Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical
Problems, 6th Edition
Test Bank
Chapter 25: Nursing Assessment: Respiratory System
1. A patient in severe respiratory distress is admitted to the medical unit at the hospital. During
the admission assessment of the patient, the nurse should
1. perform a comprehensive health history with the patient to determine the extent of prior
respiratory problems.
2. complete a full physical examination to determine the effect of the respiratory distress on
other body functions.
3. delay any physical assessment of the patient and ask family members about the patient’s
history of respiratory problems.
4. perform a physical assessment of the respiratory system and ask specific questions related
to this episode of respiratory distress.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Safe and Effective Care Environment
Text Reference: p. 550
2. A patient with respiratory disease has a shift to the left in the oxygen-hemoglobin
dissociation curve. The nurse recognizes that this finding indicates that
1. less oxygen is dissolved in plasma but is readily released to the tissue.
2. more oxygen is dissolved in plasma and is readily released to the tissue.
3. less oxygen is dissolved in plasma and is not readily released to the tissue.
4. more oxygen is dissolved in plasma but is not readily released to the tissue.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 545
3. The physician performs a thoracentesis on a patient with a right pleural effusion. In preparing
the patient for the procedure, the nurse positions the patient
1. supine with the head of the bed elevated 45 degrees.
2. on his left side with his right arm extended above his head.
3. sitting upright with his arms supported on an overbed table.
4. on his left side in Trendelenburg’s position with both arms extended.
Answer: 3
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 563
4. A patient’s arterial blood gas analysis reveals the following results: pH 7.32, PaO2 80 mm
Hg, PaCO2 55 mm Hg, and SaO2 84%. Based on these findings, the nurse would expect the
patient to experience
1. a gradual increase in respiratory rate and depth.
2. a gradual decrease in respiratory rate and depth.
3. an immediate increase in respiratory rate and depth.
4. an immediate decrease in respiratory rate and depth.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Analysis
NCLEX: Physiologic Integrity
Text Reference: p. 548
5. While caring for a patient who has a 30-pack-year history of smoking, the nurse recognizes
that the patient most likely has decreased respiratory defenses due to impaired
1. cough reflex.
2. mucociliary clearance.
3. reflex bronchoconstriction.
4. ability to filter particles from the air.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 549
6. An 80-year-old patient breathing room air has an arterial blood gas analysis. The nurse
interprets as normal the results of
1. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 sat 90%.
2. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 sat 92%.
3. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 sat 98%.
4. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 sat 94%.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 549
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
7. A patient with emphysema is admitted to the hospital with dyspnea and a cough productive
of yellow sputum. During palpation of the patient’s thorax, the nurse would expect to find
1. diminished expansion.
2. asymmetric expansion.
3. normal expansion of 1 inch.
4. unequal, diminished expansion.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 554
8. On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds just before the
end of inspiration in the right and left lower lobes. The nurse records this finding as
1. inspiratory wheezes in both lungs.
2. crackles in the right and left lower lobes.
3. abnormal lung sounds in the bases of both lungs.
4. pleural friction rub in the right and left lower lobes.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 557
9. A patient with chronic obstructive pulmonary disease has a barrel chest. The nurse would
expect the results of a chest x-ray to reveal
1. fluid in the alveoli.
2. air in the pleural space.
3. overinflation of the alveoli with air.
4. consolidation of lung tissue with mucus and exudate.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 554
10. A hemodynamically unstable patient has a PVO2 value that is lower than normal. The nurse
recognizes this finding indicates that
1. manifestations of hypoxemia are likely to occur.
2. the lungs are not able to eliminate carbon dioxide effectively.
3. there is a decreased partial pressure of oxygen in arterial blood.
4. the oxygen supply in the blood is inadequate to meet tissue oxygen demand.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 546
11. To assess a patient for tactile fremitus, the nurse
1. percusses over each rib as the patient repeats a vibratory phrase such as “mama.”
2. places the fingertips on the chest and asks the patient to cough, while palpating all areas
of the chest.
3. percusses the chest lateral to the sternum and between the scapulae while the patient
whispers “one, two, three.”
4. places the palms of the hands against the chest and asks the patient to repeat “ninetynine,” while palpating both the anterior and posterior thorax.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 546
12. A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy.
Following the bronchoscopy, the nurse should
1. keep the patient on bed rest for 8 hours.
2. keep the patient NPO until the gag reflex returns.
3. check vital signs every 15 minutes for 2 hours.
4. encourage fluid intake to promote elimination of the contrast media.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 561
13. The nurse encourages a patient to deep breathe periodically, knowing that this exercise helps
maintain respiratory function by
1. stimulating ciliary activity, promoting bronchial clearance.
2. stretching the alveoli, stimulating the production of surfactant.
3. increasing the strength of the diaphragm and intercostal muscles.
4. stimulating the Hering-Breuer reflex to increase respiratory rate.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 543-544
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
14. When auscultating a patient’s chest while the patient takes a deep breath, the nurse would
note an absence of breath sounds when lung sounds are not heard at the
1. 6th rib anteriorly.
2. 8th rib midaxillarly.
3. 10th rib posteriorly.
4. 12th rib posteriorly.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 556
15. In reading the results of a blood gas analysis, the nurse knows that the term PaO2 refers to
1. arterial oxygen tension, a measurement of the amount of oxygen dissolved in plasma.
2. arterial oxygen saturation, a measurement of the amount of oxygen dissolved in plasma.
3. arterial oxygen tension, a measurement of the amount of oxygen bound to hemoglobin.
4. arterial oxygen saturation, a measurement of the amount of oxygen bound to hemoglobin.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Knowledge
NCLEX: Physiologic Integrity
Text Reference: p. 546
16. While assessing the role-relationship health pattern in a patient with respiratory problems, the
nurse should specifically ask about
1. smoking habits.
2. alterations in sexual activity.
3. the course of the patient’s illness.
4. occupational exposure to respiratory irritants.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 553
17. While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2
drops from 94% to 85% when the patient ambulates in the hall. The nurse determines that
1. supplemental oxygen should be used when the patient exercises.
2. arterial blood gas determinations should be done to verify the SpO2.
3. this finding is a normal response to activity and the patient should continue to be
monitored.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
4. the oximetry probe should be moved from the finger to the earlobe for an accurate SpO2
during activity.
Answer: 1
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 548
18. In reviewing the results of a patient’s pulmonary function tests, the nurse recognizes that a
patient with chronic obstructive pulmonary disease is likely to have an increased
1. tidal volume.
2. residual volume.
3. forced vital capacity.
4. peak expiratory flow rate.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 564
19. When the nurse is auscultating a patient’s lungs, the appropriate technique to use to progress
from one site on the thorax to another is
1. side-to-side comparison.
2. top-to-bottom comparison.
3. any systematic comparison.
4. posterior-to-anterior comparison.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 555
20. When assessing the respiratory system of a 78-year-old patient, the nurse would expect to
find
1. increased respiratory excursion.
2. decreased chest wall compliance.
3. decreased anteroposterior diameter.
4. bronchovesicular sounds at the apex of the lungs.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Text Reference: p. 549
21. When performing an assessment of the patient’s respiratory system, the nurse uses the
following illustrated technique to evaluate
1.
2.
3.
4.
chest expansion.
tactile fremitus.
accessory muscle use.
diaphragmatic excursion.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 554
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 26: Nursing Assessment: Respiratory System
MULTIPLE CHOICE
1. A patient in respiratory distress is admitted to the medical unit at the hospital. During the initial assessment of
the patient, the nurse should
a. obtain a comprehensive health history to determine the extent of any prior respiratory problems.
b. complete a full physical examination to determine the systemic effect of the respiratory distress.
c. delay the physical assessment and ask family members about any history of respiratory problems.
d. perform a respiratory system assessment and ask specific questions about this episode of respiratory
distress.
Correct Answer: D
Rationale: When a patient has severe respiratory distress, only information pertinent to the current episode is
obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full
physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be
done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know
about the patient’s history of medical problems, the patient is the best informant for these data.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Cognitive Level: Application
Text Reference: p. 517
Nursing Process: Assessment
NCLEX: Safe and Effective Care Environment
2. A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO 2) indicates that the
O2 saturation is 95%. Which action should the nurse take next?
a. Complete a head-to-toe assessment.
b. Place the patient on high-flow oxygen.
c. Start rewarming the patient.
d. Obtain arterial blood gases (ABG).
Correct Answer: B
Rationale: Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will
decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient
is normothermic. The other actions are also appropriate, but the initial action should be to administer oxygen.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: pp. 513, 515
NCLEX: Physiological Integrity
3. The health care provider performs a thoracentesis on a patient with a right pleural effusion. In preparing the
patient for the procedure, the nurse positions the patient
a. supine with the head of the bed elevated 45 degrees.
b. sitting upright with the arms supported on an overbed table.
c. on the left side with the right arm extended above the head.
d. in Trendelenburg’s position with both arms extended.
Correct Answer: B
Rationale: The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung
bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would
increase the work of breathing for the patient and make it more difficult for the health care provider performing the
thoracentesis.
Cognitive Level: Application
Text Reference: pp. 528, 530
Nursing Process: Implementation NCLEX: Physiological Integrity
4. A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would
expect the patient to have
a. Kussmaul’s respirations.
b. slow, shallow respirations.
c. a low oxygen saturation (SpO2).
d. a decrease in PVO2.
Correct Answer: A
Rationale: Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Slow,
shallow respirations, a low oxygen saturation rate, and a decrease in PVO 2 would not be caused by acidosis.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: p. 524
NCLEX: Physiological Integrity
5. A patient who has a 30-pack-year history of smoking asks the nurse, “How does smoking really harm my
lungs?” The nurse’s response will be based on the effect of smoking on
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
a.
b.
c.
d.
cough and gag reflexes.
mucociliary clearance.
reflex bronchoconstriction.
the filtration of inspired air.
Correct Answer: B
Rationale: Smoking decreases ciliary action and the ability of the mucociliary clearance system to trap particles and
move them out of the lung. The cough/gag reflexes, reflex bronchoconstriction, and filtration of air by the nasal
hairs are not affected by smoking.
Cognitive Level: Comprehension Text Reference: p. 516
Nursing Process: Assessment
NCLEX: Physiological Integrity
6. An 80-year-old patient breathing room air has an ABG analysis. The nurse interprets which results as normal?
a. pH 7.38, arterial carbon dioxide (PaO2) 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 92%
b. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 sat 90%
c. pH 7.48, PaO2 90 mm Hg, PaCO2 31 mm Hg, and O2 sat 98%
d. pH 7.52, PaO2 91 mm Hg, PaCO2 42 mm Hg, and O2 sat 94%
Correct Answer: A
Rationale: All the values in this answer are correct. The answer beginning “pH 7.32, PaO 2 85 mm Hg” shows
respiratory acidosis. The answer beginning “pH 7.48, PaO 2 90 mm Hg” indicates respiratory alkalosis, and the
answer beginning “pH 7.52, PaO2 91 mm Hg” shows metabolic alkalosis.
Cognitive Level: Application
Text Reference: p. 514
Nursing Process: Implementation NCLEX: Physiological Integrity
7. A patient with COPD is admitted to the hospital with dyspnea and a cough producing yellow sputum. When
palpating the patient’s thorax, the nurse will expect to find that chest expansion is
a. diminished.
b. asymmetric.
c. normal.
d. increased.
Correct Answer: A
Rationale: Chronic lung hyperinflation, such as occurs in COPD, decreases expansion of the lungs with inspiration.
Lung expansion is usually symmetrical with emphysema.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 524, 526
NCLEX: Physiological Integrity
8. On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds just before the end of inspiration
in the right and left lower lobes. The nurse records this finding as
a. abnormal lung sounds in the bases of both lungs.
b. inspiratory wheezes in both lungs.
c. crackles in the right and left lower lobes.
d. pleural friction rub in the right and left lower lobes.
Correct Answer: B
Rationale: Wheezes are high-pitched sounds; in this case, they are heard during the inspiratory phase of the
respiratory cycle. Abnormal breath sounds are bronchial or bronchovesicular sounds heard in the peripheral lung
fields. Crackles are low-pitched, “bubbling’ sounds. Pleural friction rubs are grating sounds that are usually heard
during both inspiration and expiration.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Cognitive Level: Comprehension Text Reference: p. 525
Nursing Process: Assessment
NCLEX: Physiological Integrity
9. A patient with COPD has a “barrel chest.” The nurse would expect the chest x-ray report to indicate that there is
a. overinflation of the alveoli.
b. consolidation of lung tissue.
c. fluid in the alveoli.
d. air in the pleural space.
Correct Answer: A
Rationale: A barrel chest results from lung hyperinflation and is a common finding in patients with COPD.
Consolidation, fluid, and air in the pleural space all would indicate that intervention is needed.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 511, 521
NCLEX: Physiological Integrity
10. When admitting a patient who has a pleural effusion, which technique will the nurse use to assess for tactile
fremitus?
a. Percuss over the entire posterior chest.
b. Use the fingertips to assess for vibration.
c. Place the palms of the hands on the chest wall.
d. Auscultate while the patient says “ninety-nine.”
Correct Answer: C
Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when
the patient repeats a word or phrase such as “99.” Percussion, palpation with the fingertips, and auscultation are also
used during the respiratory assessment but will not assess for fremitus.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 522
NCLEX: Physiological Integrity
11. A patient with a chronic cough with blood-tinged sputum undergoes a bronchoscopy. Following the
bronchoscopy, the nurse should
a. check vital signs every 15 minutes for 2 hours.
b. place the patient on bed rest for at least 4 hours.
c. keep the patient NPO until the gag reflex returns.
d. elevate the head of the bed to 80 to 90 degrees.
Correct Answer: C
Rationale: Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse
should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Vital signs are
monitored immediately after the procedure but should not need to be obtained every 15 minutes for 2 hours. The
patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowler’s position.
Cognitive Level: Application
Text Reference: p. 528
Nursing Process: Implementation NCLEX: Physiological Integrity
12. A patient who is restricted to bed rest asks the nurse the purpose of the deep breathing exercises. Which reply
by the nurse is correct?
a. Deep breathing enhances ciliary activity and promotes bronchial clearance.
b. Deep breathing stretches the alveoli and stimulates the production of surfactant.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
c.
d.
Deep breathing increases the diaphragmatic strength improving respiratory effort.
Deep breathing stimulates the Hering-Breuer reflex to increase respiratory rate.
Correct Answer: B
Rationale: Taking deep breaths or sighs usually occurs every five to six breaths and (through alveolar stretching and
improved surfactant production) decreases the risk for atelectasis. Ciliary activity, diaphragmatic strength, and the
respiratory rate are not changed by deep breathing.
Cognitive Level: Application
Text Reference: p. 511
Nursing Process: Implementation NCLEX: Physiological Integrity
13. When auscultating a patient’s chest while the patient takes a deep breath, the nurse hears loud, high-pitched,
“blowing” sounds at both lung bases. The nurse will document these as
a. adventitious sounds.
b. abnormal sounds.
c. vesicular sounds.
d. normal sounds.
Correct Answer: B
Rationale: The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at
the lung base. Adventitious sounds are crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are lowpitched, soft sounds heard over all lung areas except the major bronchi.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 524
NCLEX: Physiological Integrity
14. In analyzing the results of a patient’s blood gas analysis, the nurse will be most concerned about an
a. arterial oxygen tension (PaO2) of 60 mm Hg.
b. arterial oxygen saturation (SaO2) of 91%.
c. arterial carbon dioxide (PaCO2) of 47 mm Hg.
d. arterial bicarbonate level (HCO3) of 27 mEq/L.
Correct Answer: A
Rationale: All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the
oxyhemoglobin dissociation curve where a small change in the PaO 2 will cause a large drop in the O2 saturation and
a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patient’s oxygenation.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: p. 513
NCLEX: Physiological Integrity
15. While assessing the role-relationship health pattern in a patient with respiratory problems, the nurse should
specifically ask about
a. any history of cigarette smoking.
b. recent alterations in sexual activity.
c. the course of the patient’s illness.
d. work exposure to respiratory irritants.
Correct Answer: D
Rationale: The role-relationship pattern includes information about the occupational exposure to fumes and
allergens. History of cigarette smoking and the course of the illness are assessed in the health perception-health
management pattern. Alterations in sexuality are assessed in the sexuality-reproductive pattern.
Cognitive Level: Application
Text Reference: p. 520
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
16. While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO 2 drops from 94% to
85% when the patient ambulates in the hall. The nurse determines that
a. supplemental oxygen should be used whenever the patient exercises.
b. arterial blood gas analysis should be done to verify the patient’s SpO 2.
c. the response is normal and the patient should continue at this activity level.
d. the patient activity should be limited until the disease process is resolved.
Correct Answer: A
Rationale: The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when
exercising. ABG measurements are unnecessary and would increase patient discomfort and expense. The patient
will need to continue to ambulate to avoid the many complications of immobility.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 515
NCLEX: Physiological Integrity
17. In reviewing the results of a patient’s pulmonary function test, the nurse recognizes that a patient with COPD is
likely to have an increased
a. forced vital capacity.
b. peak expiratory flow.
c. tidal volume.
d. residual volume.
Correct Answer: D
Rationale: Because elastic recoil of the lungs is decreased with COPD, the residual volume is increased. Tidal
volume, forced vital capacity, and peak expiratory flow rate are likely to be decreased.
Cognitive Level: Comprehension Text Reference: p. 531
Nursing Process: Assessment
NCLEX: Physiological Integrity
18. The nurse is observing a student who is auscultating a patient’s lungs. Which action by the student indicates that
the nurse should intervene?
a. The student compares breath sounds from side to side.
b. The student starts at the base of the posterior lung and moves to the apices.
c. The student places the stethoscope over the scapulae and then auscultates.
d. The student listens only over the posterior part of the chest.
Correct Answer: C
Rationale: The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be
compared from side to side. The techniques of starting at the lung base and then moving toward the apices and
listening only over the posterior chest are acceptable.
Cognitive Level: Comprehension Text Reference: p. 522
Nursing Process: Assessment
NCLEX: Physiological Integrity
19. When assessing the respiratory system of a 78-year-old patient, which of these data indicate that the nurse
should take immediate action?
a. The chest appears barrel shaped.
b. The patient has a weak cough effort.
c. Crackles are audible in the lower two thirds of the posterior chest.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
d.
Hyperresonance is present across both sides of the chest.
Correct Answer: C
Rationale: Crackles in the lower two thirds of the lungs indicate that the patient may have an acute problem such as
heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify
the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are
associated with aging. Further evaluation may be needed, but immediate action is not indicated.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 524
NCLEX: Physiological Integrity
20. When performing an assessment of the patient’s respiratory system, the nurse uses the following illustrated
technique to evaluate
a.
b.
c.
d.
chest expansion.
tactile fremitus.
accessory muscle use.
diaphragmatic excursion.
Correct Answer: A
Rationale: When assessing chest expansion on the posterior chest, the nurse will place the hands at the level of the
10th rib, position the thumbs until they meet over the spine, and have the patient breathe deeply. Tactile fremitus is
assessed by having the patient repeat a word or phrase such as “ninety-nine” while the nurse uses the palms of the
hands to assess for vibration. Accessory muscle use and anterior-posterior diameter are assessed during inspection of
the chest and do not require palpation.
Cognitive Level: Comprehension Text Reference: p. 522
Nursing Process: Assessment
NCLEX: Physiological Integrity
21. A patient with chronic hypoxemia (SaO2 levels of 89%-90%) caused by COPD has just been admitted with
increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most
effective in improving compliance with discharge teaching?
a. Have the patient repeat the instructions immediately after the teaching.
b. Arrange for the patient’s spouse to be present during the teaching.
c. Accomplish the patient teaching just before the scheduled discharge.
d. Start giving the patient discharge teaching on the day of admission.
Correct Answer: B
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Rationale: Hypoxemia interferes with the patient’s ability to learn and retain information, so having the patient’s
spouse present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the
instructions will indicate that the information is understood at the time, but it does not guarantee retention of the
information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just
before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of
admission, so teaching about discharge should be postponed.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 520
NCLEX: Physiological Integrity
22. A patient is admitted to the emergency department complaining of sudden onset shortness of breath and
diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the
patient for a
a. chest x-ray.
b. spiral CT scan.
c. bronchoscopy.
d. PET scan.
Correct Answer: B
Rationale: Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest x-ray may be
ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy is used to inspect for changes in the
bronchial tree, not to assess for vascular changes. PET scans are most useful in determining the presence of
malignancy.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 526
NCLEX: Physiological Integrity
23. The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by
the nurse indicates that the patient may need teaching regarding medication use?
a. The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days.
b. The patient became very short of breath an hour before coming to the hospital.
c. The patient has been taking acetaminophen (Tylenol) 650 mg every 6 hours for chest-wall pain.
d. The patient says there have been no acute asthma attacks during the last year.
Correct Answer: A
Rationale: The increased need for a rapid-acting bronchodilator should alert the patient that an acute attack may be
imminent and that a change in therapy may be needed. The patient should be taught to contact a health care provider
if this occurs. The other data do not indicate any need for additional teaching.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 517
NCLEX: Physiological Integrity
24. A patient is scheduled for a spiral CT scan to rule out a pulmonary embolus. Which information obtained by the
nurse is most important to communicate to the health care provider before the examination?
a. The apical pulse is irregular.
b. The oxygen saturation is 93%.
c. The patient is allergic to shellfish.
d. The patient is very tachypneic.
Correct Answer: C
Rationale: Because the contrast solution is iodine-based, the patient may need to have the CT scan without contrast
or be premedicated before contrast injection. The irregular pulse, oxygen saturation, and tachypnea all need further
assessment or intervention but are not unusual for a patient with a possible pulmonary embolus.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Cognitive Level: Application
Text Reference: p. 527
Nursing Process: Implementation NCLEX: Physiological Integrity
Lewis: Medical-Surgical Nursing: Assessment and
Management of Clinical Problems, 6th Edition
Test Bank
Chapter 27: Nursing Management: Lower Respiratory Problems
1. Following assessment of a patient with pneumonia, the nurse
identifies a nursing diagnosis of ineffective airway clearance.
The nurse bases this nursing diagnosis on the finding of
1. SpO2 of 85%.
2. respiratory rate of 28.
3. presence of greenish sputum.
4. crackles in the right and left lower lobes.
Answer: 4
2. A 56-year-old normally healthy patient at the clinic is
diagnosed with community-acquired pneumonia. The nurse
anticipates that empiric treatment of the patient could include
the administration of
1. ciprofloxacin (Cipro).
2. azithromycin (Zithromax).
3. trimethoprim-sulfamethoxazole (Bactrim).
4. a second- or third-generation cephalosporin.
Answer: 2
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3. During assessment of the chest in a patient with
pneumococcal pneumonia, the nurse would expect to find
1. hyperresonance on percussion.
2. increased vocal fremitus on palpation.
3. fine crackles in all lobes on auscultation.
4. asymmetric chest expansion on inspection.
Answer: 2
4. To promote airway clearance in a patient with pneumonia, the
nurse instructs the patient to
1. splint the chest when coughing.
2. maintain a semi-Fowler’s position.
3. wear the nasal oxygen cannula at all times.
4. use relaxation techniques to reduce anxiety.
Answer: 1
5. Four days after admission, a patient with chronic obstructive
lung disease is diagnosed with hospital-acquired pneumonia.
The nurse recognizes that a common cause of this type of
pneumonia is
1. Pneumocystis carinii.
2. Haemophilus influenzae.
3. Pseudomonas aeruginosa.
4. Mycoplasma pneumoniae.
Answer: 3
6. A 77-year-old woman is admitted to the hospital with
pneumonia. She has a fever of 101.2° F (38.5° C), chills, and
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
a productive cough with greenish sputum. She is very weak
and needs assistance to transfer from the wheelchair to the
bed. An appropriate nursing diagnosis for the patient is
1. hyperthermia related to infectious illness.
2. ineffective thermoregulation related to chilling.
3. ineffective breathing pattern related to pneumonia.
4. ineffective airway clearance related to thick secretions.
Answer: 1
7. During assessment of the patient with pneumonia, the nurse
recognizes that
1. all patients with pneumonia will have a productive cough.
2. manifestations of pneumonia vary, depending on the
causative organism.
3. the typical pneumonia symptoms are usually caused by
Mycoplasma pneumoniae.
4. although a variety of microorganisms cause pneumonia, the
pathophysiology of the disease is the same, regardless of
the cause.
Answer: 2
8. Following discharge teaching, the nurse evaluates that the
patient with pneumonia understands measures to prevent a
relapse of the pneumonia when the patient states
1. “I will increase my food intake to 2400 calories a day.”
2. “I must use home oxygen therapy for 3 months.”
3. “I will seek medical treatment for any upper respiratory
infections.”
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4. “I should continue to do deep-breathing and coughing
exercises for at least 6 weeks.”
Answer: 4
9. To protect susceptible patients in the hospital from aspiration
pneumonia, the nurse
1. turns and repositions immobile patients every 2 hours.
2. positions patients with altered consciousness in lateral
positions.
3. monitors for respiratory symptoms in those patients who
are immunosuppressed.
4. plans room assignments to prevent patients with infections
from being placed with surgical or chronically ill patients.
Answer: 2
10. A patient tells the nurse that his physician told him he had
pneumonia and he wonders whether he will be receiving
antibiotics. The nurse’s response to the patient is based on the
knowledge that
1. antibiotics are usually prescribed only if the patient is a
smoker.
2. antibiotics are prescribed only if they have been previously
effective.
3. antimicrobial agents are the indicated treatment for all
types of pneumonia.
4. the first consideration of treatment by antibiotics is where
the pneumonia was acquired.
Answer: 4
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11. The nurse teaches patients at risk for pneumonia to obtain
1. S. aureus vaccine.
2. H. influenzae vaccine.
3. S. pneumoniae vaccine.
4. bacille Calmette-Guérin (BCG) vaccine.
Answer: 3
12. A 60-year-old homeless man has a cough, late-afternoon
fever, and night sweats. The patient’s response to a purified
protein derivative (PPD) skin test is 10 mm. The nurse
recognizes that this response indicates that the patient
1. has a tubercular infection.
2. has class 3, clinically active tuberculosis.
3. has been exposed to the tuberculosis organism.
4. has tuberculosis only if abnormal chest x-ray findings are
present.
Answer: 1
13. A patient has just been started on chemotherapy for TB.
The nurse informs the patient that the disease can be
transmitted to others until
1. the night sweats have subsided.
2. three smears for acid-fast bacilli are negative.
3. the medications have been taken for 6 months.
4. sputum cultures on 3 consecutive days are negative.
Answer: 2
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14. The nurse recognizes that the goals of teaching regarding
the transmission of TB have been met when the patient with
TB
1. wears a mask when in contact with others.
2. reports daily to the public health department.
3. boils dishes and personal items between uses.
4. covers the mouth and nose when coughing or sneezing.
Answer: 4
15. A patient who has been diagnosed with TB of the bone tells
the nurse that he thought TB was a lung disease. The nurse
explains to the patient that
1. the tubercular organism is a mild bacteria that spreads only
in people who do not have good immune systems.
2. the microorganism that causes TB starts in the lungs but
usually spreads from the lungs to other parts of the body.
3. the tuberculosis organism makes a cheesy-like cyst that
breaks open and spreads the infection throughout the body.
4. the lungs are the most common site of TB infection but the
microorganism can be spread to other organs through the
blood and lymph systems.
Answer: 4
16. A patient diagnosed with TB is started on initial drug
therapy. The nurse plans to teach the patient about the uses
and effects of
1. isoniazid, rifampin, and ethambutol.
2. isoniazid, pyrazinamide, and streptomycin.
3. isoniazid, rifampin, pyrazinamide, and ethambutol.
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4. para-aminosalicylic acid, ethambutol, rifampin, and
pyrazinamide.
Answer: 3
17. The nurse emphasizes the need for especially close
monitoring in the patient who is taking antitubercular drugs
and has a history of
1. liver disease.
2. renal disease.
3. heart disease.
4. bowel disease.
Answer: 1
18. A patient being treated for TB comes to the clinic after 2
months for a follow-up visit. Sputum smears for AFB are still
positive. A sputum specimen is taken for culture and to
determine whether the microorganism is sensitive to the
drugs. The nurse questions the patient regarding the treatment
regimen with the knowledge that
1. directly observed therapy will be necessary if the patient
has been noncompliant.
2. a combination product of isoniazid, rifampin, and
pyrazinamide (Rifater) is indicated if the patient skips
doses.
3. treatment protocols involving twice weekly administration
of the drugs are not as effective as daily administration.
4. if the drugs are causing side effects, a regimen including
the administration of only isoniazid can be substituted.
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Answer: 1
19. After caring for a patient admitted with a fever and cough
who was later diagnosed with TB, a nurse has a new positive
TB skin test of 8 mm induration. A chest x-ray is negative,
and the nurse is considered to have latent tuberculosis
infection. The recommended intervention for the nurse
includes
1. a repeat of the skin test in 3 weeks.
2. administration of isoniazid (INH) daily for 6 to 9 months.
3. combination therapy of antitubercular drugs for 6 months.
4. administration of the bacille Calmette-Guérin (BCG)
vaccine.
Answer: 2
20. During IV administration of amphotericin B ordered for
treatment of coccidioidomycosis, the nurse increases the
patient’s tolerance of the drug by
1. cooling the solution to 80˚ F before administration.
2. keeping the patient flat in bed for 1 hour after the infusion
is completed.
3. diluting the amphotericin B in 500 ml of distilled water
before administering.
4. administering aspirin or diphenhydramine (Benadryl) 1
hour before the infusion.
Answer: 4
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21. While caring for a patient with bronchiectasis, the nurse
teaches the patient that one of the most important measures in
control of the condition is to use
1. pursed-lip breathing.
2. diaphragmatic breathing.
3. chest physical therapy with postural drainage.
4. intermittent positive pressure breathing treatments.
Answer: 3
22. A patient asks the nurse to explain what has caused his
bronchiectasis. The nurse responds that the structural changes
in the bronchi occurring in bronchiectasis are believed to be
most commonly associated with
1. lung tumors.
2. chronic bronchitis.
3. bacterial infections.
4. congenital defects in the bronchial wall.
Answer: 3
23. The occupational nurse at a manufacturing plant where
there is high worker exposure to beryllium dust advocates the
administration for
1. a smoke-free work area.
2. periodic chest-rays for workers.
3. the use of masks by all workers in the exposure area.
4. frequent visits by the Occupational Safety and Health
Administration (OSHA).
Answer: 2
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24. A patient with persistent cough, mild dyspnea, and weight
loss undergoes diagnostic testing for cancer of the lung. The
patient’s health history notes that the patient has smoked for
42 years and also worked with uranium for 10 years. In
evaluating the patient’s risk for lung cancer, the nurse knows
that the most influential factor is
1. duration of smoking.
2. exposure to uranium.
3. total exposure to cigarette smoke.
4. total exposure to known carcinogens.
Answer: 4
25. A lobectomy is scheduled for a patient with squamous cell
carcinoma of the lung. The patient asks the nurse whether the
surgery will cure the cancer. The most appropriate response
by the nurse is
1. “I’m not sure what your surgeon plans to do during your
surgery. Have you talked to your doctor about this?”
2. “Surgery coupled with radiation therapy offers a good
chance of cure for you. You should consider yourself
lucky.”
3. “Surgical intervention is the only real hope for cure of lung
cancer, but you need to discuss the expected outcome of
your surgery with your physician.”
4. “No one can really say cancer is cured until they have been
symptom-free for 5 years. You will just have to wait awhile
to see whether a cure occurs.”
Answer: 3
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26. A 52-year-old patient has a 40-pack-year history of
smoking and has been diagnosed with cancer of the lung. He
tells the nurse that he didn’t know that anything was wrong
until he had a routine chest x-ray. The nurse explains that
symptoms of lung cancer occur late in the disease but usually
the first thing people notice is
1. fatigue.
2. chest pain.
3. a persistent cough.
4. shortness of breath.
Answer: 3
27. A patient with lung cancer tells the nurse, “I think I am
going to die pretty soon, maybe this week.” The best response
by the nurse is
1. “None of us know when we are going to die. Are you
having a bad day?”
2. “What are your feelings about being so sick and thinking
you may die soon?”
3. “Would you like for me to call the hospital chaplain so that
you can talk to him about your feelings?”
4. “I think you are depressed about your illness and will talk
to your doctor about some medications for you.”
Answer: 2
28. A young man is admitted to the emergency department
with a stab wound to the right chest. He has moderate
bleeding from the site, and his vital signs show symptoms of
shock. Air can be heard entering his chest with each
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inspiration. To decrease the possibility of a tension
pneumothorax in the patient, the nurse should
1. position the patient on his injured side.
2. administer high-flow oxygen using a non-rebreathing mask.
3. cover the sucking chest wound with a petrolatum gauze
dressing.
4. apply a nonporous dressing taped on three sides to the chest
wound.
Answer: 4
29. The physician inserts two chest tubes connected with a Yconnecter in a patient with a hemopneumothorax. To prepare
for chest tube drainage with a three-compartment drainage
system, the nurse should
1. add sterile water to the first compartment.
2. attach suction to the second compartment.
3. add sterile water to the second compartment.
4. prime the lower chest tube with sterile water.
Answer: 3
30. A patient experiences a flail chest as a result of an
automobile accident. During the respiratory assessment the
nurse would expect to find
1. bloody sputum.
2. laryngeal stridor.
3. deep, irregular respirations.
4. paradoxic chest movement.
Answer: 4
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31. The nurse establishes the presence of a tension
pneumothorax when assessment findings reveal
1. absence of lung sounds on the affected side.
2. inability to auscultate tracheal breath sounds.
3. deviation of the trachea toward the side opposite the
pneumothorax.
4. a shift of the point of maximal impulse (PMI) to the left,
with bounding pulses.
Answer: 3
32. The nurse identifies a nursing diagnosis of ineffective
airway clearance for a patient who has undergone a
pneumonectomy. A common etiology for this nursing
diagnosis in patients who have had a pneumonectomy is
1. surgical incision pain.
2. mechanical ventilation.
3. presence of chest tubes.
4. thick, copious secretions.
Answer: 1
33. A patient has a chest tube following a thoracotomy.
Continuous bubbling in the suction chamber of the collection
device would alert the nurse that
1. an air leak may be present.
2. the lung has fully expanded.
3. the unit is functioning normally.
4. a tension pneumothorax is developing.
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Answer: 3
34. When providing preoperative instruction for a patient
scheduled for a left pneumonectomy for cancer of the lung,
the nurse informs the patient that postoperatively he can
expect
1. to be positioned on the unaffected side.
2. chest tubes to water-seal chest drainage.
3. endotracheal intubation with mechanical ventilation.
4. pain medication before deep-breathing and coughing
activities.
Answer: 4
35. A 68-year-old man has a long history of COPD and is
admitted to the hospital with cor pulmonale. The patient says
his doctor said his heart was failing and asks whether he is
having a heart attack. The nurse explains to the patient that
1. he is not having a heart attack but his heart has been
damaged by changes in his lungs.
2. it could be a heart attack and when the heart is damaged it
causes respiratory damage too.
3. it is not a heart attack but his heart has gradually weakened
over the years, causing respiratory disease.
4. it is probably a heart attack because cor pulmonale means
the heart is not getting enough blood and becomes too weak
to pump effectively.
Answer: 1
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36. While assessing a patient with diffuse pulmonary fibrosis
caused by sarcoidosis, the nurse would expect to find
1. increased resistance to airflow into the lungs.
2. use of accessory muscles of respiration to empty the lungs
of air.
3. decreased lung compliance because of chest wall
alterations or lung damage.
4. a barrel chest, reflective of an increased vital capacity and
total lung capacity.
Answer: 3
37. In teaching a patient with primary pulmonary hypertension
about the disorder, the nurse provides information to the
patient based on the knowledge that it
1. is manifested by systemic hypertension, dyspnea, and
hemoptysis.
2. can be effectively controlled long-term with
antihypertensive agents.
3. will eventually cause right ventricular hypertrophy and
right-sided heart failure.
4. results from a loss of pulmonary capillaries as a result of
alveolar wall damage.
Answer: 3
38. A patient is scheduled for a thoracentesis to obtain pleural
fluid for diagnosis of a large pleural effusion. She asks the
nurse to explain what causes the fluid in her lung. The nurse
explains that
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1. the pleural effusion could be caused by a tumor or other
growth.
2. a pleural effusion is not a disease but rather a sign of some
other disease.
3. pleural effusions occur when there is any inflammation or
infection in the lung.
4. the cause of pleural effusions is not known but they can be
treated by removing the fluid with a needle or tube.
Answer: 2
39. A 62-year-old patient with a 20-year history of COPD has
continued to smoke and now has severe pulmonary
hypertension with cardiac manifestations. As he visits the
nurse, he asks whether he would be a candidate for a heartlung transplant. The most appropriate response by the nurse is
1. “Any patient who currently smokes cigarettes would not be
considered.”
2. “I’m sorry, but heart-lung transplants are contraindicated
for people over the age of 60.”
3. “A decision regarding your eligibility would be made after
extensive psychologic and physical evaluation.”
4. “You would have to have enough financial support to pay
for the surgery and all of the immunosuppressive drugs you
would take after surgery.”
Answer: 3
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 28: Nursing Management: Lower Respiratory Problems
MULTIPLE CHOICE
1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway
clearance. Which information best supports this diagnosis?
a. Resting pulse oximetry (SpO2) of 85%
b. Respiratory rate of 28
c. Large amounts of greenish sputum
d. Weak, nonproductive cough effort
Correct Answer: D
Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The
other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 568
NCLEX: Physiological Integrity
2. A patient who was admitted to the hospital with pneumococcal pneumonia has a temperature of 101.6° F with a
frequent cough and is complaining of chest pain rated 7 on a 10-point scale with deep inspiration. Which of
these ordered medications should the nurse give first?
a. Azithromycin (Zithromax)
b. Acetaminophen (Tylenol)
c. Guaifenesin (Robitussin)
d. Codeine phosphate (Codeine)
Correct Answer: A
Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications
are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
Cognitive Level: Application
Text Reference: pp. 563, 566
Nursing Process: Implementation NCLEX: Physiological Integrity
3. During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find
a. hyperresonance on percussion.
b.
c.
d.
increased vocal fremitus on palpation.
fine crackles in all lobes on auscultation.
asymmetric chest expansion on inspection.
Correct Answer: B
Rationale: Pneumonias caused by Streptococcus pneumoniae are typically lobar or segmental. The nurse would
expect to find increased vocal fremitus over the affected area of the lungs. The area would be dull to percussion.
Fine crackles in all lobes would indicate a diffuse infection, which is more typical of viral pneumonias. Asymmetric
chest expansion is not typical with pneumonia.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 565
NCLEX: Physiological Integrity
4. To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to
a. splint the chest when coughing.
b. maintain fluid restrictions.
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c.
d.
wear the nasal oxygen cannula.
try the pursed-lip breathing technique.
Correct Answer: A
Rationale: Coughing is less painful and more likely to be effective when the patient splints the chest during
coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange in
patients with chronic obstructive pulmonary disease (COPD) but will not improve airway clearance in pneumonia.
Cognitive Level: Application
Text Reference: p. 568
Nursing Process: Implementation NCLEX: Physiological Integrity
5. The nurse will anticipate discharge today for which of these patients with community-acquired-pneumonia?
a. 24-year-old patient who has had temperatures ranging from 100.6° to 101° F
b. 35-year-old patient who has had 600 ml of oral fluids in the last 24 hours
c. 50-year-old patient who has an oxygen saturation of 91% on room air
d. 72-year-old patient with a pulse of 102 and a blood pressure (BP) of 90/56
Correct Answer: C
Rationale: The 50-year-old meets the Infectious Diseases Society of America (IDSA) hospital discharge criteria.
The other patients do not meet the criteria for discharge.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 563
NCLEX: Physiological Integrity
6. A 77-year-old patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen
saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing
diagnosis for the patient is
a. hyperthermia related to infectious illness.
b. ineffective airway clearance related to thick secretions.
c. impaired transfer ability related to weakness.
d. impaired gas exchange related to respiratory congestion.
Correct Answer: D
Rationale: All these nursing diagnoses are appropriate for the patient, but the patient’s oxygen saturation indicates
that all body tissues are at risk for hypoxia unless the gas exchange is improved.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 566
NCLEX: Physiological Integrity
7. The nurse notes new-onset confusion in an 89-year-old patient in a long-term-care facility; the patient is
normally alert and oriented. Which action should the nurse take next?
a. Check the patient’s pulse rate.
b. Obtain an oxygen saturation.
c. Notify the health care provider.
d. Document the change.
Correct Answer: B
Rationale: New-onset confusion caused by hypoxia may be the first sign of pneumonia in older patients. The other
actions are also appropriate in this order: check the pulse, notify the health care provider, and document the change
in status.
Cognitive Level: Application
Text Reference: p. 565
Nursing Process: Implementation NCLEX: Physiological Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
8. Following discharge teaching, the nurse evaluates that the patient who was admitted with pneumonia
understands measures to prevent a reoccurrence of the pneumonia when the patient states,
a. “I will increase my food intake to 3000 calories a day.”
b. “I will need to use home oxygen therapy for 3 months.”
c. “I will seek medical treatment for any upper respiratory infections.”
d. “I will do deep-breathing and coughing exercises for the next 6 weeks.”
Correct Answer: D
Rationale: Patients at risk for recurrent pneumonia should use the incentive spirometer or do deep breathing and
coughing exercises or both for 6 to 8 weeks after discharge. Although caloric needs are increased during the acute
infection, 3000 calories daily will lead to obesity and increase the risk for pneumonia. Patients with acute lower
respiratory infections do not usually require home oxygen therapy. Upper respiratory infections require medical
treatment only when they fail to resolve in 7 days.
Cognitive Level: Application
Text Reference: p. 569
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance
9. To protect susceptible patients in the hospital from aspiration pneumonia, the nurse will plan to
a. turn and reposition immobile patients at least every 2 hours.
b. position patients with altered consciousness in lateral positions.
c. monitor frequently for respiratory symptoms in patients who are immunosuppressed.
d. provide for continuous subglottic aspiration in patients receiving enteral feedings.
Correct Answer: B
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a
side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not
decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen
saturation will help detect pneumonias in immune compromised patients, but it will not decrease the risk for
aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving
enteral feedings.
Cognitive Level: Application
Text Reference: p. 567
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment
10. After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days,
which assessment data obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. Increased vocal fremitus is palpable over the right chest.
c. The patient coughs up small amounts of green mucous.
d. The patient’s white blood cell (WBC) count is 9000/µl.
Correct Answer: D
Rationale: The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that
a change in treatment is needed.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 569
NCLEX: Physiological Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
11. The nurse observes a nursing assistant doing all the following activities when caring for a patient with right
lower-lobe pneumonia. The nurse will need to intervene when the nursing assistant
a. turns the patient over to the right side.
b. splints the patient’s chest during coughing.
c. elevates the patient’s head to 45 degrees.
d. assists the patient to get up to the bathroom.
Correct Answer: A
Rationale: Positioning the patient with the left (or “good” lung) down will improve oxygenation. The other actions
are appropriate for a patient with pneumonia.
Cognitive Level: Application
Text Reference: p. 569
Nursing Process: Implementation NCLEX: Physiological Integrity
12. A hospitalized patient who may have tuberculosis (TB) has an order for a sputum specimen. When will be the
best time for the nurse to collect the specimen?
a. After the patient rinses the mouth with mouthwash
b. As soon as the order is received from the health care provider
c. Right after the patient gets up in the morning
d. After the skin test is administered
Correct Answer: C
Rationale: Sputum specimens are ideally collected in the morning because mucus is likely to accumulate during the
night. The patient should rinse the mouth with water; mouthwash may inhibit the growth of the bacilli. There is no
need to wait until the tuberculin skin test is administered.
Cognitive Level: Application
Text Reference: p. 572
Nursing Process: Implementation NCLEX: Physiological Integrity
13. A patient who has active TB has just been started on drug therapy for TB. The nurse informs the patient that the
disease can be transmitted to others until
a. the chest x-ray shows resolution of the tuberculosis.
b. three sputum smears for acid-fast bacilli are negative.
c. TB medications have been taken for 6 months.
d. sputum cultures on 3 consecutive days are negative.
Correct Answer: B
Rationale: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli. Chest xrays help to determine the presence of active TB but are not utilized to monitor the effectiveness of treatment.
Taking the medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be
eradicated after 6 months of therapy. Sputum cultures are used to diagnose the presence of active TB, but sputum
smears are usually done to establish that treatment has been effective.
Cognitive Level: Application
Text Reference: p. 574
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
14. The nurse recognizes that the goals of teaching regarding the transmission of TB have been met when the
patient with TB
a. demonstrates correct use of a nebulizer.
b. reports daily to the public health department.
c. washes dishes and personal items after use.
d. covers the mouth and nose when coughing.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Correct Answer: D
Rationale: Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not
be effective in decreasing the spread of TB.
Cognitive Level: Application
Text Reference: p. 574
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance
15. A patient is receiving isoniazid (INH) after having a positive tuberculin skin test. Which information will the
nurse include in the patient teaching plan?
a. “Take vitamin B6 daily to prevent peripheral nerve damage.”
b. “Read a newspaper daily to check for changes in vision.”
c. “Schedule an audiometric examination to monitor for hearing loss.”
d. “Avoid wearing soft contact lenses to avoid orange staining.”
Correct Answer: A
Rationale: Peripheral neurotoxicity associated can be prevented by taking vitamin B 6 when being treated with INH.
Visual changes, hearing problems, and orange staining are adverse effects of other TB medications.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 573
NCLEX: Physiological Integrity
16. When teaching the patient who is receiving standard multidrug therapy for TB about possible toxic effects of
the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient
develops
a. yellow-tinged skin.
b. changes in hearing.
c. orange-colored urine.
d. thickening of the nails.
Correct Answer: A
Rationale: Noninfectious hepatitis is a toxic effect of INH, rifampin, and pyrazinamide, and patients who develop
hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the
four medications used for initial drug therapy. Orange discoloration of body fluids is an expected side effect of
rifampin and not an indication to call the health care provider.
Cognitive Level: Application
Text Reference: pp. 572-573
Nursing Process: Implementation NCLEX: Physiological Integrity
17. An alcoholic and homeless patient is diagnosed with active TB. Which intervention by the nurse will be most
effective in ensuring adherence with the treatment regimen?
a. Giving the patient written instructions about how to take the medications
b. Teaching the patient about the high risk for infecting others unless treatment is followed
c. Arranging for a daily noontime meal at a community center and give the medication then
d. Educating the patient about the long-term impact of TB on health
Correct Answer: C
Rationale: Directly observed therapy is the most effective means for ensuring compliance with the treatment
regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The
other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.
Cognitive Level: Application
Text Reference: pp. 572, 575
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Nursing Process: Implementation NCLEX: Physiological Integrity
18. After 2 months of TB treatment with a standard four-drug regimen, a patient continues to have positive sputum
smears for acid-fast bacilli (AFB). The nurse discusses the treatment regimen with the patient with the
knowledge that
a. directly observed therapy (DOT) will be necessary if the medications have not been taken correctly.
b. the positive sputum smears indicate that the patient is experiencing toxic reactions to the
medications.
c. twice-weekly administration may be used to improve compliance with the treatment regimen.
d. a regimen using only INH and rifampin (Rifadin) will be used for the last 4 months of drug therapy.
Correct Answer: A
Rationale: After 2 months of therapy, negative sputum smears would be expected if the TB bacillus is susceptible to
the medications and if the medications have been taken correctly. The nurse will need to initiate DOT if the patient
has not been consistently taking the medications. Toxic reactions to the medications would not result in a positive
sputum smear. Twice-weekly medication administration is not one of the options for therapy. INH and rifampin are
used for the last 4 months of drug therapy only if the initial four-drug regimen has been effective as evidenced by
negative sputum smears.
Cognitive Level: Application
Text Reference: pp. 571-572
Nursing Process: Implementation NCLEX: Physiological Integrity
19. A staff nurse has a TB skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no
symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
a. use and side effects of INH.
b. standard four-drug therapy for TB.
c. need for annual repeat TB skin testing.
d. recommendation guidelines for bacille Calmette-Guérin (BCG) vaccine.
Correct Answer: A
Rationale: The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9
months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for
individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be
helpful for this individual, who already has a TB infection.
Cognitive Level: Application
Text Reference: p. 572
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
20. During IV administration of amphotericin B ordered for treatment of coccidioidomycosis, the nurse increases
the patient’s tolerance of the drug by
a. cooling the solution to 80° F before administration.
b. keeping the patient flat in bed for 1 hour after the infusion is completed.
c. diluting the amphotericin B in 500 ml of sterile water.
d. giving diphenhydramine (Benadryl) 1 hour before starting the infusion.
Correct Answer: D
Rationale: Administration of an antihistamine before giving the amphotericin B will reduce the incidence of
hypersensitivity reactions. Cooling the solution and keeping the patient flat after infusion are not indicated.
Amphotericin B does not need to be diluted in 500 ml of fluid, although the nurse should ensure adequate hydration
in the patient receiving this drug.
Cognitive Level: Application
Text Reference: p. 575
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Nursing Process: Implementation NCLEX: Physiological Integrity
21. The nurse is performing TB screening in a clinic that has many patients who have immigrated to the United
States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask?
a. “How long have you lived in the United States?”
b. “Is there any family history of TB?”
c. “Have you received the BCG vaccine for TB?”
d. “Do you take any over-the-counter (OTC) medications?”
Correct Answer: C
Rationale: Patients who have received the BCG vaccine will have a positive Mantoux test; another method for
screening (such as a chest x-ray) will be used in determining whether the patient has a TB infection. The other
information may also be valuable but is not as pertinent to the decision about doing TB skin testing.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 572
NCLEX: Physiological Integrity
22. When caring for a patient who is hospitalized with active TB, the nurse observes a family member who is
visiting the patient. The nurse will need to intervene if the family member
a. washes the hands before entering the patient’s room.
b. puts on a surgical face mask before visiting the patient.
c. brings food from a “fast-food” restaurant to the patient.
d. hands the patient a tissue from the box at the bedside.
Correct Answer: B
Rationale: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be
used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles.
Handwashing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family
member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food
from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the
patient has used, but no precautions are necessary when giving the patient an unused tissue.
Cognitive Level: Application
Text Reference: p. 574
Nursing Process: Implementation NCLEX: Physiological Integrity
23. The occupational nurse at a manufacturing plant where there is high worker exposure to beryllium dust will
monitor workers for
a. shortness of breath.
b. chest pain.
c. elevated temperature.
d. barrel-chest.
Correct Answer: A
Rationale: The nurse will monitor for the earliest signs of occupational lung disease, which are dyspnea and a
cough. The other symptoms are also consistent with occupational lung disease but would occur much later, after
significant lung involvement has occurred.
Cognitive Level: Application
Text Reference: pp. 577-578
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
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24. When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most
important for the nurse to include information about
a. reasons for annual sputum cytology testing.
b. CT screening for lung cancer.
c. erlotinib (Tarceva) therapy to prevent tumor risk.
d. options for smoking cessation.
Correct Answer: D
Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating
patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum
cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Tarceva may be used to in
patients who have lung cancer, but not to reduce risk for developing tumors.
Cognitive Level: Application
Text Reference: pp. 582, 584
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
25. A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I
would rather have radiation than surgery.” Which response by the nurse is most appropriate?
a. “Are you afraid that the surgery will be very painful?”
b. “Tell me what you know about the various treatments available.”
c. “Surgery is the treatment of choice for stage I lung cancer.”
d. “Did you have bad experiences with previous surgeries?”
Correct Answer: B
Rationale: More assessment of the patient’s concerns about surgery is indicated; an open-ended response will elicit
the most information from the patient. The answer beginning, “Surgery is the treatment of choice” is accurate, but it
discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has
jumped to conclusions about the patient’s reasons for not wanting surgery.
Cognitive Level: Application
Text Reference: pp. 583-584
Nursing Process: Implementation NCLEX: Psychosocial Integrity
26. An hour after a left upper lobectomy, a patient complains of incisional pain at a level 7 out of 10 and has
decreased left-sided breath sounds. The pleural drainage system has 100 ml of bloody drainage and a large air
leak. Which action should the nurse take first?
a. Assist the patient to deep breathe and cough.
b. Milk the chest tube gently to remove any clots.
c. Medicate the patient with the ordered morphine.
d. Notify the surgeon about the large air leak.
Correct Answer: C
Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of
100 ml is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak
is expected in the initial postoperative period after thoracotomy.
Cognitive Level: Application
Text Reference: p. 594
Nursing Process: Implementation NCLEX: Physiological Integrity
27. A patient with newly diagnosed lung cancer tells the nurse, “I think I am going to die pretty soon, maybe this
week.” The best response by the nurse is
a. “Are you afraid that the treatment for your cancer will not be effective?”
b. “Can you tell me what it is that makes you think you will die so soon?”
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c.
d.
“Would you like to talk to the hospital chaplain about your feelings?”
“Do you think that taking an antidepressant medication would be helpful?”
Correct Answer: B
Rationale: The nurse’s initial response should be to collect more assessment data about the patient’s statement. The
answer beginning “Can you tell me what it is” is the most open-ended question and will offer the best opportunity
for obtaining more data. The answer beginning, “Are you afraid” implies that the patient thinks that the cancer will
be immediately fatal, although the patient’s statement may not be related to the cancer diagnosis. The remaining two
answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether
these interventions are appropriate.
Cognitive Level: Application
Text Reference: pp. 583-584
Nursing Process: Implementation NCLEX: Psychosocial Integrity
28. A patient is admitted to the emergency department with a stab wound to the right chest. Air can be heard
entering his chest with each inspiration. To decrease the possibility of a tension pneumothorax in the patient, the
nurse should
a. position the patient so that the right chest is dependent.
b. administer high-flow oxygen using a non-rebreathing mask.
c. cover the sucking chest wound with an occlusive dressing.
d. tape a nonporous dressing on three sides over the chest wound.
Correct Answer: D
Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during
expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the
right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and
cause tension pneumothorax. The patient should receive oxygen, but this will have no effect on the development of
tension pneumothorax.
Cognitive Level: Application
Text Reference: p. 586
Nursing Process: Implementation NCLEX: Physiological Integrity
29. The health carre provider inserts two chest tubes connected with a Y-connecter in a patient with a
hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most
concerned about
a. a large air leak in the water-seal chamber.
b. 400 ml of blood in the collection chamber.
c. severe pain with each deep patient inspiration.
d. subcutaneous emphysema at the insertion site.
Correct Answer: B
Rationale: The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock.
A large air leak would be expected immediately after chest tube placement for pneumothorax. The severe pain
should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous
emphysema should be monitored but is not unusual in a patient with pneumothorax.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 586
NCLEX: Physiological Integrity
30. A patient experiences a steering wheel injury as a result of an automobile accident. During the initial
assessment, the emergency department nurse would be most concerned about
a. complaints of severe pain.
b. heart rate of 110 beats/min.
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c.
d.
a large bruised area on the chest.
paradoxic chest movement.
Correct Answer: D
Rationale: Paradoxic chest movement indicates that the patient may have flail chest, which will severely
compromise gas exchange and can rapidly lead to hypoxemia. Severe pain, a slightly elevated pulse rate, and chest
bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 586, 588
NCLEX: Physiological Integrity
31. The emergency department nurse will suspect a tension pneumothorax in a patient who has been in an
automobile accident if
a. the breath sounds on one side are decreased.
b. there are wheezes audible throughout both lungs.
c. there is a sucking sound with each patient breath.
d. paradoxic movement of the chest is noted.
Correct Answer: A
Rationale: Breath sounds are decreased on the affected side with tension pneumothorax because air trapped in the
pleural space compresses the lung on that side. Wheezes that are heard in both lungs indicate airway narrowing, but
not pneumothorax. A sucking sound with inspiration is heard with an open pneumothorax. Paradoxic chest
movement is associated with flail chest.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 586
NCLEX: Physiological Integrity
32. The nurse identifies a nursing diagnosis of ineffective airway clearance for a patient who has incisional pain, a
poor cough effort, and scattered rhonchi after having a pneumonectomy. To promote airway clearance, the
nurse’s first action should be to
a. have the patient use the incentive spirometer.
b. medicate the patient with the ordered morphine.
c. splint the patient’s chest during coughing.
d. assist the patient to sit up at the bedside.
Correct Answer: B
Rationale: A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain
(which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient
to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be
done after the morphine is given.
Cognitive Level: Application
Text Reference: pp. 591, 594
Nursing Process: Implementation NCLEX: Physiological Integrity
33. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suctioncontrol chamber of the collection device. The most appropriate action by the nurse is to
a. document the presence of a large air leak.
b. obtain and attach a new collection device.
c. notify the health care provider of a possible pneumothorax.
d. take no further action with the collection device.
Correct Answer: C
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Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control
chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of
pneumothorax. A new collection device is needed when the collection chamber is filled.
Cognitive Level: Application
Text Reference: p. 591
Nursing Process: Implementation NCLEX: Physiological Integrity
34. When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the
lung, the nurse informs the patient that the postoperative care includes
a. positioning on the right side.
b. chest tubes to water-seal chest drainage.
c. bedrest for the first 24 hours.
d. frequent use of an incentive spirometer.
Correct Answer: D
Rationale: Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote
gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used
after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for
postoperative complications such as pneumonia and deep vein thrombosis.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 596-597
NCLEX: Physiological Integrity
35. A 68-year-old man has a long history of COPD and is admitted to the hospital with cor pulmonale. Which
clinical manifestation noted by the nurse is consistent with the cor pulmonale diagnosis?
a. Audible crackles at both lung bases
b. 3+ edema in the lower extremities
c. Loud murmur at the mitral area
d. High systemic BP
Correct Answer: B
Rationale: Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations
of right ventricular failure such as peripheral edema, jugular vein distension, and right upper-quadrant abdominal
tenderness would be expected. Lung crackles, a murmur, and numbness and tingling are not caused by cor
pulmonale.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 602
NCLEX: Physiological Integrity
36. The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan).
Which assessment information requires the most immediate action?
a. The international normalized ratio (INR) is prolonged.
b. The central line is disconnected.
c. The oxygen saturation is 90%.
d. The BP is 88/56.
Correct Answer: B
Rationale: The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to
prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but
the priority action is to reconnect the infusion.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 601
NCLEX: Physiological Integrity
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37. A patient with primary pulmonary hypertension is receiving nifedipine (Procardia). The nurse will evaluate that
the treatment is effective if
a. the patient reports decreased exertional dyspnea.
b. the blood pressure is less than 140/90 mm Hg.
c. the heart rate is between 60 and 100 beats/minute.
d. the patient’s chest x-ray indicates clear lung fields.
Correct Answer: A
Rationale: Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate
that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to
monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the
therapy is not effective.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 601
NCLEX: Physiological Integrity
38. A patient with a pleural effusion is scheduled for a thoracentesis. Prior to the procedure, the nurse will plan to
a. position the patient sitting upright on the edge of the bed and leaning forward.
b. instruct the patient about the importance of incentive spirometer use after the procedure.
c. start a peripheral intravenous line to administer the necessary sedative drugs.
d. remove the water pitcher and remind the patient not to eat or drink anything for 8 hours.
Correct Answer: A
Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more
easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not
needed to assure alveolar expansion. The patient does not usually require sedation for the procedure and there are no
restrictions on oral intake, since the patient is not sedated or unconscious.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 596
NCLEX: Physiological Integrity
39. After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate
that the teaching has been effective if the patient states
a. “I will make an appointment to see the doctor every year.”
b. “I will not turn the home oxygen up higher than 2 L/minute.”
c. “I will be careful to use sterile technique with my central line.”
d. “I will write down my medications and spirometry in a journal.”
Correct Answer: D
Rationale: After lung transplant, patients are taught to keep logs of medications, spirometry, and laboratory results.
Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be
sufficient. Home oxygen use is not an expectation after lung transplant and patients would not usually have a central
IV line.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 604
NCLEX: Physiological Integrity
40. A patient who was admitted the previous day with pneumonia complains of a sharp pain “whenever I take a
deep breath.” Which action will the nurse take next?
a. Listen to the patient’s lungs.
b. Check the patient’s O2 saturation.
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c.
d.
Have the patient cough forcefully.
Notify the patient’s health care provider.
Correct Answer: A
Rationale: The patient’s statement indicates that pleurisy or a pleural effusion may have developed and the nurse
will need to listen for a pleural friction rub and/or decreased breath sounds. The re is no indication that the oxygen
saturation has decreased The patient is unlikely to be able to cough forcefully until pain medication has been
administered. The nurse will want to obtain more assessment data before calling the health care provider.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 597
NCLEX: Physiological Integrity
41. A patient with a chronic productive cough and weight loss is receiving a tuberculosis skin test and asks the
nurse the reason for the test. Which response should the nurse give?
a. The skin test will determine if you have a tuberculosis infection.
b. The skin test will indicate whether you have active tuberculosis.
c. The skin test is used to decide which antibiotic therapy will work best.
d. The skin test is done prior to notification of the public health department.
Correct Answer: A
Rationale: A positive skin test will indicate whether the patient has been infected with tuberculosis. It does not
indicate active infection, which will be established through chest x-ray and sputum culture. Initial drug treatment
with 4 antibiotics uses a standardized protocol. Although the public health department should be notified if the
patient has TB, the nurse should focus on the patient, rather than on the public health concerns.
Cognitive Level: Application
Text Reference: p. 571
Nursing Process: Implementation NCLEX: Physiological Integrity
42. All of the following information is obtained by the nurse who is caring for a patient receiving subcutaneous
heparin injections to treat a pulmonary embolus. Which assessment data is most important to communicate to
the health care provider?
a. The patient has many abdominal bruises.
b. The patient’s BP is 90/46.
c. The activated partial thromboplastin time is 2 times the patient baseline.
d. The patient’s stool is dark green and liquid.
Correct Answer: B
Rationale: The low BP may indicate that the patient is experiencing bleeding, a possible adverse effect of heparin
therapy. Subcutaneous heparin administration is given into the subcutaneous tissue of the abdomen and abdominal
bruising is not unusual. An aPTT 2 times the baseline indicates a therapeutic heparin level. The patient should be
monitored for gastrointestinal bleeding, which would be indicated by black or red stools.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 600
NCLEX: Physiological Integrity
43. In developing a teaching plan for a patient who is being discharged with a warfarin (Coumadin) prescription
after having a pulmonary embolus, the nurse will include information about
a. where to schedule activated partial thromboplastin time testing.
b. avoidance of a high protein diet.
c. how to obtain enteric-coated aspirin.
d. foods that are high in vitamin K.
Correct Answer: D
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Rationale: The patient who is taking Coumadin should have a consistent vitamin K intake, since vitamin K
interferes with the effect of the medication. INR testing, rather than aPTT testing, is used to monitor for a
therapeutic level of Coumadin. Aside from vitamin K, there are no other dietary requirements associated with
Coumadin use. Aspirin should be avoided when taking anticoagulant medications because of the effect on platelet
function.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 600
NCLEX: Physiological Integrity
44. Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis
is most important to communicate to the health care provider?
a. BP is 150/90.
b. Pain level is 5/10 with a deep breath.
c. Oxygen saturation is 89%.
d. Respiratory rate is 24 when lying flat.
Correct Answer: C
Rationale: Oxygen saturation would be expected to improve after a thoracentesis; a saturation of 89 indicates that a
complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing
assessment or intervention, but the low oxygen saturation is the priority.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 596
NCLEX: Physiological Integrity
45. All of the following orders are received for a patient who has just been admitted with probable bacterial
pneumonia and sepsis. Which one will the nurse accomplish first?
a. Obtain blood cultures from two sites.
b. Give ciprofloxin (Cipro) 400 mg IV.
c. Send to radiology for chest radiograph.
d. Administer aspirin suppository.
Correct Answer: A
Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before
antibiotic administration. The chest radiograph and aspirin administration can be done last.
Cognitive Level: Application
Text Reference: p. 566
Nursing Process: Implementation NCLEX: Physiological Integrity
46. The nurse has received change-of-shift report about these four patients. Which one will the nurse plan to assess
first?
a. A 23-year-year-old patient with cystic fibrosis who has pulmonary function testing scheduled in 30
minutes
b. A 35-year-old patient who was admitted the previous day with bacterial pneumonia and has a
temperature of 100.2° F
c. A 46-year-old patient who is complaining of dyspnea after having a thoracentesis an hour
previously
d. A 77-year-old patient with TB who has four antitubercular medications due in 15 minutes
Correct Answer: C
Rationale: Dyspnea after a thoracentesis may indicate a pneumothorax or hemothorax and requires immediate
evaluation by the nurse. The other patients should also be assessed as soon as possible, but there is no indication that
they may need immediate action to prevent clinical deterioration.
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Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 596
NCLEX: Physiological Integrity
47. A patient with a deep vein thrombophlebitis complains of sudden chest pain and difficulty breathing. The nurse
finds a heart rate of 142, BP of 100/60, and respirations of 42. The nurse’s first action should be to
a. elevate the head of the bed.
b. administer the ordered pain medication.
c. notify the patient’s health care provider.
d. offer emotional support and reassurance.
Correct Answer: A
Rationale: The patient has symptoms consistent with a pulmonary embolism; elevating the head of the bed will
improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen
is started).
Cognitive Level: Application
Text Reference: p. 599
Nursing Process: Implementation NCLEX: Physiological Integrity
Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical
Problems, 6th Edition
Test Bank
Chapter 31: Nursing Assessment: Cardiovascular System
1. While monitoring a patient’s cardiac activity, the nurse recognizes that a normal physiologic
mechanism responsible for an increase in heart rate and force of cardiac contractions is
stimulation of
1. the vagus nerve.
2. baroreceptors in the aortic arch and carotid sinus.
3. alpha-adrenergic receptors in the vascular system.
4. chemoreceptors in the aortic arch and carotid body.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 760
2. A patient is receiving a drug that decreases peripheral arterial resistance. The nurse
anticipates that the effect of this drug on the patient’s cardiac function will result in
1. an increase in preload.
2. a decrease in afterload.
3. a decrease in contractibility.
4. a decrease in stroke volume.
Answer: 2
Nursing Process: Assessment
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Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 759
3. A patient has a blood pressure of 142/84 mm Hg. The nurse calculates the patient’s mean
arterial pressure (MAP) as
1. 103 mm Hg.
2. 113 mm Hg.
3. 123 mm Hg.
4. 131 mm Hg.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 760
4. A 70-year-old patient undergoes an exercise treadmill test. The nurse anticipates that as a
result of age-related changes in cardiac function, the patient will experience
1. evidence of decreased PR, QRS, and QT intervals.
2. less increase in the heart rate than in a younger patient.
3. a narrowed pulse pressure resulting from an increased diastolic pressure.
4. faster recovery to usual heart rate after exercise than in a younger patient.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 761
5. During physical examination of a 56-year-old man, the nurse palpates the PMI in the sixth
intercostal space lateral to the midclavicular line. The most appropriate interpretation of this
finding by the nurse is that
1. the PMI is in the normal location.
2. the patient may have left ventricular hypertrophy.
3. the patient has age-related downward displacement of the heart.
4. the patient should be observed for signs of left atrial enlargement.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 766
6. To auscultate for extra heart sounds in the mitral area, the nurse listens with the
1. bell of the stethoscope with the patient in the left lateral position.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
2. diaphragm of the stethoscope with the patient in a reclining position.
3. diaphragm of the stethoscope with the patient lying flat on the left side.
4. bell of the stethoscope with the patient sitting and leaning to the right side.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 767
7. When obtaining subjective data related to the patient’s health perception-health management
functional health pattern from a patient with possible coronary artery disease, the nurse
specifically asks about
1. symptoms that occur when the patient is under stress.
2. any discomfort or indigestion resulting from exercise or activity.
3. past episodes of sore throat, fever, or known streptococcal infections.
4. the practice of preventive measures known to decrease cardiac risk factors.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 762
8. During physical examination of a 72-year-old patient, the nurse observes pulsation of the
abdominal aorta in the epigastric area just below the xiphoid process. The nurse interprets
this finding as
1. normal assessment data.
2. sclerosis and inelasticity of the aorta.
3. a possible abdominal aortic aneurysm.
4. evidence of elevated systemic arterial pressure.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 766
9. A patient is scheduled for a cardiac catheterization with coronary angiography. Prior to the
test, the nurse informs the patient that
1. a catheter will be inserted into a vein in the arm or leg and advanced to the heart.
2. ECG monitoring will be required for 24 hours following the test to detect any
arrhythmias.
3. a feeling of warmth and a fluttering sensation may be experienced as the catheter is
advanced.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
4. complications of the test include breaking of the catheter, air or blood embolism, and
puncture of the ventricles.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 770
10. To assess for jugular vein distention in a patient with congestive heart failure, the nurse
should
1. ask the patient to perform the Valsalva maneuver while lying in a supine position.
2. palpate the jugular veins, comparing the volume and pressure of one with those of the
other.
3. measure in centimeters the distance the jugular veins are distended outward from the
neck.
4. observe the vertical distention of the veins as the patient is gradually elevated to an
upright position.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 764
11. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor
to
1. remove the electrodes to shower or bathe.
2. exercise as much as possible while his monitor is in place.
3. keep a diary of his activities as long as he wears the monitor.
4. attach the recorder and call the assigned number if an episode of irregular heart beats
occurs.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 768
12. When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. The
nurse documents this finding as a(n)
1. bruit.
2. thrill.
3. heave.
4. arterial obstruction.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 764-765
13. The physician orders serum troponin levels in a patient with a possible myocardial infarction.
The nurse explains to the patient that this test
1. is the most specific indicator for myocardial damage available.
2. measures the amount of myoglobin released from damaged myocardial cells.
3. can provide evidence of myocardial damage more quickly than can enzyme tests.
4. is diagnostic for myocardial damage only when used in combination with CK-MB
isoenzymes.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 770
14. A patient with a myocardial infarction has rhythm disturbances involving the AV node. The
nurse recognizes that the coronary artery most likely occluded is the
1. right coronary artery.
2. left circumflex coronary artery.
3. left descending coronary artery.
4. right ascending coronary artery.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 758
15. The nurse hears a very faint murmur after the S1 heart sound in a patient with a stenosed
mitral valve. The nurse records the murmur as a
1. diastolic gallop.
2. I/I systolic murmur.
3. I/VI systolic murmur.
4. I/VI diastolic murmur.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 767
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
16. When analyzing the waveforms of a patient’s ECG, the nurse identifies a disturbance in
electrical conduction in the ventricles upon finding a
1. T wave of 0.16 second.
2. PR interval of 0.18 second.
3. QT interval of 0.34 second.
4. QRS interval of 0.14 second.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 758-759
17. When assessing a 76-year-old woman, the nurse finds the following results: BP 146/102,
resting HR 104 and slightly irregular, S4 heart sound, and a grade I/VI aortic systolic
murmur. The nurse recognizes that normal effects of aging may be responsible for the (select
all that apply)
1. heart rate.
2. irregular pulse.
3. S4 heart sound.
4. systolic blood pressure.
5. diastolic blood pressure.
6. grade I/VI aortic systolic murmur.
Answers: 4, 6
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 761
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 32: Nursing Assessment: Cardiovascular System
MULTIPLE CHOICE
1. While assessing a patient who has just arrived in the emergency department, the nurse notes a pulse deficit. The
nurse will anticipate that the patient may require
a. hourly blood pressure (BP) checks.
b. a coronary arteriogram.
c. electrocardiographic (ECG) monitoring.
d. a 2-D echocardiogram.
Correct Answer: C
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Rationale: Pulse deficit is a difference between simultaneously obtained apical and radial pulses and indicates that
there may be cardiac dysrhythmias that would be detected with ECG monitoring. Frequent BP monitoring, coronary
arteriograms, and echocardiograms are used for diagnosis of other cardiovascular disorders but would not be as
helpful in determining the reason for the pulse deficit.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 750-751
NCLEX: Physiological Integrity
2. The nurse is monitoring a patient with possible coronary artery disease who is undergoing exercise (stress)
testing on a treadmill. The symptom that has the most immediate implications for the patient’s care during the
exercise testing is
a. the BP rising from 134/68 to 150/80 mm Hg.
b. the heart rate (HR) increasing from 80 to 96 beats/min.
c. the patient complaining of feeling short of breath.
d. the ECG indicating the presence of coronary ischemia.
Correct Answer: D
Rationale: ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment
depression) indicate that the myocardium is not getting adequate oxygen delivery and that the exercise test should be
immediately terminated. Increases in BP and HR are normal responses to aerobic exercise. Shortness of breath is
also normal as the intensity of exercise increases during the stress testing.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 753, 757
NCLEX: Physiological Integrity
3. The standard orders on the cardiac unit state, “Notify the health care provider for mean arterial pressure (MAP)
less than 70 mm Hg.” The nurse will need to call the health care provider about
a. the patient with left ventricular failure who has a BP of 110/70.
b. the patient with a myocardial infarction who has a BP of 114/50.
c. the postoperative patient with a BP 116/42.
d. the newly admitted patient with a BP of 122/60.
Correct Answer: C
Rationale: The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic
BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than
70 mm Hg.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 744
NCLEX: Physiological Integrity
4. When reviewing the 12-lead ECG for a healthy 86-year-old patient who is having an annual physical
examination, which of these observations will be of most concern to the nurse?
a. The PR interval is 0.21 seconds.
b. The HR is 43 beats/min.
c. There is a right bundle-branch block.
d. There is a QRS duration of 0.13 seconds.
Correct Answer: B
Rationale: The resting HR does not change with aging, so the decrease in HR requires further investigation.
Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because
of increases in conduction time through the AV node, the bundle of His, and the bundle branches.
Cognitive Level: Application
Text Reference: p. 744
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Process: Assessment
NCLEX: Physiological Integrity
5. During a physical examination of a patient, the nurse palpates the PMI in the sixth intercostal space lateral to
the midclavicular line. The most appropriate action for the nurse to take next will be to
a. document that the PMI is in the normal location.
b. assess the patient for symptoms of left ventricular hypertrophy.
c. ask the patient about risk factors for coronary artery disease.
d. auscultate both the carotid arteries for a bruit.
Correct Answer: B
Rationale: The PMI should be felt at the intersection of the 5th intercostal space and the midclavicular line. A PMI
located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy.
Cardiac enlargement is not necessarily associated with coronary or carotid artery disease.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 750-751
NCLEX: Physiological Integrity
6. To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. diaphragm of the stethoscope with the patient in a reclining position.
b. diaphragm of the stethoscope with the patient lying flat on the left side.
c. bell of the stethoscope with the patient in the left lateral position.
d. bell of the stethoscope with the patient sitting and leaning forward.
Correct Answer: C
Rationale: Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope.
Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart
closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher-pitched sounds such as S1 and
S2.
Cognitive Level: Application
Text Reference: pp. 750-751
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
7. The nurse is obtaining a health history for a new patient with possible coronary artery disease. Which question
would the nurse use when obtaining subjective data related to the patient’s health perception-health
management functional health pattern?
a. “Do you every have any discomfort or indigestion resulting from exercise or activity?”
b. “Have you had any recent episodes of sore throat, fever, or streptococcal infections?”
c. “How frequently do you have your cholesterol level and blood pressure checked?”
d. “Are there any symptoms that seem to occur when you are feeling very stressed?”
Correct Answer: C
Rationale: The health perception-health management functional pattern includes information related to what the
patient knows about coronary heart disease risk factors and actions the patient is taking to decrease risk. Any patient
history of streptococcal infections or sore throat would also be included in this functional pattern, but this patient has
possible coronary artery disease, not rheumatic heart disease. Information about discomfort caused by activity would
be included in the activity-exercise pattern. The data about symptoms in response to stress would be documented in
the coping-stress tolerance functional pattern.
Cognitive Level: Application
Text Reference: pp. 745-746
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
8. During physical examination of a thin 72-year-old patient, the nurse observes pulsation of the abdominal aorta
in the epigastric area just below the xiphoid process. The nurse teaches the patient that this is
a. a normal assessment finding for a thin individual.
b. likely to be caused by age-related sclerosis and inelasticity of the aorta.
c. an indication that an abdominal aortic aneurysm has probably developed.
d. evidence of elevated systemic arterial pressure.
Correct Answer: A
Rationale: Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals.
More data would be needed to support a diagnosis of aortic sclerosis, aortic aneurysm, or hypertension.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 750
NCLEX: Physiological Integrity
9. A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse
informs the patient that
a. a catheter will be inserted into a vein in the arm or leg and advanced to the heart.
b. ECG monitoring will be required for 24 hours following the test to detect any dysrhythmias.
c. a feeling of warmth may be experienced as the contrast material is injected into the catheter.
d. it will be important to lie completely still during the coronary angiography procedure.
Correct Answer: C
Rationale: A sensation of warmth or flushing is common when the iodine-based contrast material is injected, which
can be anxiety-producing unless it has been discussed with the patient. The catheter is inserted in an artery (typically
the femoral artery) and advanced to the openings for the coronary arteries at the aortic root. Dysrhythmias may
occur during the procedure, but most patients are discharged a few hours after the coronary arteriogram or
angiogram is completed. The patient is not required to be completely immobile during the procedure.
Cognitive Level: Application
Text Reference: pp. 755, 759
Nursing Process: Implementation NCLEX: Physiological Integrity
10. While assessing a patient with heart failure, the nurse notes that the patient has jugular venous distension (JVD)
when lying flat in bed. The nurse’s next action will be to
a. have the patient perform the Valsalva maneuver and observe the jugular veins.
b. palpate the jugular veins and compare the volume and pressure on the both sides.
c. use a centimeter ruler to measure and document accurately the level of the JVD.
d. elevate the patient gradually to an upright position and examine for continued JVD.
Correct Answer: D
Rationale: When assessing for and documenting JVD, the nurse should document the angle at which the patient is
positioned. When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common
(but not clinically significant) finding. JVD that persists when the patient is sitting at a 30- to 45-degree angle or
greater is significant. The nurse may use a ruler to determine the level of JVD above the heart if the JVD persists
when the patient is at 30 to 45 degree angle or more. JVD is an expected finding when a patient performs the
Valsalva maneuver because right atrial pressure increases. Comparison of the volume and pressure of the jugular
veins is not included in jugular vein assessment.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 748-749
NCLEX: Physiological Integrity
11. The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. remove the electrodes when taking a shower or tub bath.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
b.
c.
d.
exercise more than usual while the monitor is in place.
keep a diary of daily activities while the monitor is worn.
connect the recorder to a telephone transmitter once daily.
Correct Answer: C
Rationale: The patient is instructed to keep a diary describing daily activities while Holter monitoring is being
accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should
not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities.
The recorder stores the information about the patient’s rhythm until the end of the testing, when it is removed and
the data are analyzed.
Cognitive Level: Application
Text Reference: pp. 753, 757
Nursing Process: Implementation NCLEX: Physiological Integrity
12. When auscultating over the patient’s abdominal aorta, the nurse hears a humming sound. The nurse documents
this finding as a
a. thrill.
b. bruit.
c. heave.
d. murmur.
Correct Answer: B
Rationale: A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt
when there is turbulent blood flow through the heart or in a blood vessel. Heaves are sustained lifts over the
precordium that can be observed or palpated. A murmur is the sound caused by turbulent blood flow through the
heart.
Cognitive Level: Comprehension Text Reference: pp. 748, 750
Nursing Process: Assessment
NCLEX: Physiological Integrity
13. The nurse has received the laboratory results for a patient who developed chest pain 2 hours ago and may be
having a myocardial infarction. The most important laboratory result to review will be
a. troponins T and I.
b. creatine kinase-MB.
c. LDL cholesterol.
d. C-reactive protein.
Correct Answer: A
Rationale: Cardiac troponins start to elevate 1 hour after myocardial injury and are specific to myocardium.
Creatine kinase (CK-MB) is specific to myocardial injury and infarction, but it does not increase until 4 to 6 hours
after the infarction occurs. LDL cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are
not helpful in determining whether a patient is having an acute myocardial infarction.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 751-752
NCLEX: Physiological Integrity
14. When performing an assessment of a newly admitted patient, the nurse notes a thrill along the left sternal
border. To obtain more information about the cause of the thrill, which action will the nurse take next?
a. Palpate the quality of the peripheral pulses.
b. Compare the apical and radial pulse rates.
c. Assess for murmurs.
d. Locate the PMI.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Correct Answer: C
Rationale: Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood flows through a
damaged valve. Relevant information includes the quality of the murmur, where in the cardiac cycle the murmur is
heard, and where on the thorax the murmur is heard best. The other information is also important in the cardiac
assessment but will not provide information that is relevant to the thrill.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 748-749, 751
NCLEX: Physiological Integrity
15. The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left 5th intercostal space and
midclavicular line. The best way to record this information is
a. “systolic murmur heard at mitral area.”
b. “diastolic murmur heard at aortic area.”
c. “systolic murmur heard at Erb’s point.”
d. “diastolic murmur heard at tricuspid area.”
Correct Answer: A
Rationale: The S1 sound is created by closure of the mitral and tricuspid valves and signifies the onset of ventricular
systole. S2 is caused by the closure of the aortic and pulmonic valves and signifies the onset of diastole. A murmur
occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left 5th
intercostal space and the midclavicular line. The aortic area is located at the 2nd intercostal space along the right
sternal border. Erb’s point is located at the 3rd intercostal space along the left sternal border. The tricuspid area is
located at the 5th intercostal space along the left sternal border.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 749-751
NCLEX: Physiological Integrity
16. When admitting a patient for a coronary arteriogram and angiogram, the assessment information that will be
most important for the nurse to communicate to the health care provider is that the
a. patient had an arteriogram a year ago.
b. patient has not eaten anything yet today.
c. patient is allergic to shellfish.
d. patient’s pedal pulses are +1.
Correct Answer: C
Rationale: The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will
require treatment with medications such as corticosteroids and antihistamines before the arteriogram. The other
information is also communicated to the health care provider but will not require a change in the usual prearteriogram orders or medications.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 755
NCLEX: Physiological Integrity
17. The RN is observing a student nurse who is doing a physical assessment on a patient. The RN will need to
intervene immediately if the student nurse
a. presses on the skin over the tibia for 10 seconds to check for edema.
b. palpates both carotid arteries simultaneously to compare pulse quality.
c. places the patient in the left lateral position to check for the PMI.
d. uses the palm of the hand to assess extremity skin temperature.
Correct Answer: B
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias,
and decreased cerebral blood flow. The other assessment techniques also need to be corrected; however, they are not
dangerous to the patient.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 748
NCLEX: Physiological Integrity
18. A patient with syncope is scheduled for Holter monitoring. When teaching the patient about the purpose of the
procedure, the nurse will explain that Holder monitoring provides information about the
a. ventricular ejection fraction during usual daily activities.
b. cardiovascular response to high-intensity exercise.
c. changes in cardiac output when the patient is resting.
d. HR and rhythm during normal patient activities.
Correct Answer: D
Rationale: Holter monitoring is used to assess for possible changes in HR or rhythm over a 24- to 48-hour period.
The patient is usually instructed to continue with usual daily activities rather than changing exercise or activity level.
Because Holter monitoring is useful only for detecting rhythm changes, it is not useful in determining ejection
fraction or cardiac output.
Cognitive Level: Application
Text Reference: pp. 753, 757
Nursing Process: Implementation NCLEX: Physiological Integrity
19. A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which of these
actions included in the standard TEE orders will the nurse need to accomplish first?
a. Make the patient NPO.
b. Start a large-gauge IV line.
c. Administer O2 per mask.
d. Give lorazepam (Ativan) 1 mg IV.
Correct Answer: A
Rationale: The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on
NPO status as soon as the order is received. The other actions will also need to be accomplished, but not until just
before or during the procedure.
Cognitive Level: Application
Text Reference: p. 754
Nursing Process: Implementation NCLEX: Physiological Integrity
20. Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI)
will be most important to report to the health care provider before the MRI?
a. The patient has a history of coronary artery disease.
b. The patient took all the prescribed cardiac medications today.
c. The patient has an allergy to shellfish and iodine.
d. The patient has a permanent ventricular pacemaker in place.
Correct Answer: D
Rationale: MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other
information will also be reported to the health care provider but does not impact on whether or not the patient can
have an MRI.
Cognitive Level: Application
Text Reference: p. 755
Nursing Process: Implementation NCLEX: Physiological Integrity
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
MULTIPLE RESPONSE
1. When assessing a 76-year-old woman, the nurse finds the following results: BP 146/102, resting HR 104,
slightly irregular S4 heart sound, and a grade I/VI aortic systolic murmur. The nurse recognizes that common
effects of aging may be responsible for the (Select all that apply.)
a. HR.
b. irregular pulse.
c. S4 heart sound.
d. systolic BP.
e. diastolic BP.
f. grade I/VI aortic systolic murmur.
Correct Answer: C, D, F
Rationale: An S4 gallop, increased systolic BP, and aortic stenosis are associated with aging, although all these
findings require further assessment or intervention. Increases in HR, irregular heart rhythms, and diastolic BP
increases are not associated with increased age.
Cognitive Level: Comprehension Text Reference: p. 744
Nursing Process: Assessment
NCLEX: Physiological Integrity
Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical
Problems, 6th Edition
Test Bank
Chapter 34: Nursing Management: Heart Failure and Cardiomyopathy
1. A patient with a history of chronic congestive heart failure is hospitalized with severe
dyspnea and a dry, hacking cough. She has pitting edema in both ankles, and her vital signs
are blood pressure 170/100, pulse 92, and respirations 28. The nurse recognizes that the
patient’s symptoms indicate
1. the venous return to the heart is impaired, causing a decrease in cardiac output.
2. there is impaired emptying of both the right and left ventricles, with low forward blood
flow.
3. the right side of the heart is failing to pump enough blood to the lungs to provide
systemic oxygenation.
4. the myocardium is not receiving enough blood supply through the coronary arteries to
meet its oxygen demand.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 840, 842
2. A patient with chronic congestive heart failure tells the nurse at the clinic that he has gained
5 pounds in the last 3 days, even though he has continued to follow a low-sodium diet. The
nurse recognizes the patient
1. may be consuming hidden sources of sodium that are not obvious in prepared foods.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
2. should be instructed about a low-calorie, low-fat diet in addition to the sodium restriction.
3. should have the sodium restriction increased because it appears the patient has excessive
sodium retention.
4. should be evaluated for other symptoms that would indicate an exacerbation of
congestive heart failure.
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 842
3. During assessment of a 72-year-old man with swelling in his ankles, the nurse finds jugular
venous distention with the head of the bed elevated 45 degrees. The nurse knows this finding
indicates
1. decreased fluid volume.
2. elevated right atrial pressure.
3. incompetent jugular vein valves.
4. atherosclerosis of the jugular veins.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 840
4. The nurse monitors a patient receiving IV furosemide (Lasix) and enalapril (Vasotec) 5 mg
po bid for an acute exacerbation of congestive heart failure. The nurse determines that the
treatment is effective upon finding
1. a weight loss of 2 pounds.
2. an increase in urinary output.
3. a decrease in systolic blood pressure.
4. fewer crackles upon lung auscultation.
Answer: 4
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 846
5. To prevent the development of heart failure in a patient with hypertension, the nurse stresses
the importance of compliance with antihypertensive therapy, based on the knowledge that
1. diastolic failure and venous congestion may be caused by decreased preload.
2. systolic failure and low forward blood flow can result from increased afterload.
3. systolic failure and low forward blood flow is caused by impaired contractile force of the
heart.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
4. mixed systolic and diastolic failure may result from dilated cardiomyopathy precipitated
by hypertension.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 839
6. A patient with acute congestive heart failure has severe dyspnea and is extremely anxious.
The nurse anticipates that increased cardiac output and decreased anxiety may be promoted
by the intravenous administration of
1. morphine.
2. diazepam (Valium).
3. dopamine (Intropin).
4. nitroglycerin (Tridil).
Answer: 1
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 844
7. Intravenous nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema.
During the initial administration of the drug, the nurse monitors the patient for
1. bradycardia.
2. hypotension.
3. cyanide toxicity.
4. ventricular arrhythmias.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 844
8. A patient admitted to the hospital with an exacerbation of her chronic congestive heart failure
tells the nurse she was fine when she went to bed but woke up feeling as if she were
suffocating. The nurse explains that the onset of these symptoms in the middle of the night is
not unusual because
1. lying down decreases the ability of the heart to pump and leads to accumulation of fluid
in the lungs.
2. dreaming during sleep increases the heart’s need for oxygen and can bring on the
symptoms of heart failure.
3. sleeping causes a decreased heart rate and when the heart slows down, it can’t meet the
oxygen needs of the body.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
4. lying down promotes fluid reabsorption from her legs and when it returns to the heart, it
is too much for the heart to pump out.
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 842
9. During a visit to an elderly patient with chronic congestive heart failure, the home care nurse
finds that the patient has severe dependent edema and that her legs appear to be weeping
serous fluid. The nurse identifies a nursing diagnosis of
1. activity intolerance related to edema.
2. impaired skin integrity related to edema.
3. fluid volume excess related to congestive heart failure.
4. risk for impaired tissue perfusion related to decreased circulation.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 842
10. The nurse closely monitors the fluid balance of a patient in congestive heart failure, with the
knowledge that additional sodium and water retention occur in an already congested vascular
system as a result of
1. venous congestion in the liver.
2. increased pressure in lung arterioles.
3. decreased glomerular blood flow in the kidney.
4. excessive release of ADH from stress response.
Answer: 3
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 840
11. To promote more efficient ventricular emptying by decreasing preload in the patient with
congestive heart failure, the nurse should
1. administer oxygen per mask.
2. encourage active leg exercises to increase venous return.
3. administer sedatives to promote rest and decrease myocardial oxygen demand.
4. position the patient in a high Fowler’s position with the feet horizontal in the bed.
Answer: 4
Nursing Process: Implementation
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 844
12. When teaching the patient with congestive heart failure about a 2000-mg sodium diet, the
nurse explains that foods which need to be restricted include
1. eggs.
2. canned fruit.
3. frozen vegetables.
4. milk and milk products.
Answer: 4
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Health Promotion and Maintenance
Text Reference: p. 848
13. The nurse plans discharge teaching for a patient with chronic congestive heart failure who is
to be maintained on digoxin, hydrochlorothiazide (HydroDiuril), and a potassium
supplement. Appropriate instructions for the patient include
1. avoid dietary sources of potassium because too much can cause digitalis toxicity.
2. take the hydrochlorothiazide before bedtime to prevent drowsiness during the day.
3. notify the health care provider immediately if nausea or difficulty breathing occurs.
4. take the pulse rate before taking medications and never take the digoxin if the pulse rate
is below 60 beats a minute.
Answer: 3
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: pp. 852-853
14. The nurse identifies the collaborative problem of potential complication: pulmonary edema
for a patient in acute congestive heart failure. To prevent severe symptoms, an early finding
of this problem the nurse should monitor for is
1. bradycardia.
2. pink, frothy sputum.
3. decreased urinary output.
4. restlessness and agitation.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 840, 842
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
15. When the nurse is admitting an 80-year-old woman with congestive heart failure to the
medical unit, the patient says she lives alone and that she thinks she confuses her “water pill”
with her “heart pill.” The nurse makes a note that discharge planning for the patient should
include
1. a referral for a home care nurse.
2. placement in a skilled nursing care facility.
3. transfer to a special unit for individuals with dementia.
4. arrangements for a family member to be with the patient around-the-clock.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Heath Promotion and Maintenance
Text Reference: pp. 852-853
16. After successful digitalization, a patient is to begin oral maintenance of digoxin (Lanoxin)
and furosemide (Lasix) for control of congestive heart failure. To prevent digitalis toxicity,
the nurse understands that it is most important to monitor the patient’s
1. body weight.
2. liver function.
3. blood pressure.
4. serum potassium.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 847
17. Following an acute myocardial infarction, a 67-year-old man develops congestive heart
failure. The nurse anticipates that the first-line therapy for the patient will be a(n)
1. digitalis preparation, such as digoxin (Lanoxin).
2. diuretic, such as hydrochlorothiazide (HydroDiuril).
3. b-adrenergic agonist, such as dobutamine (Dobutrex).
4. angiotensin-coverting enzyme inhibitor, such as captopril (Capoten).
Answer: 4
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 845-846
18. A patient with primary dilated cardiomyopathy is hospitalized with pulmonary edema and
hypotension. In planning care for the patient, the nurse knows that
1. aggressive treatment of the patient’s heart failure with diuretics will control his
symptoms.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
2. the patient may need information regarding his grave prognosis and candidacy for heart
transplantation.
3. the patient needs to be reassured treatment of the underlying disease process will return
normal cardiac function.
4. the clinical manifestations of cardiomyopathy resemble those of congestive heart failure
but cardiomyopathy is more responsive to pharmacologic treatment.
Answer: 2
Nursing Process: Planning
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 855
19. While the nurse is taking a health history from a patient with hypertrophic cardiomyopathy,
information that the nurse recognizes as significant includes
1. a history of chronic alcohol use.
2. a history of a recent viral infection.
3. a family history of cardiomyopathy.
4. a history of multiple myocardial infarctions.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 855
20. A patient with dilated cardiomyopathy is admitted to the hospital with fatigue, orthopnea,
and pulmonary crackles. The patient has a left ventricular ejection fraction of 18%, and the
physician prescribes continuous intravenous heparin. The nurse explains to the patient that
the heparin is used to
1. prevent thrombus formation in the left ventricle.
2. increase the circulation to the skin and skeletal muscles.
3. prevent embolization to the lungs from clots in the legs.
4. decrease the viscosity of the blood to decrease cardiac workload.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: pp. 855, 843
21. A patient with inoperable coronary artery disease and end-stage cardiomyopathy asks the
nurse whether a heart transplant is possible for him. The nurse’s best response to the patient
is
1. “Candidacy for a heart transplant is a medical decision that should be made between you
and your doctor.”
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
2. “There are many factors that determine a patient’s candidacy for heart transplant, but the
lack of donor hearts is a major problem.”
3. “Since so few hearts are available, candidates for transplants must have no other history
of heart disease except primary cardiomyopathy.”
4. “A heart transplant is still considered an experimental surgery. Are you willing to
undergo such a high-risk surgery and the intensive follow-up care that is required?”
Answer: 2
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 857
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 35: Nursing Management: Heart Failure
MULTIPLE CHOICE
1. A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea
and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an
apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is
to
a. auscultate the lung sounds.
b. assess the orientation.
c. check the capillary refill.
d. palpate the abdomen.
Correct Answer: A
Rationale: When caring for a patient with severe dyspnea, the nurse should use the ABCs to guide initial care. This
patient’s severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF
usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing
hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient’s volume
status and should also be accomplished rapidly, but detection (and treatment) of fluid-filled alveoli is the priority.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 824-825
NCLEX: Physiological Integrity
2. A patient with chronic heart failure who has been following a low-sodium diet tells the nurse at the clinic about
a 5-pound weight gain in the last 3 days. The nurse’s first action will be to
a. ask the patient to recall the dietary intake for the last 3 days because there may be hidden sources of
sodium in the patient’s diet.
b. instruct the patient in a low-calorie, low-fat diet because the weight gain has likely been caused by
excessive intake of inappropriate foods.
c. assess the patient for clinical manifestations of acute heart failure because an exacerbation of the
chronic heart failure may be occurring.
d. educate the patient about the use of diuretic therapy because it is likely that the patient will need
medications to reduce the hypervolemia.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Correct Answer: C
Rationale: The 5-pound weight gain over 3 days indicates that the patient’s chronic heart failure may be worsening;
it is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as
lung crackles. A dietary recall to detect hidden sodium in the diet and teaching about diuretic therapy are appropriate
interventions but are not the first nursing actions indicated. There is no evidence that the patient’s weight gain is
caused by excessive dietary intake of fat or calories, so the answer beginning “instruct the patient in a low-calorie,
low-fat diet” describes an inappropriate action.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 826
NCLEX: Physiological Integrity
3. During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with
the head of the patient’s bed elevated 45 degrees. The nurse knows this finding indicates
a. decreased fluid volume.
b. incompetent jugular vein valves.
c. elevated right atrial pressure.
d. jugular vein atherosclerosis.
Correct Answer: C
Rationale: The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the
patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid
volume (increased preload), not decreased fluid volume; it is not caused by incompetent jugular vein valves or
atherosclerosis.
Cognitive Level: Comprehension Text Reference: p. 825
Nursing Process: Assessment
NCLEX: Physiological Integrity
4. The nurse is caring for a patient receiving IV furosemide (Lasix) 40 mg and enalapril (Vasotec) 5 mg PO bid for
ADHF with severe orthopnea. When evaluating the patient response to the medications, the best indicator that
the treatment has been effective is
a. weight loss of 2 pounds overnight.
b. improvement in hourly urinary output.
c. reduction in systolic BP.
d. decreased dyspnea with the head of the bed at 30 degrees.
Correct Answer: D
Rationale: Because the patient’s major clinical manifestation of ADHF is orthopnea (caused by the presence of
fluid in the alveoli), the best indicator that the medications are effective is a decrease in crackles. The other
assessment data also may indicate that diuresis or improvement in cardiac output have occurred but are not as useful
in evaluating this patient’s response.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 825
NCLEX: Physiological Integrity
5. When the nurse is developing a teaching plan to prevent the development of heart failure in a patient with stage
1 hypertension, the information that is most likely to improve compliance with antihypertensive therapy is that
a. hypertensive crisis may lead to development of acute heart failure in some patients.
b. hypertension eventually will lead to heart failure by overworking the heart muscle.
c. high BP increases risk for rheumatic heart disease.
d. high systemic pressure precipitates papillary muscle rupture.
Correct Answer: B
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Rationale: Hypertension is a primary cause of heart failure because the increase in ventricular afterload leads to
ventricular hypertrophy and dilation. Hypertensive crisis may precipitate acute heart failure is some patients, but this
patient with stage 1 hypertension may not be concerned about a crisis that happens only to some patients.
Hypertension does not directly cause rheumatic heart disease (which is precipitated by infection with group A hemolytic streptococcus) or papillary muscle rupture (which is caused by myocardial infarction/necrosis of the
papillary muscle).
Cognitive Level: Application
Text Reference: p. 822
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
6. A patient in the intensive care unit with ADHF complains of severe dyspnea and is anxious, tachypneic, and
tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to
a. administer IV morphine sulfate 2 mg.
b. give IV diazepam (Valium) 2.5 mg.
c. increase dopamine (Intropin) infusion by 2 mcg/kg/min.
d. increase nitroglycerin (Tridil) infusion by 5 mcg/min.
Correct Answer: A
Rationale: Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and
afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease
patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve
cardiac output but will also increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve
cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as
quickly as morphine to decrease dyspnea.
Cognitive Level: Analysis
Text Reference: pp. 828-829
Nursing Process: Implementation NCLEX: Physiological Integrity
7. Intravenous sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the
first hours of administration, the nurse will need to adjust the Nipride rate if the patient develops
a. a drop in heart rate to 54 beats/min.
b. a systolic BP <90 mm Hg.
c. any symptoms indicating cyanide toxicity.
d. an increased amount of ventricular ectopy.
Correct Answer: B
Rationale: Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. After
48 hours of continuous use, cyanide toxicity is a possible (though rare) adverse effect. Reflex tachycardia (not
bradycardia) is another adverse effect of this medication. Nitroprusside does not cause increased ventricular ectopy.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 828
NCLEX: Physiological Integrity
8. A patient admitted to the hospital with an exacerbation of chronic heart failure tells the nurse, “I felt fine when I
went to bed, but I woke up in the middle of the night feeling like I was suffocating!” The nurse can best
document this assessment information as
a. pulsus alternans.
b. paroxysmal nocturnal dyspnea.
c. two-pillow orthopnea.
d. acute bilateral pleural effusion.
Correct Answer: B
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when
the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans
is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is
unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period.
Cognitive Level: Comprehension Text Reference: p. 825
Nursing Process: Assessment
NCLEX: Physiological Integrity
9. During a visit to an elderly patient with chronic heart failure, the home care nurse finds that the patient has
severe dependent edema and that the legs appear to be weeping serous fluid. Based on these data, the best
nursing diagnosis for the patient is
a. activity intolerance related to venous congestion.
b. disturbed body image related to massive leg swelling.
c. impaired skin integrity related to peripheral edema.
d. impaired gas exchange related to chronic heart failure.
Correct Answer: C
Rationale: The patient’s findings of severe dependent edema and weeping serous fluid from the legs support the
nursing diagnosis of impaired skin integrity. There is less evidence for the nursing diagnoses of activity intolerance,
disturbed body image, and impaired gas exchange, although the nurse will further assess the patient to determine
whether there are other clinical manifestations of heart failure to indicate that these diagnoses are appropriate.
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 836
NCLEX: Physiological Integrity
10. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly
diagnosed heart failure has been effective when the patient
a. says that the nitroglycerin patch will be used for any chest pain that develops.
b. calls when the weight increases from 124 to 130 pounds in a week.
c. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime.
d. makes an appointment to see the doctor at least once yearly.
Correct Answer: B
Rationale: Teaching for a patient with heart failure includes information about the need to weigh daily and notify
the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are
used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily,
not on an “as necessary” basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance.
Heart failure is a chronic condition that will require frequent follow-up rather than an annual health care provider
examination.
Cognitive Level: Application
Text Reference: pp. 826, 833-834, 838
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance
11. When developing a plan to decrease preload in the patient with heart failure, the nurse will include actions such
as
a. administering sedatives to promote rest and decrease myocardial oxygen demand.
b. positioning the patient in a high-Fowler’s position with the feet horizontal in the bed.
c. administering oxygen per mask or nasal cannula.
d. encouraging leg exercises to improve venous return.
Correct Answer: B
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: Positioning the patient in a high-Fowler’s position with the legs dependent will reduce preload by
decreasing venous return to the right atrium. The other interventions may also be appropriate for patients with heart
failure but will not help in decreasing preload.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 827-828
NCLEX: Physiological Integrity
12. When teaching the patient with heart failure about a 2000-mg sodium diet, the nurse explains that foods to be
restricted include
a. eggs and other high-cholesterol foods.
b. canned and frozen fruits.
c. fresh or frozen vegetables.
d. milk, yogurt, and other milk products.
Correct Answer: D
Rationale: Milk and yogurt naturally contain a significant amount of sodium, and intake of these should be limited
for patients on a diet that limits sodium to 2000 mg daily. Other milk products, such as processed cheeses, have very
high levels of sodium and are not appropriate for a 2000-mg sodium diet. The other foods listed have minimal levels
of sodium and can be eaten without restriction.
Cognitive Level: Application
Text Reference: p. 833
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
13. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin
(Lanoxin), hydrochlorothiazide (HydroDIURIL), and a potassium supplement. Appropriate instructions for the
patient include
a. avoid dietary sources of potassium because too much can cause digitalis toxicity.
b. take the pulse rate daily and never take digoxin if the pulse is below 60 beats/min.
c. take the hydrochlorothiazide before bedtime to maximize activity level during the day.
d. notify the health care provider immediately if nausea or difficulty breathing occurs.
Correct Answer: D
Rationale: Difficulty breathing is an indication of acute decompensated heart failure and suggests that the
medications are not achieving the desired effect. Nausea is an indication of digoxin toxicity and should be reported
so that the provider can assess the patient for toxicity and adjust the digoxin dose, if necessary. Digoxin toxicity is
potentiated by hypokalemia, rather than hyperkalemia. Patients should be taught to check their pulse daily before
taking the digoxin and, if the pulse is less than 60, to call their provider before taking the digoxin. Diuretics should
be taken early in the day to avoid sleep disruption.
Cognitive Level: Application
Text Reference: p. 835
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
14. The nurse identifies the collaborative problem of potential complication: pulmonary edema for a patient in
ADHF. When assessing the patient, the nurse will be most concerned about
a. an apical pulse rate of 106 beats/min.
b. an oxygen saturation of 88% on room air.
c. weight gain of 1 kg (2.2 lb) over 24 hours.
d. decreased hourly patient urinary output.
Correct Answer: B
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer
supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in
urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation
rate requires the most immediate nursing action.
Cognitive Level: Analysis
Nursing Process: Assessment
Text Reference: pp. 829-830
NCLEX: Physiological Integrity
15. While admitting an 80-year-old patient with heart failure to the medical unit, the nurse obtains the information
that the patient lives alone and sometimes confuses the “water pill” with the “heart pill.” The nurse makes a
note that discharge planning for the patient will need to include
a. transfer to a dementia care service.
b. referral to a home health care agency.
c. placement in a long-term-care facility.
d. arrangements for around-the-clock care.
Correct Answer: B
Rationale: The data about the patient suggest that assistance in developing a system for taking medications
correctly at home is needed. A home health nurse will assess the patient’s home situation and help the patient to
develop a method for taking the two medications as directed. There is no evidence that the patient requires services
such as dementia care, long-term-care, or around-the-clock home care.
Cognitive Level: Application
Text Reference: pp. 836-837
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
16. A home health care patient has recently started taking oral digoxin (Lanoxin) and furosemide (Lasix) for control
of heart failure. The patient data that will require the most immediate action by the nurse is if the patient’s
a. weight increases from 120 pounds to 122 pounds over 3 days.
b. liver is palpable 2 cm below the ribs on the right side.
c. serum potassium level is 3.0 mEq/L after 1 week of therapy.
d. has 1 to 2+ edema in the feet and ankles in the morning.
Correct Answer: C
Rationale: Hypokalemia potentiates the actions of digoxin and increases the risk for digoxin toxicity, which can
cause life-threatening dysrhythmias. The other data indicate that the patient’s heart failure requires more effective
therapies, but they do not require nursing action as rapidly as the low serum potassium level.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 832-833
NCLEX: Physiological Integrity
17. Following an acute myocardial infarction, a previously healthy 67-year-old patient develops clinical
manifestations of heart failure. The nurse anticipates discharge teaching will include information about
a. digitalis preparations, such as digoxin (Lanoxin).
b. calcium-channel blockers, such as diltiazem (Cardizem).
c. -adrenergic agonists, such as dobutamine (Dobutrex).
d. angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten).
Correct Answer: D
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Rationale: ACE-inhibitor therapy is currently recommended to prevent the development of heart failure in patients
who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin
therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol
when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient.
Calcium-channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as
dobutamine are administered through the IV route and are not used as initial therapy for heart failure.
Cognitive Level: Application
Text Reference: p. 832
Nursing Process: Implementation NCLEX: Physiological Integrity
18. A 55-year-old patient with inoperable coronary artery disease and end-stage heart failure asks the nurse whether
heart transplant is a possible therapy. The nurse’s response to the patient will be based on the knowledge that
a. heart transplants are experimental surgeries that are not covered by most insurance.
b. the patient is too old to be placed on the transplant list.
c. the diagnoses and symptoms indicate that the patient is not an appropriate candidate.
d. candidacy for heart transplant depends on many factors.
Correct Answer: D
Rationale: Indications for a heart transplant include inoperable coronary artery disease and refractory endstage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the
rigorous post-transplant regimen are also considered. Heart transplants are not considered experimental; rather,
transplantation has become the treatment of choice for patients who meet the criteria. The patient is not too old for a
transplant. The patient's diagnoses and symptoms indicate that the patient may be an appropriate candidate for a
heart transplant.
Cognitive Level: Comprehension Text Reference: p. 837
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
19. An outpatient who has developed heart failure after having an acute myocardial infarction has a new
prescription for carvedilol (Coreg). After 2 weeks, the patient returns to the clinic. The assessment finding that
will be of most concern to the nurse is that the patient
a. has BP of 88/42.
b. has an apical pulse rate of 56.
c. complains of feeling tired.
d. has 2+ pedal edema.
Correct Answer: A
Rationale: The patient’s BP indicates that the dose of carvedilol may need to be decreased because the mean arterial
pressure is only 57. Bradycardia is a frequent adverse effect of -Adrenergic blockade, but the rate of 56 is not as
great a concern as the hypotension. -adrenergic blockade will initially worsen symptoms of heart failure in many
patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected
during the initiation of therapy with this class of drugs.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 832
NCLEX: Analysis
20. An elderly patient with a 40-pack-year history of smoking and a recent myocardial infarction is admitted to the
medical unit with acute shortness of breath; the nurse need to rule out pneumonia versus heart failure. The
diagnostic test that the nurse will monitor to help in determining whether the patient has heart failure is
a. 12-lead electrocardiogram (ECG).
b. arterial blood gases (ABGs).
c. B-type natriuretic peptide (BNP).
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
d.
serum creatine kinase (CK).
Correct Answer: C
Rationale: BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a
probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK may also be used in determining
the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 827
NCLEX: Physiological Integrity
21. A patient with ADHF who is receiving nesiritide (Natrecor) asks the nurse how the medication will work to
help improve the symptoms of dyspnea and orthopnea. The nurse’s reply will be based on the information that
nesiritide will
a. dilate arterial and venous blood vessels, decreasing ventricular preload and afterload.
b. improve the ability of the ventricular myocardium to contract, strengthening contractility.
c. enhance the speed of impulse conduction through the heart, increasing the heart rate.
d. increase calcium sensitivity in vascular smooth muscle, boosting systemic vascular resistance.
Correct Answer: A
Rationale: Nesiritide, a recombinant form of BNP, causes both arterial and venous vasodilation, leading to
reductions in preload and afterload. Inotropic medications, such as dopamine and dobutamine, may be used in
ADHF to improve ventricular contractility. Nesiritide does not increase impulse conduction or calcium sensitivity in
the heart.
Cognitive Level: Application
Text Reference: p. 829
Nursing Process: Implementation NCLEX: Physiological Integrity
22. A patient who is receiving dobutamine (Dobutrex) for the treatment of ADHF has all of the following nursing
actions included in the plan of care. Which action will be best for the RN to delegate to an experienced
LPN/LVN?
a. Teach the patient the reasons for remaining on bed rest.
b. Monitor the patient’s BP every hour.
c. Adjust the drip rate to keep the systolic BP >90 mm Hg.
d. Call the health care provider about a decrease in urine output.
Correct Answer: B
Rationale: An experienced LPN/LVN would be able to monitor BP and would know to report significant changes to
the RN. Teaching patients and making adjustments to the drip rate for vasoactive medications are RN-level skills.
Because the health care provider may order changes in therapy based on the decrease in urine output, the RN should
call the health care provider about the decreased urine output.
Cognitive Level: Application
Text Reference: pp. 827-829
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment
23. A hospitalized patient with heart failure has a new order for captopril (Capoten) 12.5 mg PO. After
administering the first dose and teaching the patient about captopril, which statement by the patient indicates
that teaching has been effective?
a. “I will need to include more high-potassium foods in my diet.”
b. “I will expect to feel more short of breath for the next few days.”
c. “I will be sure to take the medication after eating something.”
d. “I will call for help when I need to get up to the bathroom.”
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
Correct Answer: D
Rationale: Captopril can cause hypotension, especially after the initial dose, so it is important that the patient not
get up out of bed without assistance until the nurse has had a chance to evaluate the effect of the first dose. The ACE
inhibitors are potassium sparring, and the nurse should not teach the patient to increase sources of dietary potassium.
Increased shortness of breath is expected with initiation of -blocker therapy for heart failure, not for ACE-inhibitor
therapy. ACE inhibitors are best absorbed when taken an hour before eating.
Cognitive Level: Application
Nursing Process: Evaluation
Text Reference: p. 832
NCLEX: Physiological Integrity
Lewis: Medical-Surgical Nursing: Assessment and Management of Clinical
Problems, 6th Edition
Test Bank
Chapter 36: Nursing Management: Inflammatory and Valvular Heart Diseases
1. The nurse obtains a health history from a patient with a prosthetic mitral valve who has
symptoms of infective endocarditis. A significant finding that constitutes a risk factor for
infective endocarditis in this patient is a history of a recent
1. myocardial infarction.
2. streptococcal pharyngitis.
3. professional teeth cleaning.
4. viral upper respiratory infection.
Answer: 3
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 889
2. The physician writes the following admitting orders for a patient with suspected infective
endocarditis who has fever and chills: ceftriaxone (Rocephin) 1.0 g IVPB q12hr, ASA for
temperature above 102° F (38.9° C), and blood cultures x 3, CBC, SMAC, and ECG. When
admitting the patient, the nurse gives the highest priority to
1. scheduling the ECG.
2. initiating the IV antibiotic.
3. obtaining the blood cultures.
4. administering the antipyretic agent.
Answer: 3
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 888
3. During the assessment of a patient with infective endocarditis, the nurse would expect to find
1. a new regurgitant murmur.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
2. splinter hemorrhages of the lips.
3. dyspnea and a dry, hacking cough.
4. substernal chest pain and pressure.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 887
4. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular
insufficiency for the patient with infective endocarditis, based on the assessment finding of
1. decreasing urine output.
2. fever, chills, and diaphoresis.
3. petechiae of the buccal mucosa and conjunctiva.
4. an increase in pulse rate of 20 bpm with activity.
Answer: 1
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 891
5. A patient hospitalized with a streptococcal infective endocarditis tells the nurse that the
physician said treatment would require 4 to 6 weeks of antibiotic therapy and says she needs
to get back to work as soon as possible. In advising the patient about the expected treatment
regimen for infective endocarditis, the nurse explains that
1. after 2 weeks of IV antibiotic therapy, she may be discharged with oral antibiotics to take
for another 4 weeks.
2. hospitalization for 4 to 6 weeks will be necessary to prevent a relapse while she receives
IV antibiotic therapy.
3. she may be able to receive outpatient IV antibiotic therapy with home nursing care if
complications do not develop.
4. she will be able to return to work as soon as her fever subsides, if she does not develop
any symptoms of heart failure.
Answer: 3
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: pp. 890, 892
6. A patient hospitalized with infective endocarditis develops sharp left flank pain and
hematuria. The nurse notifies the physician, recognizing that these symptoms may indicate
1. bacterial colonization in the kidneys.
2. vegetative embolization to the kidneys.
Copyright © 2004, 2000, Mosby, Inc. All Rights Reserved.
3. septicemia resulting in decreased glomerular blood flow.
4. hemolysis of red blood cells by hemolytic microorganisms.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 888
7. A patient is admitted to the hospital with possible acute pericarditis. The nurse explains to the
patient that to confirm a diagnosis of acute pericarditis, the physician will most likely use
1. multiple ECGs.
2. daily blood cultures.
3. cardiac catheterization.
4. fluid obtained by pericardiocentesis.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 894
8. To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse
should
1. place the diaphragm of the stethoscope at the lower left sternal border of the chest.
2. ask the patient to stop breathing during auscultation to distinguish the sound from a
pleural rub.
3. use the diaphragm of the stethoscope to listen for a rumbling, low-pitched sound that
occurs during systole.
4. palpate the precordial area with the tips of the fingers to detect a vibration that occurs
with each cardiac contraction.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 893
9. The nurse suspects the development of cardiac tamponade in a patient with acute pericarditis
upon finding
1. increased systolic BP.
2. jugular vein distention.
3. a pulsus paradoxus of 8 mm Hg.
4. increased systolic blood pressure with widening pulse pressure.
Answer: 2
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 893
10. Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the
presence of pulsus paradoxus, the nurse should
1. subtract one-third of the diastolic blood pressure from the systolic blood pressure.
2. auscultate for a pericardial friction rub that increases in volume during inspiration.
3. evaluate the rhythm of the pulse in relation to the patient’s inspiration and expiration.
4. note the first Korotkoff sound occurring during both inspiration and expiration, while
deflating the blood pressure cuff.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Comprehension
NCLEX: Physiologic Integrity
Text Reference: p. 893
11. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for
a patient with acute pericarditis. The most appropriate intervention by the nurse for this
problem is to
1. force fluids to 3000 ml/day to decrease fever and inflammation.
2. teach the patient to take deep, slow respirations to control the pain.
3. position the patient in Fowler’s position, leaning forward on a padded overbed table.
4. consult with the physician to provide patient-controlled analgesia (PCA) with a narcotic
analgesic.
Answer: 3
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 895
12. While obtaining a nursing history from a 23-year-old man with rheumatic fever, the nurse
recognizes that the most significant information related by the patient is that he
1. has used illicit intravenous drugs within the last 3 months.
2. has been unemployed for 6 months and has been eating poorly.
3. suffered chest trauma with a fractured rib during a fight 2 weeks ago.
4. had an upper respiratory infection with a sore throat about 3 weeks ago.
Answer: 4
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 897
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
13. A 22-year-old patient with rheumatic fever has subcutaneous nodules, erythema marginatum,
and polyarthritis of multiple joints. An appropriate nursing diagnosis based on these findings
is
1. activity intolerance related to arthralgia.
2. risk for infection related to open skin lesions.
3. risk for impaired skin integrity related to pruritus and scratching.
4. risk for impaired physical mobility related to permanent joint fixation.
Answer: 1
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: pp. 898-899
14. The nurse establishes the nursing diagnosis of ineffective therapeutic regimen management
related to lack of knowledge concerning long-term management of rheumatic fever when a
patient recovering from rheumatic endocarditis says
1. “I will have to take prophylactic antibiotics for years, perhaps indefinitely.”
2. “I know I should see my physician if I develop excessive fatigue or difficulty breathing.”
3. “I should avoid contact with school-aged children and persons with upper respiratory
infections.”
4. “My monthly antibiotic injection will protect me during any invasive procedures I need
to have performed.”
Answer: 4
Nursing Process: Diagnosis
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 900
15. The community health nurse involved in programs to prevent rheumatic fever knows that the
most important intervention to decrease the incidence of the disease includes
1. immunizing susceptible groups of people with streptococcal vaccine.
2. providing prophylactic antibiotics to people with a family history of rheumatic fever.
3. teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis.
4. promoting hygienic measures to prevent the transmission of streptococcal infections.
Answer: 3
Nursing Process: Planning
Cognitive Level: Comprehension
NCLEX: Health Promotion and Maintenance
Text Reference: p. 899
16. During the nursing assessment of any patient with a valvular disorder, the nurse would
expect to find
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
1.
2.
3.
4.
murmurs.
systolic clicks.
pericardial friction rubs.
brisk, hammering pulses.
Answer: 1
Nursing Process: Assessment
Cognitive Level: Knowledge
NCLEX: Physiologic Integrity
Text Reference: p. 901
17. During assessment of a patient with mitral valve stenosis, findings that the nurse recognizes
are characteristic of the pressure gradient differences occurring with mitral valve stenosis
include
1. angina and syncope.
2. dyspnea and hemoptysis.
3. jugular vein distention and peripheral edema.
4. hypotension and paroxysmal nocturnal dyspnea.
Answer: 2
Nursing Process: Assessment
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 901
18. A 21-year-old female student is scheduled for an open mitral valve commissurotomy for
treatment of a mitral stenosis resulting from rheumatic endocarditis when she was a child. A
factor supporting the choice of valve repair over valve replacement in this patient is that
1. there are no artificial valves available yet to replace mitral valves.
2. valve repair has a lower operative mortality rate than does valve replacement.
3. biologic replacement valves stimulate antibody production, necessitating long-term
immunosuppressive therapy.
4. long-term anticoagulation necessary with mechanical valve replacement is
contraindicated in women of childbearing age.
Answer: 4
Nursing Process: Planning
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 906
19. While caring for a patient with mitral valve prolapse with mild valvular regurgitation, the
nurse determines that discharge teaching has been effective when the patient tells the nurse
she will
1. take 1 aspirin a day to prevent embolization.
2. limit her physical activity to avoid stressing her heart valves.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
3. consider undergoing valvular surgery within the next 6 months.
4. request prophylactic antibiotic therapy prior to any invasive dental or medical procedures.
Answer: 4
Nursing Process: Evaluation
Cognitive Level: Application
NCLEX: Health Promotion and Maintenance
Text Reference: p. 903
20. A patient with an acute myocardial infarction develops ischemic papillary muscle
dysfunction. The nurse assesses the patient for manifestations of
1. aortic regurgitation.
2. mitral regurgitation.
3. mitral valve prolapse.
4. tricuspid regurgitation.
Answer: 2
Nursing Process: Diagnosis
Cognitive Level: Comprehension
NCLEX: Application
Text Reference: p. 901
21. The nurse establishes a nursing diagnosis of pain related to decreased coronary blood flow
while caring for a patient with aortic stenosis. An appropriate intervention by the nurse is to
1. promote rest to decrease myocardial oxygen demand.
2. consult with the physician about the use of nitroglycerine.
3. monitor peripheral pulses to detect peripheral embolization.
4. elevate the head of the bed 40 degrees to decrease venous return.
Answer: 1
Nursing Process: Implementation
Cognitive Level: Application
NCLEX: Physiologic Integrity
Text Reference: p. 904
22. During postoperative teaching with a patient who has had a mitral valve replacement with a
mechanical valve, the nurse instructs the patient regarding
1. the need to avoid high-voltage electrical fields.
2. the need for anticoagulation therapy for the duration of the valve.
3. the probability that the valve will need to be replaced in 7 to 10 years.
4. the need to check the pulse daily to determine the functioning of the valve.
Answer: 2
Nursing Process: Implementation
Cognitive Level: Comprehension
NCLEX: Health Promotion and Maintenance
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Text Reference: pp. 906, 908
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 37: Nursing Management: Inflammatory and Structural Heart Disorders
MULTIPLE CHOICE
1. The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective
endocarditis. Which question by the nurse is most appropriate?
a. “Do you have a history of a heart attack?”
b. “Have you any recent immunizations?”
c. “Have you been to the dentist lately?”
d. “Is there a family history of endocarditis?”
Correct Answer: C
Rationale: Dental procedures place the patient with a prosthetic mitral valve at risk for infectious endocarditis (IE).
Myocardial infarction (MI), immunizations, and a family history of endocarditis are not risk factors for IE.
Cognitive Level: Application
Nursing Process: Assessment
2.
a.
b.
c.
d.
Text Reference: pp. 867, 869
NCLEX: Physiological Integrity
The health care provider writes the following admitting orders for a patient with suspected IE who has fever and
chills: ceftriaxone (Rocephin) 1.0 g intravenous piggyback (IVPB) q12hr, acetylsalicylic acid (ASA) for
temperature above 102° F (38.9° C), and blood cultures 2, complete blood cell count (CBC), and
electrocardiogram (ECG). When admitting the patient, the nurse gives the highest priority to
obtaining the blood cultures.
initiating the IV antibiotic.
scheduling the ECG.
administering the ASA.
Correct Answer: A
Rationale: Treatment of the IE with antibiotics should be started as quickly as possible, but it is essential to obtain
blood cultures before initiating antibiotic therapy to obtain accurate sensitivity results. The ECG and ASA should
also be accomplished rapidly, but the blood cultures (and then administration of the antibiotic) have highest priority.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 867
NCLEX: Physiological Integrity
3. During the assessment of a patient with IE, the nurse would expect to find
a. substernal chest pain and pressure.
b. splinter hemorrhages of the lips.
c. dyspnea and a dry, hacking cough.
d. a new regurgitant murmur.
Correct Answer: D
Rationale: New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Splinter
hemorrhages occur on the nailbeds. Chest pain for pressure is not typical for the patient with IE and would be more
consistent with angina or MI. Although dyspnea may occur as a result of heart failure, a moist cough would be
expected rather than a dry, hacking cough.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
80
Cognitive Level: Comprehension Text Reference: p. 867
Nursing Process: Assessment
NCLEX: Physiological Integrity
4. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the
patient with IE based on the assessment finding of
a. petechiae of the buccal mucosa and conjunctiva.
b. fever, chills, and diaphoresis.
c. urine output less than 30 ml/hr.
d. an increase in pulse rate of 15 beats/min with activity.
Correct Answer: C
Rationale: Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine output. Petechiae,
fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in
pulse rate of 15 beats/min is normal with exercise
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 870
NCLEX: Physiological Integrity
5. A patient hospitalized with a streptococcal infective endocarditis tells the nurse,” I know that I need antibiotics,
but I do not want to be hospitalized for very long.” The nurse explains that
a. after 2 weeks of IV antibiotic therapy, the patient may be discharged with oral antibiotics to take for
another 4 weeks.
b. hospitalization for 4 to 6 weeks will be necessary to prevent a relapse while receiving IV antibiotic
therapy.
c. the patient will be able to receive outpatient IV antibiotic therapy if complications such as heart
failure do not develop.
d. hospitalization for IV antibiotics is necessary until the fever is resolved, but then the patient can be
discharged on oral antibiotics.
Correct Answer: C
Rationale: Treatment for IE involves 4 to 6 weeks of IV antibiotic therapy in order to eradicate the bacteria, but
patients frequently receive IV antibiotics on an outpatient basis. Oral antibiotics do not result in the consistently high
antibiotic level that is needed to eradicate the infective bacteria. The resolution of the fever is not an indication that
the patient can be discharged or that oral antibiotics are adequate for treatment.
Cognitive Level: Application
Text Reference: p. 871
Nursing Process: Implementation NCLEX: Physiological Integrity
6. A patient hospitalized with IE develops sharp left flank pain and hematuria. The nurse notifies the health care
provider, recognizing that these symptoms may indicate
a. septicemia.
b. acute pyelonephritis.
c. vegetative embolization.
d. glomerulonephritis.
Correct Answer: C
Rationale: The patient’s clinical manifestations and history of IE indicate embolization. Sudden onset flank pain is
not typical of pyelonephritis, septicemia, or glomerulonephritis.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 869
NCLEX: Physiological Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
81
7. A patient is admitted to the hospital with possible acute pericarditis. The nurse will plan to teach the patient
about the purpose of
a. multiple ECGs.
b. daily blood cultures.
c. cardiac catheterization.
d. pericardiocentesis.
Correct Answer: A
Rationale: Pericarditis causes changes such as ST segment elevation in multiple leads on the ECG, which evolve
over the course of the inflammatory process. Blood cultures are not indicated unless the patient has evidence of
sepsis. Cardiac catheterization is not a diagnostic procedure for pericarditis. Pericardiocentesis will not be done
unless the patient has symptoms of cardiac tamponade.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 872
NCLEX: Physiological Integrity
8. To assess the patient with pericarditis for the presence of a pericardial friction rub, the nurse should
a. place the diaphragm of the stethoscope at the lower left sternal border of the chest.
b. ask the patient to stop breathing during auscultation to distinguish the sound from a pleural friction
rub.
c. use the diaphragm of the stethoscope to listen for a rumbling, low-pitched, systolic sound.
d. feel the precordial area with the palm of the hand to detect vibration with cardiac contraction.
Correct Answer: A
Rationale: Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. Because
dyspnea is one clinical manifestation of pericarditis, the nurse should time the friction rub with the pulse rather than
ask the patient to stop breathing during auscultation. Friction rubs are not typically low pitched or rumbling and are
not confined to systole. Rubs are not assessed by palpation.
Cognitive Level: Comprehension Text Reference: p. 872
Nursing Process: Assessment
NCLEX: Physiological Integrity
9. Which of these assessment data obtained by the nurse when assessing a patient with acute pericarditis should be
reported immediately to the health care provider?
a. Blood pressure (BP) of 166/96
b. Jugular vein distension (JVD) to the level of the jaw
c. Pulsus paradoxus 8 mm Hg
d. Level 6/10 chest pain with deep inspiration
Correct Answer: B
Rationale: The JVD indicates that the patient may have developed cardiac tamponade and may need rapid
intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of
pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care
provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with
pericarditis.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 872
NCLEX: Physiological Integrity
10. Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess for the presence of pulsus
paradoxus, the nurse should
a. subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
b. auscultate for a pericardial friction rub that increases in volume during inspiration.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
c.
d.
82
note when Korotkoff sounds are audible during both inspiration and expiration.
check the ECG for variations in rate in relation to inspiration and expiration.
Correct Answer: C
Rationale: Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds
can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods
described would not be useful in determining the presence of pulsus paradoxus.
Cognitive Level: Comprehension Text Reference: p. 873
Nursing Process: Assessment
NCLEX: Physiological Integrity
11. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with
acute pericarditis. The most appropriate intervention by the nurse for this problem is to
a. force fluids to 3000 ml/day to decrease fever and inflammation.
b. teach the patient to take deep, slow respirations to control the pain.
c. position the patient in Fowler’s position, leaning forward on the overbed table.
d. remind the patient to ask for the opioid pain medication every four hours.
Correct Answer: C
Rationale: Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis.
Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial
pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually
ordered PRN. The patient would receive scheduled doses of a nonsteroidal antiinflammatory drug (NSAID).
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 874
NCLEX: Physiological Integrity
12. While obtaining an admission health history from a patient with possible rheumatic fever, which question will
be most pertinent to ask?
a. “Are you using any illegal IV drugs?”
b. “Do you have any family history of congenital heart disease?”
c. “Can you recall having any chest injuries in the last few weeks?”
d. “Have you had a recent sore throat?”
Correct Answer: D
Rationale: Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal infection.
Although illicit IV drug use should be discussed with the patient before discharge, it is not a risk factor for
rheumatic fever and would not be as pertinent when admitting the patient. Family history is not a risk factor for
rheumatic fever. Chest injury would cause musculoskeletal chest pain rather than rheumatic fever.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 875
NCLEX: Physiological Integrity
13. A patient with rheumatic fever has subcutaneous nodules, erythema marginatum, and polyarthritis. An
appropriate nursing diagnosis based on these findings is
a. activity intolerance related to fatigue and arthralgia.
b. risk for infection related to open skin lesions.
c. risk for impaired skin integrity related to pruritus.
d. impaired physical mobility related to permanent joint fixation.
Correct Answer: A
Rationale: The clinical manifestations of rheumatic fever include fatigue and arthralgia. The skin lesions seen in
rheumatic fever are not open or pruritic. Joint inflammation is a temporary clinical manifestation of rheumatic fever.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
83
Cognitive Level: Application
Nursing Process: Diagnosis
Text Reference: p. 877
NCLEX: Physiological Integrity
14. The nurse establishes the nursing diagnosis of ineffective therapeutic regimen management related to lack of
knowledge concerning long-term management of rheumatic fever when a patient recovering from rheumatic
fever says,
a. “I will need to have monthly antibiotic injections for at 5 years or longer.”
b. “I will call the doctor if I develop excessive fatigue or difficulty breathing.”
c. “I will need to let my dentist know that I have had this rheumatic fever.”
d. “I will be immune to further episodes of rheumatic fever after this infection.”
Correct Answer: D
Rationale: Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient
statements are correct and would not support the nursing diagnosis of ineffective therapeutic regimen management
related to lack of knowledge.
Cognitive Level: Application
Text Reference: p. 878
Nursing Process: Diagnosis
NCLEX: Health Promotion and Maintenance
15. The community health nurse involved in programs to prevent rheumatic fever knows that the most important
intervention to decrease the incidence of the disease is
a. teaching people to seek medical diagnosis and treatment for streptococcal pharyngitis.
b. providing prophylactic antibiotics to people with a family history of rheumatic fever.
c. immunizing susceptible groups of people with streptococcal vaccine.
d. promoting hygienic measures to prevent the transmission of streptococcal infections.
Correct Answer: A
Rationale: The incidence of rheumatic fever is decreased by treatment of streptococcal infections with antibiotics.
Family history is not a risk factor for rheumatic fever. There is no immunization that is effective in decreasing the
incidence of rheumatic fever. Hygienic measures may help to decrease the spread of streptococcal infections but is
not the primary means of decreasing risk for rheumatic fever.
Cognitive Level: Comprehension Text Reference: p. 878
Nursing Process: Planning
NCLEX: Health Promotion and Maintenance
16. Which assessment information obtained by the nurse for a patient with aortic stenosis would be most important
to report to the health care provider?
a. A loud systolic murmur is audible along the right sternal border.
b. The patient complains of chest pain associated with ambulation.
c. The point of maximum impulse (PMI) is at the left midclavicular line.
d. A thrill is palpable at the 2nd intercostal space, right sternal border.
Correct Answer: B
Rationale: Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information
would be a priority. A systolic murmur and thrill would not be unusual for a patient with aortic stenosis. A PMI at
the left midclavicular line is normal.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 879, 880
NCLEX: Physiological Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
84
17. When caring for a patient with mitral valve stenosis, it is most important that the nurse assess for
a. angina and syncope.
b. dyspnea and hemoptysis.
c. JVD and peripheral edema.
d. hypotension and paroxysmal nocturnal dyspnea (PND).
Correct Answer: B
Rationale: The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in dyspnea
and hemoptysis. Angina and syncope are associated with aortic stenosis. JVD and peripheral edema are more
common in right-sided valvular disorders. Hypotension and PND suggest aortic regurgitation.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 879
NCLEX: Physiological Integrity
18. A 21-year-old woman is scheduled for an open mitral valve commissurotomy for treatment of mitral stenosis.
When explaining the advantage of valve repair instead of valve replacement to the patient, the nurse will
include the information that
a. mechanical mitral valves require replacement about every 10 years.
b. no antibiotic prophylaxis to prevent endocarditis is needed after valve repair.
c. biologic replacement valves require the use of life-long immunosuppressive drugs.
d. long-term anticoagulation is necessary after mechanical valve replacement.
Correct Answer: D
Rationale: Long-term anticoagulation therapy is needed after mechanical valve replacement, and this would restrict
decisions about career and childbearing in this patient. Mechanical valves are durable and typically last longer than
10 years. Patients require prophylactic antibiotics when having invasive procedures after either valve repair or
replacement. Biologic valves do not activate the immune system, and immunosuppressive therapy is not needed.
Cognitive Level: Application
Text Reference: p. 882
Nursing Process: Implementation NCLEX: Physiological Integrity
19. While caring for a patient with mitral valve prolapse with mild valvular regurgitation, the nurse determines that
discharge teaching has been effective when the patient tells the nurse she will
a. take 1 aspirin a day to prevent embolization from the valve.
b. limit physical activity to avoid stressing the heart valves.
c. schedule an appointment with the doctor every 6 months.
d. discuss the diagnosis of mitral valve prolapse with the dentist.
Correct Answer: D
Rationale: Mitral valve prolapse with regurgitation is a risk factor for infective endocarditis, and the patient needs
to discuss the need for antibiotic prophylaxis with the provider before any invasive medical or dental procedure is
done. Anticoagulation, restriction of physical activity, and frequent medical appointments are not required for mild
mitral valve prolapse.
Cognitive Level: Application
Text Reference: p. 880
Nursing Process: Evaluation
NCLEX: Health Promotion and Maintenance
20. While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of pain related to
decreased coronary blood flow. An appropriate intervention by the nurse is to
a. promote rest to decrease myocardial oxygen demand.
b. teach the patient to use sublingual nitroglycerin for chest pain.
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
c.
d.
85
educate the patient about the need for anticoagulant therapy.
elevate the head of the bed 40 degrees to decrease venous return.
Correct Answer: A
Rationale: Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The
patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to
decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial
fibrillation.
Cognitive Level: Application
Text Reference: p. 880
Nursing Process: Implementation NCLEX: Physiological Integrity
21. During postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve, the
nurse instructs the patient regarding
a. the need to avoid high-voltage electrical fields.
b. how to monitor anticoagulation therapy.
c. the need for valve replacement in 7 to 10 years.
d. how to check the radial pulse.
Correct Answer: B
Rationale: Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent
clotting on the valve. There is no need to avoid high-voltage electrical fields. Mechanical valves are durable and
would last longer than 7 to 10 years. Monitoring of radial pulse is not necessary after valve replacement.
Cognitive Level: Comprehension Text Reference: p. 882
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance
22. A few days after an acute MI, a patient complains of stabbing chest pain that increases with deep breathing.
Which action will the nurse take first?
a. Notify the patient’s health care provider.
b. Auscultate the heart sounds.
c. Check the patient’s oral temperature.
d. Give the ordered acetaminophen (Tylenol).
Correct Answer: B
Rationale: The patient’s clinical manifestations and history are consistent with pericarditis, and the first action by
the nurse should be to listen for a pericardial friction rub. Checking the temperature, giving acetaminophen
(Tylenol), and notifying the health care provider are also appropriate actions but would not be done before listening
for a rub.
Cognitive Level: Application
Text Reference: p. 872
Nursing Process: Implementation NCLEX: Physiological Integrity
23. A patient who has had recent cardiac surgery develops pericarditis and complains of severe chest pain with deep
breathing. Which of these ordered PRN medications should the nurse administer?
a. Oral acetaminophen (Tylenol) 650 mg
b. Oral ibuprofen (Motrin) 800 mg
c. IV morphine sulfate 6 mg
d. Fentanyl 2 mg IV
Correct Answer: B
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
86
Rationale: The pain associated with pericarditis is caused by inflammation, so nonsteroidal antiinflammatory
medications like ibuprofen are most effective. The patient does not need opioid pain medication.
Cognitive Level: Application
Text Reference: p. 873
Nursing Process: Implementation NCLEX: Physiological Integrity
24. Which information obtained by the nurse when assessing a patient admitted with mitral valve stenosis should be
communicated to the health care provider immediately?
a. The patient has a loud diastolic murmur all across the precordium.
b. The patient has crackles audible to the lung apices.
c. The patient has a palpable thrill felt over the left anterior chest.
d. The patient has 4+ peripheral edema in both legs.
Correct Answer: B
Rationale: Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left
ventricular failure and needs immediate interventions such as diuretics. A diastolic murmur and palpable thrill
would be expected in a patient with mitral stenosis. Although 4+ peripheral edema indicates a need for a change in
therapy, it does not need to be addressed urgently.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: p. 884
NCLEX: Physiological Integrity
25. When caring for the patient with infective endocarditis of the tricuspid valve, the nurse will plan to monitor the
patient for
a. flank pain.
b. hemiparesis.
c. dyspnea.
d. splenomegaly.
Correct Answer: C
Rationale: Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain,
hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves.
Cognitive Level: Application
Nursing Process: Planning
Text Reference: p. 867
NCLEX: Physiological Integrity
26. A patient who has developed acute pulmonary edema is hospitalized and diagnosed with dilated
cardiomyopathy. Which information will the nurse plan to include when teaching the patient about management
of this disorder?
a. Careful compliance with diet and medications will control the patient’s symptoms.
b. Notify the doctor about any symptoms of heart failure such as shortness of breath.
c. No more than one or two alcoholic drinks daily are permitted.
d. Elevating the legs above the heart will help relieve angina.
Correct Answer: B
Rationale: The patient should be instructed to notify the health care provider about any worsening of heart failure
symptoms. Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance
with therapy may have recurrent episodes of heart failure. The patient is instructed to avoid alcoholic beverages.
Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with
hypertrophic cardiomyopathy).
Cognitive Level: Application
Nursing Process: Planning
Text Reference: pp. 886, 888
NCLEX: Physiological Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Test Bank
87
27. The nurse is taking a health history from a 24-year-old patient with hypertrophic cardiomyopathy (HC); which
information obtained by the nurse is most relevant?
a. The patient reports using cocaine once at age 16.
b. The patient has a history of a recent upper respiratory infection.
c. The patient’s 29-year-old brother has had a sudden cardiac arrest.
d. The patient has a family history of coronary artery disease (CAD).
Correct Answer: C
Rationale: About half of all cases of HC have a genetic basis, and HC is the most common cause of sudden cardiac
death in otherwise healthy young people; the information about the patient’s brother will be helpful in planning care
(such as an automatic implantable cardioverter-defibrillator [AICD]) for the patient and in counseling other family
members. The patient should be counseled against use of stimulant drugs, but the one-time use indicates that the
patient is not at current risk for cocaine use. Viral infections and CAD are risk factors for dilated cardiomyopathy,
but not for HC.
Cognitive Level: Application
Nursing Process: Assessment
Text Reference: pp. 886, 888
NCLEX: Physiological Integrity
28. Heparin is prescribed for a patient who has dilated cardiomyopathy has been admitted to the hospital with
fatigue and orthopnea. Which statement is appropriate for the nurse to use in patient teaching about
anticoagulation therapy?
a. “Heparin will help prevent blood clots from forming in your heart chambers.”
b. “Heparin is used to improve the circulation to the muscles in your arms and legs.”
c. “Heparin has been prescribed to stop blood clots from traveling to your lungs.”
d. “Heparin makes it easier for your heart to pump and will decrease your symptoms.”
Correct Answer: A
Rationale: Decreased blood flow through the heart causes blood stasis and the formation of blood clots in the
ventricles, which then may embolize. Anticoagulant therapy will not improve circulation to the skeletal muscles.
The patient with dilated cardiomyopathy who is inactive may be at risk for deep-vein thrombosis and pulmonary
emboli, but this is not the usual reason for anticoagulation. There is no indication in the stem that the patient is
immobile. Heparin will not decrease cardiac workload or decrease the patient’s fatigue or orthopnea.
Cognitive Level: Application
Text Reference: p. 886
Nursing Process: Implementation NCLEX: Physiological Integrity
Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc.