Chicago Review Press NCLEX-PN Practice Test and Review

By Linda Waide and Berta Roland

Fully revised to conform to the 2003 NCLEX Test Plan, this study guide and test includes hot spot,” fill-in-the-blank, and check-the-box questions to reflect the new test format with 10 written practice tests covering all the body systems, plus two additional practice tests on mental health and miscellaneous topics. Altogether, more than 500 practice test items are provided. Each practice test includes a system overview and complete rationales and explanations for both correct and incorrect answers. Also offered are explanations of how the computerized licensure exam is administered and advice on preparing for the exam and mastering the test format. In addition to the written tests, a 100-item interactive-software CD in the NCLEX format is also included to allow students to become comfortable with the on-screen exam.

• Language: English
• Publisher: Chicago Review Press
• Release date: Apr 1, 2004
• ISBN: 9781569766026

Book preview

777-7601

Practice Test 1

Cardiocirculatory and Peripheral Circulatory Systems

The Cardiocirculatory System

OVERVIEW

The cardiocirculatory system consists of blood, vessels to transport the blood, and a four-chambered muscular pump called the heart. The cardiocirculatory system is responsible for transporting food and oxygen to all the cells and organs of the body.

Blood vessels in the lungs absorb oxygen that is inhaled from the air, and blood vessels in the small intestine absorb food materials from the digestive tract. Blood also provides a means whereby cellular wastes, i.e., carbon dioxide and urea, are transported to the lungs and kidneys, where they are eliminated from the body.

BLOOD VESSELS

There are three types of blood vessels: arteries, veins, and capillaries.

Arteries

Arteries are large vessels that carry oxygenated blood away from the heart. In order to withstand the high pressure of the heart’s pumping action, arteries are made of connective tissue, elastic fibers, and inner walls of epithelial cells. As the heart forces blood into the arteries, their elastic qualities enable them to expand and contract. Some of the arteries in the body are very large compared to their smaller branches, called arterioles. The walls of arterioles are much thinner than the walls of the larger arteries. The thin walls of arterioles allow them to carry blood to the smallest of vessels, which are known as capillaries.

Capillaries

The walls of capillaries are very thin (just one epithelial cell thick). Because they are so small (microscopic), they are capable of allowing oxygen and nutrients to pass out of the bloodstream and into the tissue fluid (interstitial fluid) that surrounds all body cells. Once nutrients and oxygen are inside the cells, the nutrients are burned (catabolized) and needed energy is released within the cells. At the same time that oxygen and nutrients are passing into the interstitial fluid, the waste products of catabolism, namely, carbon dioxide and water, pass out of the cells and into the thin-walled capillaries. These waste products flow back to the heart via small veins known as venules, which branch to form larger vessels known as veins.

Veins

Veins do not have to withstand the pressures that arteries do. Therefore, vein walls are thinner than arterial walls, and veins are less elastic and have less connective tissue than arteries. Compared to arteries, blood pressure in the veins is low. To keep blood flowing toward the heart, veins have small valves on their inner walls that prevent blood from flowing backward. In addition to these valves, muscular action also helps to milk blood flow along in the veins.

THE HEART

The four chambers of the heart actually form two pumps. The right side of the heart pumps blood from the heart into the lungs, where it gives off carbon dioxide and picks up oxygen; the left side of the heart pumps the oxygenated blood from the lungs into the body.

Pulmonary Circulation

Pulmonary circulation consists of the flow of blood through the vessels from the heart to the lungs and then back to the heart again.

When blood goes into the heart, the top two chambers (the right and left atria) relax and deoxygenated blood flows from the veins into the right atrium. This is known as venous return. At the same time, oxygenated blood coming from the lungs flows into the left atrium. At this point the blood-filled atria contract and the blood pushes open the heart valves (the bicuspid and tricuspid valves). This allows oxygenated blood from the left atrium to pass into the left ventricle, and deoxygenated blood from the right atrium to pass into the right ventricle.

When blood leaves the heart, the right and left ventricles contract and deoxygenated blood in the right ventricle flows into the lung (via the pulmonary artery), where it will give off its carbon dioxide and pick up oxygen, and oxygenated blood in the left ventricle flows out of the heart (via the coronary arteries and aorta), where it begins its travels into the body.

DISEASES/DISORDERS OF THE CARDIOCIRCULATORY SYSTEM INCLUDE

Acquired Inflammatory Heart Disease

ENDOCARDITIS Other names for endocarditis are infective or bacterial endocarditis. The infection affects the endocardium, heart valves, or cardiac processes and is characterized by bacteria or fungi creating vegetative growths on the heart valves and on the endocardial lining of the heart chambers. These growths may also be located on the endothelium of a blood vessel, where they may embolize to organs such as the spleen, kidneys, central nervous system, and lungs. An organism commonly associated with endocarditis is Streptococcus viridans.

MYOCARDITIS Myocarditis is associated with diffuse inflammation of the cardiac muscle (the myocardium). This condition is caused by viral infections, bacterial infections, immune reactions, radiation therapy, chemical poisons, parasitic infestations, and helminthic infestations.

PERICARDITIS Pericarditis is the inflammation of the pericardium (the membranous fibroserous sac that encloses the heart and the bases of the great vessels). Common causes include infections with bacteria, viruses, or fungi; also neoplasms, radiation to the chest, and postcardiac injury.

RHEUMATIC FEVER/HEART DISEASE Rheumatic fever is a consequence of infection with a group of beta-hemolytic streptococcal bacteria. Rheumatic heart disease refers to the sequelae, or aftereffects, of rheumatic fever, and may include: Myocarditis, pericarditis, endocarditis, and eventually, valvular disease.

Cardiac Complications

CARDIAC ARRHYTHMIAS/DYSRHYTHMIAS Cardiac arrhythmias/dysrhythmias are faulty electrical conductions that change the rate and rhythm of the heart. Types of arrhythmias include: Sinus arrhythmia, sinus tachycardia, sinus bradycardia, sinoatrial arrest/block, premature atrial contraction, ventricular tachycardia, and ventricular fibrillation.

CARDIAC TAMPONADE Cardiac tamponade is a sequela of pericarditis or injuries to the heart or great blood vessels that cause an accumulation of blood in the pericardial sac. The classic signs of cardiac tamponade are increased venous pressure with neck vein distention, reduced arterial blood pressure, muffled heart sounds, and pulsus paradoxus (an abnormal inspiratory drop in systemic blood pressure greater than 15 mm Hg.)

CARDIOGENIC SHOCK Cardiogenic shock occurs when cardiac output diminishes and severe tissue ischemia takes place. Cardiogenic shock is associated with left-sided heart failure and is seen in approximately 15% of clients experiencing a myocardial infarction (MI).

HYPOVOLEMIC SHOCK Hypovolemic shock is best described as lack of tissue perfusion due to insufficient blood volume. Untreated, this condition may cause irreversible cerebral and renal damage, cardiac arrest, and death. Typical causes of this condition are gastrointestinal bleeding and accidental or surgical trauma, severe burns, or ascites resulting in significant blood loss..

VENTRICULAR ANEURYSM An aneurysm is an abnormal ballooning or dilatation of a blood vessel (usually an artery) due to either a congenital defect or weakness in the vessel wall. A ventricular aneurysm is a ballooning or out-pouching of the left ventricle. Untreated, this condition may lead to arrhythmias, systemic embolization, and heart failure, including sudden death.

Congential Acyanotic Defects

ATRIAL SEPTAL DEFECT (ASD) An atrial septal defect is a congenital heart defect that allows blood to flow through an opening between the right and left atria.

COARCTATION OF THE AORTA This is a localized malformation that results in the narrowing of the aorta. Untreated, it may lead to left-sided heart failure and possibly cerebral hemorrhage and aortic rupture.

PATENT DUCTUS ARTERIOSUS (PDA) In PDA, the lumen of the ductus remains open following birth, allowing blood to flow from the aorta to the pulmonary artery and causing recirculation of arterial blood through the lungs. Respiratory distress and signs of heart failure are the two most common symptoms.

VENTRAL SEPTAL DEFECT (VSD) This is the most common congenital heart disorder. The defect (a septum between the left and right ventricles of the heart) allows blood to be shunted between the ventricles, and may cause left atria and right ventricle hypertrophy. Untreated, the condition leads to biventricular heart failure and cyanosis.

Congenital Cyanotic Defects

TETRALOGY OF FALLOT As the name implies, this condition is created by four cardiac defects, namely: ventricular septal defect (VSD), right ventricular outflow tract obstruction (pulmonary stenosis), right ventricular hypertrophy, and dextroposition of the aorta with an overriding of the ventricular septal defect. These defects allow unoxygenated blood to mix with oxygenated blood, causing cyanosis.

Degenerative Cardiovascular Disorders

CORONARY ARTERY DISEASE (CAD) CAD is associated with narrowing of the coronary arteries sufficient to prevent an adequate supply of blood to the myocardium (heart muscle). The usual cause is atherosclerosis, the most common form of arteriosclerosis, which is marked by cholesterol-lipid-calcium deposits in the linings of the arteries.

DILATED CARDIOMYOPATHY In this condition, the striated muscle fibers of the myocardium (heart muscle) suffer extensive damage, interfering with myocardial metabolism and causing gross dilatation of all four chambers of the heart.

HEART FAILURE This condition results from failure of the heart to maintain adequate circulation to the heart. As a consequence, failure of the right, left, or both ventricles may occur.

HYPERTENSION Hypertension is a condition in which a person has greater than normal blood pressure. A person is said to have hypertension if the systolic pressure is persistently above 140 mm Hg, if the diastolic pressure is persistently above 90 mm Hg, and when either the systolic pressure is 160 or above, or the diastolic pressure is 115 or above.

HYPERTROPHIC CARDIOMYOPATHY This is a primary disease of cardiac muscle. Another name for it is idio-pathic hypertrophic subaortic stenosis. It is associated with thickening of the interventricular septum (especially in the free wall of the left ventricle). If low cardiac output occurs, the condition may lead to fatal heart failure.

MYOCARDIAL INFARCTION (MI) Myocardial infarction is commonly known as a heart attack. It is a consequence of prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries. MI is the leading cause of death in the United States and Western Europe.

RESTRICTIVE CARDIOMYOPATHY Characterized by restricted ventricular filling, this condition is the result of left ventricular hypertrophy as well as endocardial fibrosis and thickening. In some cases, it may be irreversible.

Vascular Disorders

ABDOMINAL ANEURYSM An abdominal aneurysm is a localized dilatation (ballooning) of the wall of the abdominal aorta. This disorder may be asymptomatic; however, symptoms may include generalized abdominal pain, low back pain that is unaffected by movement, a feeling of gastric fullness, and a pulsating mass in the periumbilical area.

ARTERIAL OCCLUSIVE DISEASE This disease is characterized by the narrowing of the lumen of the aorta and the major branches of the aorta. This narrowing affects blood flow to the legs and feet. Occlusions may cause ischemia, skin ulcerations, and gangrene.

BEURGER’S DISEASE This disease is associated with chronic recurring inflammation and vascular occlusion. It typically affects the peripheral arteries and veins of the extremities. Smoking tobacco is thought to be the main cause. Treatment includes the discontinuation of tobacco in any form.

FEMORAL AND POPLITEAL ANEURYSMS Also known as peripheral arterial aneurysms, these are the result of progressive atherosclerotic changes in the walls of the major peripheral arteries. Symptoms include pain in the legs and feet due to ischemia.

RAYNAUD’S DISEASE This is a peripheral vascular disorder found almost exclusively in women between 18 and 40 years of age. It is characterized by severe vasoconstriction in the extremities when exposed to cold or vasoconstriction associated with emotional stress. Symptoms include intermittent attacks of pallor or cyanosis in the digits (typically the fingers). Other symptoms include numbness and tingling in the fingers. Rarely, gangrene necessitating amputation of the affected digits may occur.

THORACIC AORTIC ANEURYSM This condition is characterized by widening (ballooning) of either the ascending, transverse, or descending parts of the aorta. The most common cause is atherosclerosis, which weakens the wall of the aorta and slowly distends the lumen. Pain is the most common symptom.

THROMBOPHLEBITIS An acute condition associated with inflammation and thrombus formation in deep or superficial veins, this disease is usually progressive and may lead to pulmonary embolism. Superficial thrombophlebitis is generally self-limiting and rarely leads to pulmonary embolism.

Valvular Heart Diseases

All of these conditions interfere with the normal flow of blood into, through, and out of the heart. They include

Mitral insufficiency

Mitral stenosis

Mitral valve prolapse (MVP)

Aortic insufficiency

Aortic stenosis

Pulmonic insufficiency

Pulmonic stenosis

Tricuspid insufficiency

Practice Test 1

Questions

1-1

Which of the following findings by the nurse would constitute a significant index of hypertension?

1. a pulse of 10 beats per minute

2. a regular pulse of 90 beats per minute

3. a systolic pressure fluctuating between 150 and 160 mm Hg

4. a diastolic pressure sustained at greater than 90 mm Hg

1-2

A client with thrombophlebitis is placed on bed rest. The client asks why bed rest is necessary. Which of the following responses by the nurse would be best?

1. Bed rest promotes venous pressure in the extremities.

2. Bed rest improves the venous circulation.

3. Bed rest minimizes the potential for release of a blood clot.

4. Bed rest prevents blood clot formation in the unaffected extremity.

1-3

A client has 0.08 mg of digoxin prescribed. The bottle contains 0.05 mg of the drug in 1 cc of solution. How much solution should the nurse prepare for administration?

Answer: _____________________________.

                  Fill in the blank

1-4

Supportive stockings have been prescribed to reduce and prevent edema. If the client has been ambulating, the nurse should:

1. have the client wash and dry the feet prior to applying the stockings.

2. wrap the legs with soft gauze prior to applying the stockings.

3. tell the client that the shoe size may be increased to accommodate the stockings.

4. have the client lie down and elevate the legs for 15 to 20 minutes before applying the stockings.

1-5

A client has vascular occlusion of the left leg. Which of the following will the nurse include in the client’s assessment?

1. Compare pulses in the lower extremities.

2. Compare temperatures of the lower extremities.

3. Note the pulse in the left leg.

4. Note the temperature of the left leg.

1-6

A diversional activity for a client recently diagnosed with a myocardial infarction needs to be selected. To which of these questions should the nurse give the greatest consideration?

1. Will the diversion be new to the client?

2. Will the diversion amuse the client?

3. Does the diversion promote relaxation?

4. Does the diversion require mental concentration?

1-7

A client is to receive nitroglycerin. The desired effect of this medication is to:

1. constrict peripheral blood vessels.

2. improve coronary blood flow.

3. produce slower and stronger heartbeats.

4. increase the rate and depth of respirations.

1-8

You are preparing a client for an electrocardiogram. Which of the following information about the procedure should be included?

1. The client will have nothing by mouth for 12 hours before the procedure.

2. The client will have no discomfort during the procedure.

3. The client will be required to do mild exercise during the procedure.

4. The client will have to remain flat in bed for several hours after the procedure.

1-9

A client has coronary artery disease (CAD). The nurse is teaching the client to recognize modifiable risk factors associated with this condition. Which one of the following risk factors is modifiable?

1. genetic predisposition

2. cigarette smoking and physical inactivity

3. gender

4. race

1-10

A client has been discharged from the hospital. Prescriptions include a digitalis preparation. Which of the following statements, if made by the client, would indicate a need for further teaching?

1. I am a little thirsty today, but I should take the medicine anyway.

2. I have been urinating a little more than usual, but I should take my medicine anyway.

3. I have been nauseated for a couple of days, but I should take my medicine anyway.

4. My pulse was 64 today, but I should take my medicine anyway.

1-11

The nurse will describe a pulse rate that has an irregular rhythm as:

Answer: _____________________________.

                  Fill in the blank

1-12

A client with generalized arteriosclerosis tells the nurse, I awaken at night because my feet get cold. The client asks the nurse, How can I keep my feet warm? Which of the following comments would be best for the nurse to make?

1. Rub your feet briskly to improve circulation.

2. Place a light blanket over your feet.

3. Place your feet on a covered hot-water bottle.

4. Put a covered heating pad on your feet with the dial at the lowest setting.

1-13

Your client has thromboangiitis obliterans. You are teaching the client how to participate in the treatment of this condition. Which statement by the client indicates a need for further teaching?

1. It will be helpful if I can find employment that allows me to sit most of the time.

2. I know it is essential that I quit smoking.

3. I intend to walk 30 minutes twice daily.

4. I’ll need to be careful that I don’t injure my legs.

1-14

You are planning the care for a child in the acute stage of rheumatic fever. You know to emphasize the child’s need for:

1. rest.

2. fluids.

3. exercise.

4. social interaction.

1-15

A client is suspected of having angina pectoris. Which of the following observations made by the nurse is associated with this condition?

1. experiences shortness of breath when climbing stairs

2. very lethargic after eating an unusually heavy meal

3. experiences numbness and tingling in the fingers when relaxed and resting

4. complains of sudden pain in the substernal region after a disagreement with an employee

1-16

A client is receiving an oral anticoagulant. The nurse should observe the client for which adverse effect?

1. hives

2. difficulty in breathing

3. restlessness

4. hematuria

1-17

Your client has an asymptomatic abdominal aortic aneurysm. Ultrasonographic examination indicated the aneurysm is 3.5 centimeters. You anticipate:

1. administration of an antihypertensive medication.

2. excision of the aneurysm with replacement of the excised segment with a synthetic graft.

3. gastrointestinal bleeding that may progress to shock.

4. a complaint by the client of intense back and flank pain with awareness of a pulsating mass in the abdomen.

1-18

Which characteristics are associated with a thready pulse?

1. slow and irregular

2. slow and forceful

3. rapid and weak

4. rapid and bounding

1-19

An 18-month-old child with congestive heart failure is being discharged. Which one of the following observations will the nurse instruct the parents to report immediately?

1. increased food intake

2. decreased number of wet diapers

3. enlargement of fingers and toes

4. restless sleep the first night at home

1-20

A 2-month-old with tetralogy of Fallot is being prepared for cardiac catheterization. Which of the following assessments would be the lowest priority?

1. skin turgor

2. body temperature and breath sounds

3. skin free of infection in diaper area and thigh

4. oxygen saturation level

1-21

A 10-day-old infant has a large ventricular septal defect and is being treated with digoxin bid. Before administering the morning dose, the nurse notes that the infant’s apical pulse is 118. Previous pulse rates have been between 150 and 190. The most appropriate intervention is:

1. Give the dose as scheduled since the desired response is occurring.

2. Give potassium supplement along with the lanoxin.

3. Hold the dose until after the next feeding.

4. Hold the dose and discuss the findings with the physician.

1-22

A client whose serum cholesterol is 567 mg/dl would probably benefit most from:

1. cholestyramine.

2. quinidine gluconate.

3. chloroquine sulfate.

4. clidinium bromide.

1-23

You are teaching your client about the medication Tridil. Which of the following comments by the client suggests a need for additional teaching about this medication?

1. I should expect my cholesterol levels to go down by taking this drug.

2. I will try to remember not to get up too quickly if I am lying down.

3. I will notify the doctor if I get a headache.

4. I am looking forward to less chest pain.

1-24

Your client is walking in the hallway when a sudden attack of angina occurs. You will first:

1. have the client cease all movement.

2. place the client in a semi-upright position after assisting the client to the bed.

3. administer oxygen.

4. notify the physician immediately.

1-25

Your client is experiencing Raynaud’s phenomenon. You will recommend:

1. moving to a warmer climate.

2 cutting back on tobacco use.

3. wearing gloves when exposed to cold or cold objects.

4. limiting activity to decrease metabolic demands upon the body.

1-26

Which of the following parental comments about their infant is most likely to indicate a possible cardiac defect?

1. Our baby is always fussy and irritable.

2. Our baby vomits shortly after eating.

3. Our baby’s skin is often pale and warm.

4. Our baby doesn’t feed well.

1-27

The plan of care for an infant who is scheduled for an echocardiogram is most likely to include:

1. nothing by mouth 6 to 8 hours prior to the procedure.

2. clear liquids only for 6 to 8 hours prior to the procedure.

3. electrode placement on the chest.

4. mild sedation just prior to the procedure.

1-28

A client who had a coronary artery bypass graft 2 years ago has been admitted to intensive care complaining of chest pain. Included in the client’s medications is dipyridamole po, 100 mg 4 times daily in divided doses. The nurse knows the purpose of this medication is to:

1. decrease the heart rate.

2. dilate the coronary arteries.

3. increase stroke volume.

4. inhibit platelet aggregation.

1-29

Which of the following symptoms would be indicative of intermittent claudication?

1. extensive discoloration

2. dependent edema

3. pain associated with activity

4. petechiae

1-30

You are taking your client’s apical pulse. You know the apex of the heart is located over the area of the:

1. right atrium.

2. right ventricle.

3. left atrium.

4. left ventricle.

1-31

A 3-year-old is scheduled for cardiac surgery. Which statement made by the child’s parents indicates a need for further teaching about the postoperative period?

1. We understand our child will have several tubes.

2. We will be able to see and help soothe and comfort our child.

3. Suctioning will be done often to keep our child’s airway from blocking.

4. Oral fluids will probably not be restarted for a day or two after surgery.

1-32

A 7-month-old infant with tetralogy of Fallot has been admitted to the recovery room after a right heart cardiac catheterization. Which of the following assessment findings needs to be reported immediately?

1. apical pulse of 74

2. left foot cool to the touch

3. mild clubbing of the fingers and toes

4. irritable when dressing is being checked

1-33

A client is returned to the unit following an arteriography. Which nursing action is appropriate at this time?

1. Discourage fluid intake and place the client in a prone position.

2. Apply heat to the puncture site and passively exercise the involved extremity.

3. Limit motion of the affected extremity and assess the puncture site.

4. Restrict fluid intake and encourage ambulation.

1-34

A client states, I have tenderness in my right leg. During assessment, you observe heat and redness of the right leg. The client’s temperature is 99.2°F. Which action is contraindicated?

1. elevating the affected leg

2. massaging the affected leg every 4 hours

3. applying continuous moist heat over the affected vessels

4. bed rest

1-35

The physician has prescribed morphine sulfate for relief of pain following a myocardial infarction. After administering the medication, you know to observe the client for:

1. hypertension and tachycardia.

2. respiratory depression.

3. polyuria.

4. palpitations.

1-36

Your client is experiencing Coumadin overdose. Phytonadione has been prescribed. When administering this medication, you will:

1. be alert for the possibility of an anaphylactic-like reaction.

2. warm the solution to room temperature before administration.

3. use a special filter needle when administering the solution.

4. avoid aspiration when administering parenterally.

1-37

A client is experiencing a hypertensive crisis. Blood pressure is 227/143 mm Hg. Prescriptions reads: Diazoxide 100 mg intravenously. You know the action of this drug will:

1. decrease the heart’s rate by vagal stimulation.

2. directly relax arteriolar smooth muscle.

3. promote diuresis.

4. block calcium channels.

1-38

Your client is on a daily dose of warfarin sodium 2.5 mg po as a prophylaxis for venous thrombosis. When administering this medication, you know:

1. frequent large portions of leafy green vegetables should be included in the diet.

2. black, tarry-looking stools are an expected outcome.

3. a soft toothbrush should be used.

4. to administer the medication on a prn basis only.

1-39

A client with venous stasis ulcerations on both legs asks the nurse, What caused these ulcers on my legs? The nurse will tell the client that the ulcers were caused by:

1. tissue hypoxia resulting from stasis of venous blood flow.

2. collateral circulation secondary to varicose veins.

3. poor tissue oxygenation due to altered arterial blood flow.

4. microbial invasion of inadequately perfused tissue.

1-40

A 66-year-old complains of chest pain. Vital signs include: Blood pressure 110/70, pulse 94 beats per minute, and respirations 26 breaths per minute. History reveals acute angina that is usually relieved by rest and nitroglycerin. Nitrostat 0.6 mg sublingually is prescribed for this client. You will teach the client to avoid which of the following while taking this medication?

1. cheese

2. peanuts

3. milk

4. alcoholic beverages

1-41

Prior to administering a digitalis derivative, the nurse will count the client’s apical-radial pulse rate. Counting the apical-radial pulse rate is the only way to ensure against:

1. bradycardia.

2. tachycardia.

3. pulse deficit.

4. hypotension.

1-42

Your client is experiencing an acute myocardial infarction. Included in the client’s stat medications is a prescription for aspirin. You know this medication was prescribed to:

1. act as an analgesic.

2. help decrease myocardial inflammation.

3. help prevent fever.

4. decrease platelet aggregation.

1-43

A client with crushing chest pain has already received 3 sublingual nitroglycerin tablets at 5-minute intervals. A prescription has been given to administer a nitroglycerin infusion. When preparing the infusion, you recall that:

1. the maximum allowable dosage of nitro-glycerin is 20 mcg/min.

2. the intravenous form of nitroglycerin acts as an analgesic.

3. special, non-PVC tubing should be used.

4. this medication is notorious for causing hypertension.

1-44

Your client had surgery 2 days ago and you are now concerned that the client may develop thrombophlebitis. Which specific nursing assessment will give you the best information about this condition?

1. dorsiflexion of the feet

2. palpation of pedal pulses

3. assessment for peripheral edema

4. assessment of capillary refill

1-45

Which of the following do you recognize as correct statements about the circulation of blood?

Select all that apply by placing a in the square:

1. Oxygen-poor blood returns to the heart via the left atrium.

2. Blood that is oxygen-poor flows through the superior and inferior vena cava on its way to the heart.

3. Blood flows from the right ventricle into the pulmonary artery.

4. Blood becomes oxygen-poor at the tissue capillaries.

1-46

You are taking your client’s apical pulse. At which location will you place your stethoscope?

Answer: _____________________________.

                  Fill in the blank

1-47

In the emergency unit a client complains of severe tightness in the chest and dyspnea. The physician prescribes 02 at 3l/min via nasal prongs and morphine sulfate for pain. The most effective route for administration of the morphine sulfate is:

1. orally.

2. intramuscularly.

3. intravenously.

4. rectally.

1-48

A client is experiencing varicose veins and complains of burning and aching in the legs at night. This client’s body mass index (BMI) is 34. Which of the following statements is true regarding this client’s complaints?

1. Weight loss would likely result in a decrease in symptoms.

2. Weight gain is essential to help this client achieve an ideal body weight.

3. Family history of varicose veins is irrelevant.

4. Varicose veins typically present with sharp, cramping pain.

1-49

A client is admitted to the hospital complaining of mild chest pain and dyspnea. The physician diagnoses mild congestive heart failure following an evaluative workup. Lanoxin 0.25 mg po is prescribed. Available are scored tablets of Lanoxin labeled 0.125 mg. How many tablets will the nurse administer?

Answer: _____________________________.

                  Fill in the blank

1-50

Your client is experiencing right-sided heart failure. You expect your assessment to reveal:

Select all that apply by placing a in the square:

1. peripheral edema.

2. pulmonary congestion.

3. jugular vein distention.

4. vascular congestion of gastrointestinal tract.

Practice Test 1

Answers, Rationales, and Explanations

1-1

4 A sustained diastolic pressure greater than 90 mm Hg, which is due to peripheral resistance, is the best indicator of hypertension. Diastolic pressure is the pressure of the blood in the arteries when the ventricles of the heart are at rest. Normal adult diastolic pressure should be <85 mm Hg.

1. Hypertension is an abnormally high blood pressure, whereas a pulse rate of 10 beats per minute (BPM) refers to an abnormally slow pulse rate (bradycardia <60 BPM).

2. A pulse rate of 90 beats per minute (BPM) is within the normal range for an adult (60 to 100) and is not an indication of hypertension.

3. An adult systolic blood pressure that fluctuates between 150 and 160 mm Hg is indicative of hypertension. However, because of fluctuations, it is not the best indicator of hypertension.

Client Need: Physiological Integrity

1-2

3 Bed rest minimizes the potential for release of a blood clot (thrombus). Any movement of the affected extremity increases the likelihood for the release of a thrombus that could travel through the circulatory system to a vital structure and obstruct circulation.

1. Bed rest relieves venous pressure in the extremities.

2. Bed rest does improve venous circulation in the extremities. However, the principal reason for bed rest in this situation is to prevent a thrombus from dislodging.

4. The unaffected extremity should have passive range-of-motion exercise to prevent stasis of blood flow and the possibility of thrombus formation.

Client Need: Health Promotion and Maintenance

1-3

Fill in the blank correct answer:

The nurse should prepare 1.6 cc.

Client Need: Physiological Integrity

1-4

4 Following ambulation, the client should lie down and elevate the legs 15 to 20 minutes. Elevating the legs will reduce edema and will also facilitate venous return.

1. Washing and drying the feet prior to applying the stockings will not reduce edema or facilitate venous return.

2. Wrapping the legs with soft gauze prior to applying the stockings will do nothing to reduce the edema that may have developed during ambulation.

3. An increase in shoe size indicates edema has developed during ambulation. Increasing the shoe size will not reduce the edema or facilitate venous return.

Client Need: Physiological Integrity

1-5

1 Assessment of a client with vascular occlusion will include a comparison of pulses in both lower extremities. A comparison of pulses in the extremities helps to identify the degree of occlusion in the affected extremity.

2 and 4. Comparing the temperatures of the lower extremities will not identify the degree of occlusion as objectively as a comparison of the pulses in the extremities.

3. Noting the pulse in only one of the extremities will not provide a standard for comparison.

Client Need: Physiological Integrity

1-6

3 Selecting a diversional activity for a client recently diagnosed with a myocardial infarction should focus on the client’s need for rest and relaxation.

1. A new diversion may be challenging and may compromise the client’s need for rest and relaxation.

2. Providing amusement at the expense of rest and relaxation would not meet the client’s needs.

4. A diversion that requires mental concentration may generate stress and compromise the client’s need for rest and relaxation.

Client Need: Safe, Effective Care Environment

1-7

2 The desired effect of nitroglycerin is to improve coronary blood flow by dilating arteries and intercoronary collateral vessels. Nitroglycerin usually relieves the pain of angina pectoris in 1 to 2 minutes.

1. Nitroglycerin produces vasodilatation, not constriction.

3. Digoxin (Lanoxin) is administered to increase the force and decrease the rate of myocardial contractions, not nitroglycerin.

4. Nitroglycerin does not directly affect the rate and depth of respirations.

Client Need: Physiological Integrity

1-8

2 Clients scheduled for an electrocardiogram (ECG) should be told they will experience no discomfort.

1, 3, and 4. An electrocardiogram requires no preparation, no physical exercise, and no need to restrict activity after it has been completed.

Client Need: Safe, Effective Care Environment

1-9

2 Modifiable risk factors associated with coronary artery disease (CAD) include: Cigarette smoking, inactivity, elevated serum lipids, hypertension, obesity, diabetes mellitus, and stressful lifestyles.

1, 3, and 4. Unmodifiable risk factors associated with coronary artery disease (CAD) include: Age, gender, race, and genetic disposition.

Client Need: Health Promotion and Maintenance

1-10

3 Clients should be taught to withhold digitalis if they experience nausea. Symptoms of digitalis toxicity include: Decreased pulse rate, cardiac arrhythmias, nausea, vomiting, loss of appetite, abdominal cramps, and visual disturbance.

1 and 2. Thirst and voiding more than usual are not symptoms of digitalis toxicity.

4. A pulse rate of 64 beats per minute is not a symptom of digitalis toxicity. Digitalis is withheld on adults if the pulse rate is <60 or >100 beats per minute (BPM).

Client Need: Physiological Integrity

1-11

Fill in the blank correct answer:

A pulse rate that has an irregular rhythm is described as dysrhythmia or arrhythmia, an abnormal or disturbed rhythm.

Client Need: Physiological Integrity

1-12

2 Placing a light blanket over the client’s feet is the safest method of keeping the feet warm.

1. Clients with arteriosclerosis are susceptible to the formation of thrombi. Rubbing their feet is dangerous since it could cause the release of thrombi.

3 and 4. Clients with poor circulation and lack of feeling in the lower extremities (neuropathy) could be burned by hot-water bottles and heating pads.

Client Need: Physiological Integrity

1-13

1 The nurse will teach the client that sitting or standing in one position for long periods of time is not recommended since this contributes to venous stasis. Thromboangiitis obliterans (Buerger’s disease) is characterized by inflammation of the small and intermediate arteries and veins. It results in the formation of thrombi and eventually occlusion of vessels.

2. Clients with Buerger’s disease should absolutely not use tobacco in any form. Research indicates that heavy smoking is either a causative or contributing factor. Cigarette smoking causes arterial constriction and increases platelet adhesion, which leads to thrombus