MS Exam 1 Review

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

• Apical pulse rate different than the radial pulse rate

• Increase in heart rate by 20% when standing

• Drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position

• Drop in systolic BP more than 10 mm Hg on inspiration

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

• Check pedal pulses every 15 min.

• Perform passive range-of-motion for the affected extremity.

• Remind the client not to turn from side to side.

• Keep the client in high-Fowler's position for 6 hr.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• Frothy sputum

• Dyspnea

• Orthopnea

• Peripheral edema

A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

• Myoglobin

• Creatinine kinase-MB

• Troponin T

• Creatinine phosphokinase

A nurse is reinforcing teaching with an older adult client who has had a newly inserted permanent pacemaker. Which of the following manifestations should the nurse include in the teaching as a pacemaker malfunction that the client should report to the provider?

• Increased urine output

• Rapid pulse

• Fatigue

• Sneezing

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?

• Frothy sputum

• Dependent edema

• Nocturnal polyuria

• Jugular distention

A nurse is reinforcing teaching with a client who is taking warfarin about monitoring its therapeutic effect. The nurse should issue which of the following statements about the provider’s use of the international normalized ratio (INR)?

• You will need to fast 12 hours prior to having the test completed.

• This is the only test available for anticoagulant therapy monitoring.

• You will need the test done twice per month starting this medication.

• This is a standardized test, so it eliminates the variations different laboratories report in prothrombin times.

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the client's pulse, which of the following terms should the nurse use?

• Slow

• Not palpable

• Irregular

• Bounding

A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder?

• heart murmur

• Dyspnea

• Fever

• Petechiae

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

• Positive Kernig’s sign

• Positive Homan’s sign

• Dull, aching calf pain

• Soft, pliable calf muscle