68

Cardiovascular system

7. Following a left anterior myocardial

infarction, a client undergoes insertion of
a pulmonary artery catheter. Which finding most strongly suggests left-sided heart
failure?
1. A drop in central venous pressure
2. An increase in the cardiac index
3. A rise in pulmonary artery diastolic
pressure
4. A decline in mean pulmonary artery
pressure
Answer: 3. A rise in pulmonary artery diastolic pressure suggests left-sided heart
failure. Central venous pressure would rise in
heart failure. The cardiac index would decline
in heart failure. The mean pulmonary artery
pressure would increase in heart failure.

NCLEX keys
Client needs category: Physiological integrity
Client needs subcategory: Physiological
adaptation
Cognitive level: Application
Congrats! You
finished the chapter.
My advice: Take a
break to exercise
your body and give
your mind a rest.

8. A client with dilated cardiomyopathy,

pulmonary edema, and severe dyspnea is
placed on dobutamine. Which assessment
finding indicates that the drug is effective?
1. Increased activity tolerance
2. Absence of arrhythmias
3. Negative Homans sign
4. Blood pressure of 160/90 mm Hg
Answer: 1. Dobutamine should improve the
clients symptoms and the client should experience an increased tolerance for activity. The
absence of arrhythmias doesnt indicate effectiveness of dobutamine. A negative Homans
sign indicates absence of blood clots, which
isnt a therapeutic effect of dobutamine.

NCLEX keys
Client needs category: Physiological integrity
Client needs subcategory: Pharmacological
and parenteral therapies
Cognitive level: Analysis
9. A nurse administers warfarin (Coumadin) to a client with deep vein thrombophlebitis. Which laboratory value indicates
that the client has a therapeutic level of
warfarin?

313419NCLEX-RN_Chap03.indd 68

1.

Partial thromboplastin time (PTT)

11/2 to 2 times the control
2. Prothrombin time (PT) 11/2 to 2
times the control
3. International Normalized Ratio (INR)
of 3 to 4
4. Hematocrit (HCT) of 32%
Answer: 2. Warfarin is at a therapeutic level
when the PT is 11/2 to 2 times the control.
Values greater than this increase the risk
of bleeding and hemorrhage; lower values
increase the risk of blood clot formation.
Heparin, not warfarin, prolongs PTT. The INR
may also be used to determine whether warfarin is at a therapeutic level; however, an INR
of 2 to 3, not 3 to 4, is considered therapeutic.
HCT doesnt provide information on the effectiveness of warfarin. However, a falling HCT
in a client taking warfarin may be a sign of
hemorrhage.

NCLEX keys
Client needs category: Physiological integrity
Client needs subcategory: Pharmacological
and parenteral therapies
Cognitive level: Application
10. A client comes to the emergency
department with a dissecting aortic aneurysm.
The client is at greatest risk for:
1. septic shock.
2. anaphylactic shock.
3. cardiogenic shock.
4. hypovolemic shock.
Answer: 4. A dissecting aortic aneurysm is
a precursor to aortic rupture, which leads to
hemorrhage and hypovolemic shock. Septic
shock occurs with overwhelming infection.
Anaphylactic shock is an allergic response.
Cardiogenic shock is the result of ineffective
cardiac function.

NCLEX keys
Client needs category: Physiological integrity
Client needs subcategory: Reduction of risk
potential
Cognitive level: Comprehension

4/8/2010 7:01:55 PM