A nurse is caring for a client who is postoperative following vein ligation and stripping

1. A client is admitted to an emergency department with chest pain that is being ruled out for myocardial infarction. Vital signs are as follows: at 11 AM, pulse (P), 92 beats/min, respiratory rate (RR), 24 breaths/min, blood pressure (BP), 140/88 mm Hg; 11:15 AM, P, 96 beats/min, RR, 26 breaths/min, BP, 128/82 mm Hg; 11:30 AM, P, 104 beats/min, RR, 28 breaths/min, BP, 104/68 mm Hg; 11:45 AM, P, 118 beats/min, RR, 32 breaths/min, BP, 88/58 mm Hg. The nurse should alert the physician because these changes are most consistent with which of the following complications?
 

a. Cardiogenic shock
b. Cardiac tamponade
c. Pulmonary embolism
d. Dissecting thoracic aortic aneurysm

2. A client admitted to the hospital with chest pain and history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which of the following medications would need to be withheld for 48 hours before and after the procedure?
 

a. Regular insulin
b. Glipizide (Glucotrol)
c. Repaglinide (Prandin)
d. Metformin (Glucophage)

3. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds?
 

a. Stridor
b. Crackles
c. Scattered rhonchi
d. Diminished breath sounds

4. A client who had cardiac surgery 24 hours ago has a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL and the serum creatinine level is 2.2 mg/dL. Based on these findings, the nurse would anticipate that the client is at risk for which of the following?
 

a. Hypovolemia
b. Acute renal failure
c. Glomerulonephritis
d. Urinary tract infection

5. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which of the following should be the priority action of the nurse?
 

a. Call a code blue.
b. Call the physician.
c. Check the client status and lead placement.
d. Press the recorder button on the electrocardiogram console.

6. A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following?
 

a. Sensation of palpitations
b. Causative factors, such as caffeine
c. Precipitating factors, such as infection
d. Blood pressure and oxygen saturation

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7. A client has developed atrial fibrillation, with a ventricular rate of 150 beats/min. The nurse should assess the client for which associated signs or symptoms?
 

a. Flat neck veins
b. Nausea and vomiting
c. Hypotension and dizziness
d. Hypertension and headache

8. 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?
 

a. The neurovascular status is normal because of increased blood flow through the leg.
b. The neurovascular status is moderately impaired, and the surgeon should be called.
c. The neurovascular status is slightly deteriorating and should be monitored for another hour.
d. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

9. 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?
 

a. Call the physician.
b. Check the urine specific gravity.
c. Check to see if the client had a sample for serum albumin level drawn.
d. Put the intravenous line on a pump so that the infusion rate is sure to stay stable.

10. 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?
 

a. Stable angina
b. Variant angina
c. Unstable angina
d. Nonanginal pain

11. A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse would determine that the client is receiving the therapeutic effect based on which of the following results?
 

a. Prothrombin time of 12.5 seconds
b. Activated partial thromboplastin time of 60 seconds
c. Activated partial thromboplastin time of 28 seconds
d. Activated partial thromboplastin time longer than 120 seconds

12. A nurse provides discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching?
 

a. "I will take my pills every day at the same time."
b. "I will avoid alcohol consumption."
c. "I have already called my family to pick up a Medic-Alert bracelet."
d. "I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

13. A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which of the following is a priority nursing intervention?
 

a. Monitor for renal failure.
b. Monitor psychosocial status.
c. Monitor for signs of bleeding.
d. Have heparin sodium available.

14. A nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. The nurse understands that which of the following are concerns related to the administration of this medication?
 

a. Hypouricemia, hyperkalemia
b. Increased risk of osteoporosis
c. Hypokalemia, hyperglycemia, sulfa allergy
d. Hyperkalemia, hypoglycemia, penicillin allergy

15. A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education?
 

a. "Constipation and bloating might be a problem."
b. "I'll continue to watch my diet and reduce my fats."
c. "Walking a mile each day will help the whole process."
d. "I'll continue my nicotinic acid from the health food store."

16. A client is on nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client would indicate an understanding of the instructions?
 

a. "It is not necessary to avoid the use of alcohol."
b. "The medication should be taken with meals to decrease flushing."
c. "Clay-colored stools are a common side effect and should not be of concern."
d. "Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing."

17. A 66-year-old client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include atenolol (Tenormin), digoxin (Lanoxin), and chlorothiazide (Diuril). A tentative diagnosis of digoxin toxicity is made. Which of the following assessment data would support this diagnosis?
 

a. Dyspnea, edema, and palpitations
b. Chest pain, hypotension, and paresthesia
c. Double vision, loss of appetite, and nausea
d. Constipation, dry mouth, and sleep disorder

18. Intravenous heparin therapy is prescribed for a client. While implementing this prescription, a nurse ensures that which of the following medications is available on the nursing unit?
 

a. Protamine sulfate
b. Potassium chloride
c. Aminocaproic acid (Amicar)
d. Vitamin K (AquaMEPHYTON)

19. 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?
 

a. Administer oxygen and protamine sulfate.
b. Stop the infusion and call the physician.
c. Cut the infusion rate in half and sit the client up in bed.
d. Administer diphenhydramine

20. 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?
 

a. Adventitious breath sounds
b. Temperature of 99.4° F orally
c. Blood pressure of 198/110 mm Hg
d. Respiratory rate of 28 breaths/min

21. The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity. Select all that apply.
 

a. Tremors
b. Diarrhea
c. Irritability
d. Blurred vision
e. Nausea and vomiting

22. A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse discriminate pain caused by a noncardiac problem? 

a. "Can you describe the pain to me?"
b. "Have you ever had this pain before?"
c. "Does the pain get worse when you breathe in?"

d. "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

23. A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities? 
 

a. Strict bed rest for 24 hours after transfer
b. Bathroom privileges and self-care activities
c. Ad lib activities because the client is monitored
d. Unsupervised hallway ambulation with distances under 200 feet

24. A nurse notes bilateral 12 edema in the lower extremities of a client with myocardial infarction who was admitted 2 days ago. The nurse would plan to do which of the following next? 
 

a. Order daily weights starting on the following morning.
b. Review the intake and output records for the last 2 days.
c. Request a sodium restriction of 1 g/day from the physician.
d. Change the time of diuretic administration from morning to evening.

25. A nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure? 
 

a. Atrial fibrillation
b. Nutritional anemia
c. Peptic ulcer disease
d. Recent upper respiratory infection

26. A client who has developed severe pulmonary edema would most likely exhibit which of the following? 
 

a. Mild anxiety
b. Slight anxiety
c. Extreme anxiety
d. Moderate anxiety

27. A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg intravenous push. Knowing that the client will also be started on digoxin (Lanoxin), the nurse should review which laboratory result? 
 

a. Sodium level
b. Digoxin level
c. Creatinine level
d. Potassium level

28. A nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened, with no apparent drainage. Temperature is 99° F orally. The white blood cell count is 7500 cells/mm3. How should the nurse interpret these findings? 

a. Incision is slightly edematous but shows no active signs of infection.
b. Incision shows early signs of infection, although the temperature is nearly normal.
c. Incision shows early signs of infection, supported by an elevated white blood cell count.
d. Incision shows no sign of infection, although the white blood cell count is elevated.

29. A nurse is preparing to ambulate a client on the third day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation? 
 

a. Remove telemetry equipment.
b. Provide the client with a walker.
c. Premedicate the client with an analgesic.
d. Encourage the client to cough and deep breathe.

30. A nurse notices frequent artifact on the electrocardiographic monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? 
 

a. Frequent movement of the client
b. Tightly secured cable connections
c. Leads applied over hairy areas
d. Leads applied to the limbs

31. A client has frequent bursts of ventricular tachycardia on the cardiac monitor. Why should the nurse be most concerned about with this dysrhythmia? 
 

a. It can develop into ventricular fibrillation at any time.
b. It is almost impossible to convert to a normal rhythm.
c. It is uncomfortable for the client, giving a sense of impending doom.
d. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

32. A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? 
 

a. Lie down flat in bed.
b. Remove any metal jewelry.
c. Breathe deeply, regularly, and easily.
d. Inhale deeply and cough forcefully every 1 to 3 seconds.

33. A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid sinus massage. Which of the following would be reflective of a correct explanation provided by the nurse? 
 

a. The vagus nerve slows the heart rate.
b. The diaphragmatic nerve slows the heart rate.
c. The diaphragmatic nerve overdrives the rhythm.
d. The vagus nerve increases the heart rate, overdriving the rhythm.

34. A nurse is evaluating a client's response to cardioversion. Which of the following observations would be of highest priority to the nurse? 
 

a. Blood pressure
b. Status of airway
c. Oxygen flow rate
d. Level of consciousness

35. A nurse is performing cardiopulmonary resuscitation on a client who has had a cardiac arrest. An automatic external defibrillator is available to treat the client. Which of the following activities will allow the nurse to assess the client's cardiac rhythm? 

a. Hold the defibrillator paddles firmly against the chest.
b. Apply adhesive patch electrodes to the chest and move away from the client.

c. Apply standard electrocardiographic monitoring leads to the client and observe the rhythm.

d. Connect standard electrocardiographic electrodes to a transtelephonic monitoring device.

36. A nurse employed in a cardiac unit determines that which of the following clients is the least likely to have implantation of an automatic internal cardioverter-defibrillator (AICD)? 
 

a. A client with syncopal episodes related to ventricular tachycardia
b. A client with ventricular dysrhythmias despite medication therapy
c. A client with an episode of cardiac arrest related to myocardial infarction
d. A client with three episodes of cardiac arrest unrelated to myocardial infarction

37. A nurse is caring for a client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. Which of the following activities will assist with preventing dislodgement of the pacing catheter? 
 

a. Limiting movement and abduction of the left arm
b. Limiting movement and abduction of the right arm
c. Assisting the client to get out of bed and ambulate with a walker
d. Having the physical therapist do active range-of-motion exercises to the right arm

38. A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of which of the following? 
 

a. Pneumonia
b. Pulmonary edema
c. Pulmonary embolism
d. Myocardial infarction

39. A client is having a follow-up physician office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which of the following would be an appropriate action by the nurse based on evaluation of the client's comment? 

a. Instruct the client to apply warm packs.

b. Report the complaint to the physician.
c. Reassure the client that this is only temporary.
d. Advise the client to take acetaminophen (Tylenol) until it is gone.

40. 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?
 

a. Bleeding and infection
b. Thrombosis and infection
c. Bleeding and wound dehiscence
d. Wound dehiscence and evisceration

41. A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure? 
 

a. Intake and output
b. Height and weight
c. Allergy to iodine or shellfish
d. Baseline peripheral pulse rates

42. 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? 
 

a. The neurovascular status is normal because of increased blood flow through the leg.
b. The neurovascular status is moderately impaired, and the surgeon should be called.
c. The neurovascular status is slightly deteriorating and should be monitored for another hour.
d. The neurovascular status is adequate from an arterial approach, but venous complications are arising.

43. A nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which of the following observations would indicate that the procedure was unsuccessful? 
 

a. Rising blood pressure
b. Clearly audible heart sounds
c. Client expressions of relief
d. Rising central venous pressure

44. 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? 
 

a. Pulsatile abdominal mass
b. Hyperactive bowel sounds in the area
c. Systolic bruit over the area of the mass
d. Subjective sensation of "heart beating" in the abdomen

45. 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? 
 

a. Client has a pacemaker.
b. Client is allergic to iodine.
c. Client has diabetes mellitus.
d. Client has a biological porcine valve.

46. A client develops atrial fibrillation with a ventricular rate of 140 beats/min and signs of decreased cardiac output. Which of the following medications should the nurse first anticipate administering? 
 

a. Atropine sulfate
b. Warfarin (Coumadin)
c. Lidocaine (Xylocaine)
d. Metoprolol (Lopressor)

47. In reviewing the medication records of the following group of clients, the nurse determines that which client would be at greatest risk for developing hyperkalemia? 
 

a. Client receiving furosemide (Lasix)
b. Client receiving bumetanide (Bumex)
c. Client receiving spironolactone (Aldactone)
d. Client receiving hydrochlorothiazide (HCTZ)

48. A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A physician orders a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin? 
 

a. 0.5 to 2 ng/mL
b. 1.2 to 2.8 ng/mL
c. 3 to 5 ng/mL
d. 3.5 to 5.5 ng/mL

49. A client is being treated with procainamide (Procanbid) for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 
 

a. Administer ordered nitroglycerin tablets.
b. Measure the heart rate on the rhythm strip.
c. Obtain a 12-lead electrocardiogram immediately.
d. Auscultate the client's apical pulse and obtain a blood pressure.

50. A home health care nurse is visiting an older client at home. Furosemide (Lasix) is prescribed for the client and the nurse teaches the client about the medication. Which of the following statements, if made by the client, indicates the need for further teaching? 
 

a. "I will sit up slowly before standing each morning."
b. "I will take my medication every morning with breakfast."
c. "I need to drink lots of coffee and tea to keep myself healthy."
d. "I will call my doctor if my ankles swell or my rings get tight."

51. A nurse is caring for a client receiving a heparin intravenous (IV) infusion. The nurse anticipates that which laboratory study will be prescribed to monitor the therapeutic effect of heparin? 
 

a. Hematocrit
b. Hemoglobin
c. Prothrombin time
d. Activated partial thromboplastin time

52. A home health nurse instructs a client about the use of a nitrate patch. The nurse tells the client that which of the following will prevent client tolerance to nitrates? 
 

a. "Do not remove the patches."
b. "Have a 12-hour 'no-nitrate' time."
c. "Have a 24-hour 'no-nitrate' time."
d. "Keep nitrates on 24 hours, then off 24 hours."

53. A client is admitted to a medical unit with nausea and bradycardia. The family hands a nurse a small white envelope labeled "heart pill." The envelope is sent to the pharmacy and it is found to be digoxin (Lanoxin). A family member states, "That doctor doesn't know how to take care of my family." Which of the following statements would convey a therapeutic response by the nurse? 
 

a. "Don't worry about this. I'll take care of everything."
b. "You are concerned your loved one receives the best care."
c. "You're right! I've never seen a doctor put pills in an envelope."
d. "I think you're wrong. That physician has been in practice over 30 years."

54. A nurse is caring for a client receiving dopamine. Which of the following potential nursing diagnoses is appropriate for this client? 
 

a. Fluid volume, excess
b. Cardiac output, increased
c. Tissue perfusion, ineffective
d. Sensory perception, disturbed

55. A client has developed paroxysmal nocturnal dyspnea. Which of the following medications does a nurse anticipate will be prescribed by the physician?
 

a. Propranolol (Inderal)
b. Bumetanide (Bumex)
c. Lidocaine (Xylocaine)
d. Streptokinase (Streptase)

56. 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? 
 

a. Client needs to have test repeated.
b. Client results are within the therapeutic range.
c. Client results are higher than the therapeutic range.
d. Client results are lower than the needed therapeutic level.

57. A client is on enalapril (Vasotec) for the treatment of hypertension. The nurse teaches the client that he should seek emergent care if he experiences which adverse effect? 
 

a. Nausea
b. Insomnia
c. Dry cough
d. Swelling of the tongue

58. A client is admitted to a hospital with acute myocardial infarction and is started on tissue plasminogen activator (tPA, Activase) by infusion. Of the following parameters, which one would a nurse determine requires the least frequent assessment to detect complications of therapy with tissue plasminogen activator? 
 

a. Neurological signs
b. Presence of bowel sounds
c. Blood pressure and pulse
d. Complaints of abdominal and back pain

59. A client with coronary artery disease complains of substernal chest pain. After assessing the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Select the appropriate actions that the nurse should take. Select all that apply. 
 

a. Call a Code Blue.
b. Contact the physician.
c. Contact the client's family.
d. Assess the client's pain level.
e. Check the client's blood pressure
f. Administer a second nitroglycerin, 0.4 mg, sublingually.

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60. A nurse is monitoring a client who is taking propranolol (Inderal). Which assessment data would indicate a potential serious complication associated with propranolol?
 

a. The development of complaints of insomnia
b. The development of audible expiratory wheezes
c. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication
d. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication

What is vein ligation and stripping?

Which complications is seen after varicose vein stripping?

What is the procedure for vein stripping?

What happens to blood flow after vein stripping?