1.
Which of the following complications is indicated by a third heart sound? (S3)?
Correct Answer
A. Ventricular dilation
Explanation
A third heart sound (S3) is typically associated with ventricular dilation. Ventricular dilation occurs when the ventricles of the heart become enlarged and stretched, leading to decreased contractility and impaired filling of the ventricles. This can result in the generation of an extra heart sound (S3) due to the rapid filling of the ventricles during the early diastolic phase. Systemic hypertension, aortic valve malfunction, and increased atrial contractions are not typically associated with the presence of a third heart sound.
2.
After an anterior wall myocardial infarcition, which of the following problems is indicated by auscultation of crackles in the lungs?
Correct Answer
A. Left sided heart failure
Explanation
Crackles in the lungs indicate the presence of fluid in the alveoli, which can be a result of left sided heart failure. In this condition, the left ventricle fails to pump blood effectively, causing a backup of blood in the lungs. This increased pressure can lead to the leakage of fluid from the pulmonary capillaries into the alveoli, causing crackles to be heard on auscultation. Pulmonic valve malfunction, right sided heart failure, and tricuspid valve malfunction may also cause symptoms such as fluid retention, but crackles in the lungs specifically point towards left sided heart failure.
3.
Which of the following diagnostic tools is most commonly used to determine the location of myocardial damage
Correct Answer
D. Electrocardiogram
Explanation
An electrocardiogram (ECG) is the most commonly used diagnostic tool to determine the location of myocardial damage. An ECG measures the electrical activity of the heart and can identify abnormalities in the heart's rhythm and conduction. It can also detect changes in the ST segment, which can indicate myocardial damage. Cardiac catheterization is a procedure that involves inserting a catheter into the heart to diagnose and treat certain heart conditions, but it is not primarily used for determining the location of myocardial damage. Cardiac enzymes and echocardiogram can provide additional information about heart function, but they are not as specific for determining the location of myocardial damage as an ECG.
4.
What is the first intervention for a client experiencing myocardial infarction?
Correct Answer
B. Administer oxygen
Explanation
Administering oxygen is the first intervention for a client experiencing myocardial infarction. Oxygen therapy helps to increase the oxygen supply to the heart muscle, reducing the workload on the heart and preventing further damage. It also helps to improve oxygenation of the blood and tissues, relieving symptoms such as chest pain and shortness of breath. Administering oxygen is a critical step in the initial management of myocardial infarction and should be done promptly to ensure adequate oxygenation and prevent complications.
5.
What is the most appropriate nursing response to a myocardial infarction client who is fearful of dying?
Correct Answer
A. Tell me about your feelings right now
Explanation
The most appropriate nursing response to a myocardial infarction client who is fearful of dying is to encourage them to express their feelings. By asking the client to share their emotions, the nurse creates a supportive and empathetic environment. This allows the client to openly discuss their fears and concerns, which can help alleviate anxiety and promote emotional well-being. It also gives the nurse valuable insight into the client's emotional state, allowing them to provide appropriate support and interventions.
6.
Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation
Correct Answer
A. Beta adrenergic blockers
Explanation
Beta adrenergic blockers protect the ischemic myocardium by blocking the effects of catecholamines (such as epinephrine and norepinephrine) and sympathetic nerve stimulation. These medications work by binding to beta-adrenergic receptors in the heart, thereby reducing the heart rate, contractility, and oxygen demand of the myocardium. By blocking the effects of catecholamines, beta blockers help to prevent or reduce the severity of myocardial ischemia, which occurs when the blood supply to the heart muscle is decreased. This makes beta adrenergic blockers an important class of medications in the management of conditions such as angina and myocardial infarction.
7.
What is the most common complication of a myocardial infarction
Correct Answer
C. Arrhythmias
Explanation
Arrhythmias are the most common complication of a myocardial infarction. During a heart attack, the blood supply to a part of the heart muscle is blocked, leading to damage. This damage can disrupt the electrical signals that control the heart's rhythm, resulting in abnormal heart rhythms or arrhythmias. These arrhythmias can range from mild palpitations to life-threatening conditions such as ventricular fibrillation. Prompt medical intervention is crucial to manage and treat arrhythmias to prevent further complications and improve patient outcomes.
8.
With which of the following disorders is jugular vein distention most prominent?
Correct Answer
B. Heart failure
Explanation
Jugular vein distention is most prominent in heart failure. In heart failure, the heart is unable to pump blood effectively, causing fluid to accumulate in the body. This fluid buildup can lead to increased pressure in the jugular veins, causing them to become distended. This can be observed as a bulging or swelling of the jugular veins in the neck. In contrast, abdominal aortic aneurysm, myocardial infarction, and pneumothorax are not typically associated with jugular vein distention.
9.
What position should the nurse place the head of the bed in to obtain the most accurate reading of jugular vein distention?
Correct Answer
C. Raised 30 degrees
Explanation
Raising the head of the bed to 30 degrees allows for the most accurate reading of jugular vein distention. This position helps to optimize venous return, making it easier to visualize any distention or abnormality in the jugular veins. It also helps to reduce the effect of gravity on the veins, allowing for a more accurate assessment. The supine position would not be ideal as it may cause the veins to collapse, while the other options (high fowler's and raised 10 degrees) may not provide enough elevation to accurately assess jugular vein distention.
10.
Which of the following parameters should be checked before administering digoxin?
Correct Answer
A. Apical pulse
Explanation
Before administering digoxin, it is important to check the apical pulse. Digoxin is a medication used to treat heart conditions, and it works by increasing the strength and efficiency of the heart's contractions. Checking the apical pulse allows the healthcare provider to assess the heart rate and rhythm, which is crucial before administering a medication that affects the heart. By monitoring the apical pulse, any abnormalities or irregularities can be detected, and appropriate action can be taken to ensure the safe administration of digoxin.
11.
Toxicity from which of the following medications may cause a client to see a green halo around lights
Correct Answer
A. Digoxin
Explanation
Toxicity from digoxin can cause a client to see a green halo around lights. Digoxin is a medication commonly used to treat heart conditions, but it can have toxic effects if the levels in the body become too high. One of the symptoms of digoxin toxicity is disturbances in vision, which can include seeing a green halo around lights. This visual symptom is a result of the drug's effect on the optic nerve and can be a warning sign that the client is experiencing toxicity from digoxin.
12.
Which of the following symptoms is most commonly associated with left sided heart failure?
Correct Answer
A. Crackles
Explanation
Crackles are the most commonly associated symptom with left sided heart failure. Left sided heart failure occurs when the left side of the heart is unable to effectively pump blood to the rest of the body. This can lead to fluid buildup in the lungs, causing crackling sounds, also known as rales, to be heard during lung auscultation. Other symptoms of left sided heart failure may include shortness of breath, fatigue, and fluid retention.
13.
In which of the following disorders would the nurse expect to assess sacral edema in a bedridden client?
Correct Answer
D. Right sided heart failure
Explanation
Right-sided heart failure can lead to fluid retention and edema in various parts of the body, including the sacral area. This is because when the right side of the heart is not functioning properly, blood can back up into the veins and cause fluid to leak out into the surrounding tissues. This can result in swelling and edema, particularly in dependent areas such as the sacrum when the client is bedridden. Diabetes mellitus, pulmonary emboli, and renal failure can also cause edema, but they are not specifically associated with sacral edema in a bedridden client.
14.
Which of the following symptoms might a client with right sided heart failure exhibit
Correct Answer
C. Olguria
Explanation
A client with right-sided heart failure may exhibit oliguria, which is a decreased urine output. Right-sided heart failure occurs when the right side of the heart is unable to pump blood effectively, causing blood to back up into the veins. This can lead to fluid retention and congestion in the body, including the kidneys. As a result, the kidneys may not be able to produce an adequate amount of urine, leading to oliguria. Adequate urine output, polyuria (excessive urine production), and polydispia (excessive thirst) are not typically associated with right-sided heart failure.
15.
Which of the following classes of medications maximizes cardiac performance in clients with heart failure by increasing ventricular contractility?
Correct Answer
D. Inotropic agents
Explanation
Inotropic agents are a class of medications that maximize cardiac performance in clients with heart failure by increasing ventricular contractility. These agents work by strengthening the force of the heart's contractions, which improves the pumping ability of the heart and increases cardiac output. This helps to alleviate symptoms of heart failure and improve overall cardiac function. Beta adrenergic blockers, calcium channel blockers, and diuretics do not have the same direct effect on ventricular contractility as inotropic agents.