
of action as heparin, and the crossover time

12. is needed for the serum level of warfarin
.sodium to be therapeutic
:Answer
. 3
:Rationale
Warfarin sodium works in the liver and
inhibits synthesis of four vitamin K-
dependent clotting factors (X, IX , VII , and II
) , but it takes 3 to 4 days before the
.. therapeutic effect of warfarin is exhibited
:Question -65
A client is receiving thrombolytic therapy
with a continuous infusion of streptokinase
(Streptase). The client suddenly becomes
extremely anxious and complains of itching.
A nurse hears stridor and on examination of
the client notes generalized urticaria and
hypotension. Which of the following should be
?the priority action of the nurse
:Options
Administer oxygen and protamine . 1
.sulfate
.Stop the infusion and call the physician . 2
Cut the infusion rate in half and sit the . 3
.client up in bed
Administer diphenhydramine (Benadryl) . 4
.and continue the infusion
:Answer
. 2
:Rationale
The client is experiencing an anaphylactic
reaction to streptokinase, which is allergenic.

13. The infusion should be stopped, the physician
notified, and the client treated with
epinephrine, antihistamines, and
.corticosteroids
:Question -66
A nurse has an order to begin administering
warfarin sodium (Coumadin) to a client. While
implementing this order, the nurse ensures
that which of the following medications is
available on the nursing unit as the antidote
?for warfarin sodium
:Options
Protamine sulfate . 1
Potassium chloride . 2
(Aminocaproic acid (Amicar . 3
(Vitamin K (AquaMEPHYTON . 4
:Answer
. 4
:Rationale
The antidote to warfarin sodium (Coumadin)
is vitamin K and should be readily available
for use if excessive bleeding or hemorrhage
occurs. Aminocaproic acid is the antidote for
thrombolytic agents. Protamine sulfate is the
antidote for heparin. Potassium chloride is
.administered to treat potassium deficit
:Question -67
A client is admitted with pulmonary embolism
and is to be treated with streptokinase
(Streptase). A nurse would report which of
the following assessments to the physician
:before initiating this therapy? Options

14. Adventitious breath sounds . 1
Temperature of 99.4° F orally . 2
Blood pressure of 198/110 mm Hg . 3
Respiratory rate of 28 breaths/min . 4
:Answer
. 3
:Rationale
Thrombolytic therapy is contraindicated in a
number of preexisting conditions in which
there is a risk of uncontrolled bleeding,
similar to the case in anticoagulant therapy.
Thrombolytic therapy also is contraindicated
in severe uncontrolled hypertension because
of the risk of cerebral hemorrhage.
Therefore, the nurse would report the results
of the blood pressure to the physician before
.initiating therapy
:Question -68
The client is brought into the emergency
room in ventricular fibrillation (VF). The
advanced cardiac life support (ACLS) nurse
prepares to defibrillate by placing conductive
?gel pads on which part of the chest
:Options
The upper and lower halves of the . 1
sternum
The right of the sternum, just below the . 2
clavicle and to the left of the precordium
The right shoulder and the back of the . 3
left shoulder
Parallel between the umbilicus and the . 4
right nipple

15. :Answer
. 2
:Rationale
The ACLS nurse would place one gel pad to
the right of the sternum just below the
clavicle and the other gel pad to the left of
the precordium. The nurse would then place
the electrode paddles over the pads. Options
. 1 , 3 , and 4 identify incorrect positions
:Question -69
The nurse has given discharge instructions to
the client who has undergone vein ligation
and stripping early in the day. The nurse
evaluates that the client understands activity
and positioning limitations if the client states
:that it is appropriate to
:Options
Lie down with the legs elevated and . 1
.avoid sitting
Cross the ankles at the ankle only, but . 2
.not at the knee
Sit in the chair 3 times a day for 3 hours . 3
. at a time
Walk upright for as much as possible . 4
.each day
:Answer
. 1
:Rationale
The client who has had vein ligation and
stripping should avoid standing or sitting for
prolonged periods. The client should remain
lying down unless performing a specific

16. activity for the first few days following the
procedure. Prolonged standing and sitting
increase the risk of edema in the legs by
decreasing blood return to the heart. The
client should avoid crossing the legs at any
level for the same
:Question -70
To perform cardiopulmonary resuscitation
(CPR), the nurse would use the method shown
in the Figure to open the airway in which of
?the following situations
:Options
In all situations requiring CPR . 1
If neck trauma is suspected . 2
If the client is unconscious . 3
If the client has a history of headaches . 4
:Answer
. 2
:Rationale
The jaw thrust without the head tilt maneuver
is used when head and/or neck trauma is
suspected. This maneuver opens the airway
while maintaining proper head and neck
alignment, thus reducing the risk of further
damage to the neck . Option 1 is incorrect .
In situations requiring CPR , the client will be
unconscious . Option 4 is also incorrect .
Additionally , it is unlikely that the nurse will
.be able to obtain these data
:Question -71
The client with heart disease is provided
instructions regarding a low-fat diet. The

17. nurse determines that the client understands
the diet if the client states that a food item
:to avoid is
:Options
.Apples . 1
.Oranges . 2
.Avocado . 3
.Cherries . 4
:Answer
. 3
:Rationale
Fruits and vegetables, except avocado,
olives, and coconut, contain minimal amounts
.of fat
:Question -72
A nurse is performing an assessment on a
client admitted to the hospital who was
diagnosed with toxic shock syndrome (TSS).
Which of the following assessment questions
would assist in eliciting more specific data
?regarding the cause of this syndrome
:Options
Have your menstrual periods been ” . 1
“ ?irregular
Do you use tampons during your ” . 2
“ ?menstrual period
Have you been consuming a high intake ” . 3
“ ?of green leafy vegetables
Did you start your menses at an early ” . 4
“ ?age
:Answer
. 2

18. :Rationale
TSS is caused by infection and is often
associated with tampon use. Disseminated
intravascular coagulation is a complication of
TSS . Options 1 , 3 , and 4 are unrelated to
. the etiology of TSS
:Question -73
A nurse is monitoring a client with acute
pericarditis for signs of cardiac tamponade.
Which assessment finding would indicate the
?presence of this complication
:Options
A pulse rate of 60 beats/min . 1
Flat neck veins . 2
Muffled or distant heart sounds . 3
A blood pressure (BP) of 128/82 mm Hg . 4
. Answer: 3
:Rationale
Assessment findings associated with cardiac
tamponade include tachycardia, distant or
muffled heart sounds, jugular vein distention,
and a falling blood pressure accompanied by
pulsus paradoxus (a drop in inspiratory BP
greater than 10 mm Hg). Bradycardia is not a
. sign of cardiac tamponade
:Question -74
A home care nurse is providing instructions
to a client with an arterial ischemic leg ulcer
about home care management and self-care
management. Which statement if made by the
client indicates a need for further
?instruction

19. :Options
I need to be sure not to go barefoot ” . 1
“ .around the house
I need to be sure that I elevate my leg ” . 2
above my heart level for at least an hour
every day. ”3 . “If I cut my toenails I need to
“ .be sure that I cut them straight across
It is all right to apply lanolin to my feet, ” . 4
“ .but I shouldn ’t place it between my toes
:Answer
. 2
:Rationale
Foot care instructions for the client with
peripheral arterial disease are the same
instructions as those for a client with
diabetes mellitus. The client with arterial
disease, however, should avoid raising the
legs above the level of the heart unless
instructed to do so as part of an exercise
program, such as Buerger- Allen exercises,
.or unless venous stasis is also present
:Question -75
A clinic nurse is providing instructions to a
client with hypertension who will be taking
captopril (Capoten). Which statement by the
client indicates a need for further
?instruction
:Options
I need to drink increased amounts of ” . 1
“ .water
“ .I need to change positions slowly ” . 2
I need to avoid taking hot baths or ” . 3

20. “ .showers
I need to sit down and rest if dizziness ” . 4
“ .or lightheadedness occurs
:Answer
. 1
:Rationale
Captopril is an antihypertensive medication
(angiotension-converting enzyme inhibitor).
Orthostatic hypotension can occur in clients
taking this medication. Clients are advised to
avoid standing in one position for long
periods of time, to change positions slowly,
and to avoid extreme warmth such as with
baths, showers, or heat from the sun in warm
weather. The client should be instructed to
monitor for signs of orthostatic hypotension
such as dizziness, lightheadedness,
weakness, and syncope. An increased intake
of water could actually aggravate the
.hypertension
:Question -76
A nurse is providing instructions regarding
high-sodium food items to avoid to a client
with a diagnosis of hypertension. The nurse
:instructs the client to avoid
:Options
Cantaloupe . 1
Broccoli . 2
Mineral water . 3
Bananas . 4
:Answer
. 3

21. :Rationale
The sodium level can increase by the use of
several types of products including
toothpaste and mouthwash; over-the-counter
medications such as analgesics, antacids,
laxatives, and sedatives; and softened water,
as well as some mineral water. Clients are
instructed to read labels for sodium content.
Water that is bottled, distilled, deionized, and
demineralized may be used for drinking and
cooking. Fresh fruits and vegetables are low
in sodium. The client would avoid consuming
.mineral water
:Question -77
A home care nurse is visiting a client to
provide follow-up evaluation and care of a
leg ulcer. On removing the dressing from the
leg ulcer, the nurse notes that the ulcer is
pale and deep and that the surrounding tissue
is cool to touch. The nurse should document
that these findings identify which type of
?ulcer
:Options
A vascular ulcer . 1
A venous stasis ulcer . 2
An arterial ulcer . 3
A stage 1 ulcer . 4
:Answer
. 3
:Rationale
Arterial ulcers have a pale, deep base and
are surrounded by tissue that is cool with

22. trophic changes such as dry, skin and loss of
hair. Arterial ulcers are caused by tissue
ischemia from inadequate arterial supply of
oxygen and nutrients. A venous stasis ulcer
is one that has a dark red base and is
surrounded by brown skin with local edema.
This type of ulcer is caused by the
accumulation of waste products of metabolism
that are not cleared , as a result of venous
congestion . A stage 1 ulcer indicates a
.reddened area with an intact skin surface
:Question -78
A nurse is developing a plan of care for a
client who will be admitted to the hospital
with a diagnosis of deep vein thrombosis
(DVT) of the right leg. The nurse develops
the plan expecting that the physician will
?prescribe which of the following
:Options
Maintain the affected leg in a dependent . 1
.position
Apply cool packs to the affected leg for . 2
. 20 minutes every 4 hours
.Maintain bedrest . 3
Administer a opioid analgesic every 4 . 4
. hours around the clock
:Answer
. 3
:Rationale
Standard management for the client with DVT
includes bed rest for 5 to 7 days , limb

23. elevation , relief of discomfort with warm
moist heat, and analgesics as needed.
Ambulation is contraindicated because such
activity can cause the thrombus to dislodge
and travel to the lungs. Opioid analgesics are
not required to relieve pain, and pain
normally is relieved with acetaminophen
.((Tylenol
:Question
A client with a diagnosis of varicose veins is
scheduled for treatment by sclerotherapy and
asks the nurse to describe the procedure.
The appropriate nursing response is which of
?the following
:Options
It involves tying off the veins to ” . 1
prevent sluggishness of blood from
“ .occurring
It involves tying off the veins so that ” . 2
“ .circulation is redirected in another area
It involves surgically removing the ” . 3
“ .varicosity, so anesthesia will be required
It involves injecting an agent into the ” . 4
.vein to damage the vein wall and close it off
“
:Answer
. 4
:Rationale
Sclerotherapy is the injection of a sclerosing
agent into a varicosity. The agent damages
the vessel and causes aseptic thrombosis that
results in vein closure. With no blood flow

24. through the vessel, distention will not occur.
The surgical procedure for varicose veins is
vein ligation and stripping. This procedure
involves tying off the varicose vein and large
tributaries and then removal of the vein with
the use of a hook and wires applied through
.multiple small incisions in the leg
:Question -80
A female client calls the nurse at the clinic
and reports that ever since the vein ligation
and stripping procedure was performed, she
has been experiencing a sensation as though
the affected leg is falling asleep. Which
?response to the client is appropriate
:Options
Keep the leg elevated as much as ” . 1
“ .possible
“ .Apply warm packs to the leg ” . 2
This normally occurs after surgery and ” . 3
“ .will subside when the edema goes down
Contact your physician right away to ” . 4
“ .report this problem
:Answer
. 4
:Rationale
A sensation of pins and needles, or feeling as
though the surgical limb is falling asleep, may
indicate temporary or permanent nerve
damage after surgery. The saphenous vein
and the saphenous nerve run close together,
and damage to the nerve will produce

25. paresthesias . Options 1 , 2 , and 3 are
.inaccurate responses
:Question -81
A nurse in the emergency department is
caring for a client who was in a motor vehicle
accident and is experiencing hypovolemic
shock. A pneumatic antishock garment
(PASG) is applied for treatment until the
client can be transferred to the intensive
care unit (ICU). While awaiting client transfer
to the ICU, the emergency department nurse
?performs which critical assessment
:Options
Monitoring hemoglobin and hematocrit . 1
levels
Monitoring vascular status of the lower . 2
extremities
Assessing radial pulses . 3
Assessing vascular status of the upper . 4
extremities
:Answer
. 2
:Rationale
A PASG may be useful in the treatment of
hypovolemic shock associated with traumatic
injury to provide circulatory assistance. The
device is used only as a temporary measure
until definitive treatment is given because it
can compromise blood flow to the lower half
of the body. The critical nursing assessment
includes monitoring the vascular status of the
lower extremities . Although options 1 , 3 ,

26. and 4 may be components of the nursing
assessment , these actions are not part of the
critical assessment required with use of a
.PASG
:Question -82
A left atrial catheter is inserted into a client
during cardiac surgery. The nurse is
monitoring the left atrial pressure (LAP) and
documents that the pressure is normal if
?which of the following LAP values is noted
:Options
mm Hg 8 . 1
mm Hg 15 . 2
mm Hg 25 . 3
mm Hg 32 . 4
:Answer
. 1
:Rationale
The normal LAP is 1 to 10 mm Hg . Because
the left atrium does not generate significant
pressure during atrial contraction, the atrial
pressure is recorded as an average (mean)
pressure, rather than as a systolic or
diastolic pressure . Options 2 , 3 , and 4 are
. incorrect
:Question -83
A female client is at risk for developing
disseminated intravascular coagulopathy
(DIC). On reviewing the laboratory test
results for this client, the nurse determines
that the fibrinogen level is normal if which of

27. the following values is noted on the
?laboratory report
:Options
mg/dL 180 . 1
mg/dL 400 . 2
mg/dL 480 . 3
mg/dL 500 . 4
:Answer
. 2
:Rationale
The normal fibrinogen level is 180 to 340 mg/
dL for males and 190 to 420 mg/dL for
females . A critical value is one that is less
than 100 mg/dL . With DIC , the fibrinogen
level drops because fibrinogen is used up in
the clotting process . Option 2 is the only
. option that identifies a normal level
:Question -84
A nurse is preparing discharge instructions
for a client with Raynaud ’s disease. The
:nurse plans to tell the client to
:Options
Stop smoking because it causes . 1
.cutaneous vasospasm
Always wear warm clothing even in warm . 2
.climates to prevent vasoconstriction
Use nail polish to protect the nail beds . 3
.from injury
Wear gloves for all activities involving . 4
.use of both hands
:Answer

28. . 1
:Rationale
Raynaud ’s disease is peripheral vascular
disease characterized by abnormal
vasoconstriction in the extremities. Smoking
cessation is one of the most important
lifestyle changes that the client needs to
make. The nurse should emphasize the
effects of tobacco on the blood vessels and
the principles involved in stopping smoking.
The nurse needs to provide information to
the client about smoking cessation programs
available in the community . Options 2 and 3
are incorrect . It is not necessary to wear
.gloves for all activities
:Question -85
A nurse is developing a plan of care for a
client with varicose veins in whom skin
breakdown occurred over the varicosities as
a result of secondary infection. A priority
intervention in the plan of care is to:
:Options
.Keep the legs aligned with the heart . 1
Position the client onto the side every . 2
.shift
.Clean the skin with alcohol every hour . 3
.Elevate the legs higher than the heart . 4
:Answer
. 4
:Rationale
In the client with a venous disorder, the legs
are elevated above the level of the heart to

29. assist with the return of venous blood to the
heart . Option 2 specifies infrequent care
intervals , so it is not the priority
intervention. Alcohol is very irritating and
drying to tissues and should not be used in
.areas of skin breakdown
:Question -86
A nurse is reviewing the medical record of a
client transferred to the medical unit from
the critical care unit. The nurse notes that
the client received intra-aortic balloon pump
(IABP) therapy while in the critical care unit.
The nurse suspects that the client received
this therapy for which of the following
?conditions
:Options
Congestive heart failure . 1
Cardiogenic shock . 2
Pulmonary edema . 3
Aortic insufficiency . 4
:Answer
. 2
:Rationale
IABP therapy most often is used in the
treatment of cardiogenic shock and is most
effective if instituted early in the course of
treatment. Use of the IABP is contraindicated
in clients with aortic insufficiency and
thoracic and abdominal aneurysms. This
therapy is not used in the treatment of
.congestive heart failure or pulmonary edema

30. :Question -87
A nurse in the medical unit is reviewing the
laboratory test results for a client who has
been transferred from the intensive care unit.
The nurse notes that a cardiac troponin T
level assay was performed while the client
was in the intensive care unit. The nurse
determines that this test was performed to
assist in diagnosing which of the following
?conditions
:Options
Myocardial infarction . 1
Congestive heart failure . 2
Ventricular tachycardia . 3
Atrial fibrillation . 4
:Answer
. 1
:Rationale
Cardiac troponin T or cardiac troponin I has
been found to be a protein marker in the
detection of myocardial infarction, and assay
for this protein is used in some institutions to
aid in the diagnosis of a myocardial
infarction. The test is not used to diagnose
congestive heart failure, ventricular
.tachycardia, or atrial fibrillation
:Question -88
A nurse is caring for a client with cardiac
disease who has been placed on a cardiac
monitor. The nurse notes that the client has
developed atrial fibrillation and has a
ventricular rate of 150 beats/min . The nurse

31. should next assess the client for which of the
?following
:Options
Flat neck veins . 1
Complaints of nausea . 2
Complaints of headache . 3
Hypotension . 4
:Answer
. 4
:Rationale
The client with uncontrolled atrial fibrillation
with a ventricular rate higher than 100 beats/
min is at risk for low cardiac output due to
loss of atrial kick. The nurse assesses the
client for palpitations, chest pain or
discomfort, hypotension, pulse deficit,
fatigue, weakness, dizziness, syncope,
shortness of breath, and distended neck
.veins
:Question -89
A nurse is performing an assessment on a
client with a diagnosis of left-sided heart
failure. Which assessment component would
elicit specific information regarding the
:client's left-sided heart function? Options
Listening to lung sounds . 1
Assessing for peripheral and sacral . 2
edema
Assessing for jugular vein distention . 3
Monitoring for organomegaly . 4
. Answer: 1
:Rationale

32. The client with heart failure may present
with different symptoms depending on
whether the right or the left side of the heart
is failing. Peripheral and sacral edema,
jugular vein distention, and organomegaly all
are manifestations of problems with right-
sided heart function. Lung sounds constitute
an accurate indicator of left-sided heart
.function