Cardiovascular System | Myocardial Infarction And Heart Failure NCLEX Quiz 18

1.

Which of the following is an expected outcome for a client on the second day of hospitalization after an MI?
- A.
  
  Has severe chest pain
- B.
  
  Can identify risks factors for MI
- C.
  
  Agrees to participate in a cardiac rehabilitation walking program
- D.
  
  Can perform personal self-care activities without pain
Correct Answer
D. Can perform personal self-care activities without pain

Explanation
By day 2 of hospitalization after an MI. clients are expected to be able to perform personal care without chest pain. Day 2 hospitalization may be too soon for clients to be able to identify risk factors for MI or begin a walking program; however. the client may be sitting up in a chair as part of the cardiac rehabilitation program. Severe chest pain should not be present.

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2.

Which of the following reflects the principle on which a client’s diet will most likely be based during the acute phase of MI?
- A.
  
  Liquids as ordered
- B.
  
  Small. easily digested meals
- C.
  
  Three regular meals per day
- D.
  
  NPO
Correct Answer
B. Small. easily digested meals

Explanation
Recommended dietary principles in the acute phase of MI include avoiding large meals because small. easily digested foods are better digested foods are better tolerated. Fluids are given according to the client’s needs. and sodium restrictions may be prescribed. especially for clients with manifestations of heart failure. Cholesterol restrictions may be ordered as well.Options A and D: Clients are not prescribed a diet of liquids only or NPO unless their condition is very unstable.

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3.

An older. sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:
- A.
  
  Left ventricular atrophy
- B.
  
  Irregular heartbeats
- C.
  
  Peripheral vascular occlusion
- D.
  
  Pacemaker placement
Correct Answer
A. Left ventricular atrophy

Explanation
In older adults who are less active and do not exercise the heart muscle. atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result. under sudden emotional or physical stress. the left ventricle is less able to respond to the increased demands on the myocardial muscle.

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4.

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.
- A.
  
  Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
- B.
  
  Activity intolerance related to increased cardiac output.
- C.
  
  Decreased cardiac output related to structural and functional changes.
- D.
  
  Impaired gas exchange related to decreased sympathetic nervous system activity.
Correct Answer(s)
A. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output.
C. Decreased cardiac output related to structural and functional changes.

Explanation
HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result. blood pools in the left ventricle and backs up into the left atrium. and eventually into the lungs. Therefore. greater amounts of blood remain in the ventricle after contraction thereby decreasing cardiac output. In addition. this pooling leads to thrombus formation and ineffective tissue perfusion because of the decrease in blood flow to the other organs and tissues of the body. Typically. these clients have an ejection fraction of less than 50% and poorly tolerate activity.Option B: Activity intolerance is related to a decrease. not increase. in cardiac output.Option D: Gas exchange is impaired. However. the decrease in cardiac output triggers compensatory mechanisms. such as an increase in sympathetic nervous system activity.

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5.

Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?
- A.
  
  Risk for infection related to stasis of alveolar secretions
- B.
  
  Impaired skin integrity related to pressure
- C.
  
  Activity intolerance related to pump failure
- D.
  
  Constipation related to immobility
Correct Answer
C. Activity intolerance related to pump failure

Explanation
Activity intolerance is a primary problem for clients with heart failure and pulmonary edema. The decreased cardiac output associated with heart failure leads to reduced oxygen and fatigue. Clients frequently complain of dyspnea and fatigue.Options A. B. and D: The client could be at risk for infection related to stasis of secretions or impaired skin integrity related to pressure. However. these are not the priority nursing diagnoses for the client with HF and pulmonary edema. nor is constipation related to immobility.

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6.

Captopril may be administered to a client with HF because it acts as a:
- A.
  
  Vasopressor
- B.
  
  Volume expander
- C.
  
  Vasodilator
- D.
  
  Potassium-sparing diuretic
Correct Answer
C. Vasodilator

Explanation
ACE inhibitors have become the vasodilators of choice in the client with mild to severe HF. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart failure.

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7.

Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drugs desired effect?
- A.
  
  5 to 10 minutes
- B.
  
  30 to 60 minutes
- C.
  
  2 to 4 hours
- D.
  
  6 to 8 hours
Correct Answer
A. 5 to 10 minutes

Explanation
After IV injection of furosemide. diuresis normally begins in about 5 minutes and reaches its peak within about 30 minutes. Medication effects last 2 to 4 hours.

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8.

Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet?
- A.
  
  Apples
- B.
  
  Tomato juice
- C.
  
  Whole wheat bread
- D.
  
  Beef tenderloin
Correct Answer
B. Tomato juice

Explanation
Canned foods and juices. such as tomato juice. are typically high in sodium and should be avoided on a sodium-restricted diet.

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9.

The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects:
- A.
  
  Left atrial enlargement
- B.
  
  Left ventricular enlargement
- C.
  
  Right atrial enlargement
- D.
  
  Right ventricular enlargement
Correct Answer
B. Left ventricular enlargement

Explanation
A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.

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10.

Which of the following arteries primarily feeds the anterior wall of the heart?
- A.
  
  Circumflex artery
- B.
  
  Internal mammary artery
- C.
  
  Left anterior descending artery
- D.
  
  Right coronary artery
Correct Answer
C. Left anterior descending artery

Explanation
The left anterior descending artery is the primary source of blood for the anterior wall of the heart.Options A. B. and D: The circumflex artery supplies the lateral wall. the internal mammary artery supplies the mammary. and the right coronary artery supplies the inferior wall of the heart.

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Cardiovascular System | Myocardial Infarction And Heart Failure NCLEX Quiz 18

Which of the following is an expected outcome for a client on the second day of hospitalization after an MI?

Which of the following reflects the principle on which a client’s diet will most likely be based during the acute phase of MI?

An older. sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:

Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply.

Which of the following would be a priority nursing diagnosis for the client with heart failure and pulmonary edema?

Captopril may be administered to a client with HF because it acts as a:

Furosemide is administered intravenously to a client with HF. How soon after administration should the nurse begin to see evidence of the drugs desired effect?

Which of the following foods should the nurse teach a client with heart failure to avoid or limit when following a 2-gram sodium diet?

The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects:

Which of the following arteries primarily feeds the anterior wall of the heart?