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Which client would the nurse suspect of having a mitral valve prolapse?
- A. A 60-year-old female with congestive heart failure.
- B. A 23-year-old male with Marfan's syndrome.
- C. An 80-year-old male with atrial fibrillation.
- D. A 33-year-old female with Down syndrome.
Correct Answer: B
Rationale: Mitral valve prolapse is common in Marfan’s syndrome (B) due to connective tissue defects. CHF (A), atrial fibrillation (C), and Down syndrome (D) are not strongly associated.
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Which laboratory data confirm the diagnosis of congestive heart failure?
- A. Chest x-ray (CXR).
- B. Liver function tests.
- C. Blood urea nitrogen (BUN).
- D. Beta-type natriuretic peptide (BNP).
Correct Answer: D
Rationale: Elevated BNP (D) is specific for CHF, reflecting ventricular stress. CXR (A) shows fluid but is not diagnostic, liver tests (B) and BUN (C) are nonspecific.
According to the 2010 American Heart Association Guidelines, which steps of cardiopulmonary resuscitation for an adult suffering from a cardiac arrest should the nurse teach individuals in the community? Rank in order of performance.
- A. Place the hands over the lower half of the sternum.
- B. Look for obvious signs of breathing.
- C. Begin compressions at a ratio of 30:2.
- D. Call for an AED immediately.
- E. Position the victim on the back.
Correct Answer: E,B,D,A,C
Rationale: 1. Position on back (E): Ensures a firm surface. 2. Look for breathing (B): Confirms arrest. 3. Call for AED (D): Activates help. 4. Place hands on sternum (A): Prepares for compressions. 5. Begin compressions 30:2 (C): Starts CPR.
Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease?
- A. Assess the client's radial pulse.
- B. Assess the client's serum potassium level.
- C. Assess the client's glucometer reading.
- D. Assess the client's pulse oximeter reading.
Correct Answer: B
Rationale: Loop diuretics cause hypokalemia, which can precipitate dysrhythmias in CAD. Assessing potassium (B) is critical. Pulse (A), glucose (C), and SpO2 (D) are less directly related.
Which intervention should the nurse implement when defibrillating a client who is in ventricular fibrillation?
- A. Defibrillate the client at 50, 100, and 200 joules.
- B. Do not remove the oxygen source during defibrillation.
- C. Place petroleum jelly on the defibrillator pads.
- D. Shout 'all clear' prior to defibrillating the client.
Correct Answer: D
Rationale: Shouting 'all clear' (D) ensures safety before defibrillation. Energy levels (A) are 200–360 joules, oxygen (B) is removed to prevent fire, and petroleum jelly (C) is not used.
Which assessment data would the nurse expect to auscultate in the client diagnosed with mitral valve insufficiency?
- A. A loud S1, S2 split, and a mitral opening snap.
- B. A holosystolic murmur heard best at the cardiac apex.
- C. A midsystolic ejection click or murmur heard at the base.
- D. A high-pitched sound heard at the third left intercostal space.
Correct Answer: B
Rationale: Mitral insufficiency (regurgitation) causes a holosystolic murmur at the apex (B) due to backflow. S1/S2 snap (A) is mitral stenosis, ejection click (C) is aortic/pulmonic, and high-pitched sound (D) is nonspecific.