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A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. ventricular depolarization B. Guillain-Barre syndrom C. myelodysplastic syndrome D. Valvular disease

D

A nurse is caring for a client who presents to the ER with a BP of 254/138 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. obtain blood samples for laboratory testing B. Tell the client to report vision changes C. Place the head of the bed at 45 degrees D. initiate an IV

C

A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? a. apply the new patch to the same site as the previous patch b. place the patch on an area of skin away from skin folds and joints c. keep the patch on 24 hr per day d. replace the patch at the onset of angina

b

A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions? a. delivery of precordial thump b. vagal stimulation c. administration of atropine IV d. defibrillation

b

A nurse is assess a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? A. confusion B. friction rub C. hypertension D. dry skin

a

A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? a. "I can't get rid of these hiccups." b. "I feel dizzy when i stand." c. "My incision site stings." d. "I have a headache."

a

A nurse is caring for a client who has dilated cardiomyopathy. The client reports increasing difficulty completing her daily 1-mile walks. The nurse should recognize that this is a finding of which of the following? a. left ventricular failure b. peripheral vasodilation c. pericardial effusion d. dec vascular volume

a

A nurse is providing discharge teaching for a client who has HF. The nurse should instruct the client to report which of the following findings immediately to the provider? a. weight gain of 2 lb in 24 hr b. inc of 10 mmHg in systolic BP c. dyspnea with exertion d. dizziness when rising quickly

a

A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching? a. "you may no longer be able to feel chest pain." b. "your level of activity tolerance will not change." c. "after 6 months, you will no longer need to restrict your sodium intake." d. "you will be able to stop taking immunosuppressants after 12 months."

a

a nurse is caring for a client who has HF and is experiencing AF. The nurse should plan to monitor for and report which of the following findings to the provider immediately? a. slurred speech b. irregular pulse c. dependent edema d. persistent fatigue

a

A client is being evaluated in the ED for a possible brain attack (stroke). Assessment findings consistent with a brain attack include which of the following? (select all that apply) a. facial droop b. slurred speech c. weakness of affected extremity d. crackles in lungs e. decreased urine output

a, b, c

a nurse is planning a presentation about hypertension for a community women's group. which of the following lifestyle modifications should the nurse include (select all that apply) a. limited alcohol intake b. regular exercise program c. dec Mg intake d. reduced K intake e. smoking cessation

a, b, e

A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following? a. tendon pain b. persistent cough c. frequent urination d. constipation

b

A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? a. inc abdominal girth b. weak peripheral pulses c. jugular vein distention d. dependent edema

b

A nurse is caring for a client in the first 8 hr following coronary artery bypass graft surgery. Which of the following client findings should the nurse report to the provider? a. mediastinal drainage 100 mL/hr b. BP 160/80 mmHg c. Temp 37.1 (98.8) d. K 3.8 mEq/L

b

a nurse is caring for a client who is being treated for HF and has prescriptions for digoxin and furosemide. The nurse should plan to monitor for which of the following as an adverse effect of these medications? a. SOB b. lightheadedness c. dry cough d. metallic taste

b

a nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? a. a client who has hypothyroidism b. a client who has DM c. a client whose daily caloric intake consists of 25% fat d. a client who consumes two bottles of beer a day

b

A client is admitted with a diagnosis of acute stroke. The provider orders "diet as tolerated." Before feeding this client, which nursing action is priority? a. determine client's food preferences b. elevate the head of the bed 30 degrees c. assess client's swallowing reflex d. review serum albumin level to determine appropriate diet

c

A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? a. explore the clients family history of peripheral vascular disease b. note the presence or absence of pain at the ulcer site c. inquire about the presence or absence of claudication d. ask if the client has had a recent infection

c

A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? a. serosanguinous drainage on dressing b. severe pain with coughing c. urine output of 20 mL/hr d. increase in temp from 36.C (98.2F)- 37.5C (99.5F)

c

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI? a. myoglobin b. c-reactive protein c. creatine kinase- MB d. Homocysteine

c

A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? a. "My arthritis is really bothering me because I haven't taken my aspiring in a week." b. "My blood pressure shouldn't be high because I took my BP medication this morning." c. "I took my warfarin last night according to my usually schedule." d. "I will check my BP because I took a reduced dose of insulin this morning."

c

A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values? a. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL b. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL c. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL d. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL

c

a nurse is monitoring a client following coronary artery bypass graft surgery. Which of the following findings can indicate cardiac tamponade? a. sternal instability b. inc WBC count c. BP 140/82 mmHg on inspiration and 154/90 mmHg on expiration d. sinus rhythm with occasional premature atrial contraction and HR 88/min

c

A nurse caring for a client following an abdominal aortic aneurysm resection. Which of the following is the priority assessment for this client? a. neck vein distention b. bowel sounds c. peripheral edema d. urine output

d

A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. administering IV morphine sulfate B. administering oxygen at 2 :/min via nasal cannula C. helping the client to the bedside commode D. assisting with thrombolytic therapy

d

A nurse is caring for a client who has a history of angina and is schedules for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? a. "I'm still hungry after the bowl of cereal I ate at 7am." b. "I didn't take my heart pills this morning because the doctor told me not to." c. "I have had chest pain a couple of times since I saw my doctor in the office last week." d. "I smoked a cigarette this morning to calm my nerves about having this procedure."

d

A nurse is preparing a client for coroncary angiography. The nurse should report which of the following findings to the provider prior to the procedure? a. hemoglobin 14.4 g/dL b. history of peripheral arterial disease c. urine output 200 mL/4 hr d. previous allergic reaction to shellfish

d

A nurse is reviewing the medical record of a client who is receiving heparin therapy for treatment of DVT. Which of the following interventions should the nurse anticipate taking if the client's aPTT is 96 seconds? a. Increase the heparin infusion flow rate by 2 mL/hr b. continue to monitor the heparin infusion as prescribed c. request a prothrombin time d. stop the heparin infusion

d

a nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? a. hemoglobin 14 g/dL b. minimal bruising of extremities c. reduced circumference of affected extremity d. INR 2.5

d