Cardio, Shock, PVD Adult 3 Final

A nurse is caring for a client who has rhabdomyolysis. The provider prescribes 0.9% sodium chloride to infuse at a rate of 200 mL/hr. How many hours will it take for a 1-L bag of IV fluid to infuse?

5 hr

A nurse is talking with a client who is about to start using transdermal nitroglycerin (Nitro-Dur) to treat angina pectoris. Which of the following is an appropriate instruction for this medication therapy?

Apply the transdermal patch in the morning

A nurse is caring for a client who just had a cardiac catheterization. Which nursing interventions should the nurse include in the client's plan of care for the next 8 hr? (Select all that apply.)

Check peripheral pulses in the affected extremity. Keep the client's hip and leg extended. Have the client remain in bed up to 6 hr.

A nurse is caring for a client who is post-operative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

Encourage increased fluid intake

A nurse is caring for a client who is post-operative following a total knee replacement. Which of the following actions should the nurse implement to prevent deep vein thrombophlebitis?

Encourage increased fluid intake.

A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement clients might use to help lower blood pressure?

Garlic

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain a venous duplex ultrasound.

A nurse is caring for a client who has heart failure. The client's arterial blood gas values reveal a pH of 7.24, PaCO2 of 53, and an HCO3 of 24. The nurse recognizes that the client is experiencing which of the following?

Respiratory acidosis

A nurse is teaching a group of nursing students about the various routes of medication administration. The nurse should explain that, of the following routes, the one that results in the most rapid absorption of the medication into the bloodstream is

Sublingual

A nurse is assessing a client before administering a unit of RBC. Which of the following data are most important prior to transfusing the RBC?

Temperature

A nurse in the emergency department is caring for a client who reports chest pressure, indigestion, fatigue, and occasional shortness of breath. Which of the following laboratory tests will provide the most specific indication of whether or not the client has had a myocardial infarction (MI)?

Troponin I

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect?

Hepatomegaly

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

Hypercholesterolemia HTN Obesity Smoking

To evaluate a client following cardiac catheterization with a left antecubital insertion site, the nurse should palpate the

radial pulse in the left arm

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI) and is reviewing the provider's orders. Which of the following prescriptions by the provider requires clarification?

0.9% normal saline IV at 50 mL/hr continuous

A nurse is reviewing the morning laboratory results of electrolytes of four cardiac clients who are receiving digoxin (Lanoxin). Which of the clients should the nurse identify as being at risk for developing digoxin toxicity?

A client taking furosemide (Lasix) for chronic hypertension

A nurse is caring for a group of clients on a surgical unit. Which of the following should be the nurse's initial action?

Assessing a client who experiences unilateral calf pain when ambulating

A nurse providing discharge teaching for a client who has a new arteriovenous fistula in the right forearm. Which of the following should the nurse include in the teaching as a possible indication of venous insufficiency?

Cold and numb fingers of the right arm

A nurse is giving a presentation about preventing deep-vein thrombosis. Which of the following should the nurse includes as a risk factor for this disorder?

Dehydration Oral contraceptive use Immobility

A nurse is assisting with the care of a child who is receiving a blood transfusion. Which of the following indicates the child is experiencing a complication?

Difficulty breathing

A nurse is caring for a client who had a cardiac catheterization 6 hr prior. The nurse makes the following observations: Urine output for the first 4 hr of the evening shift was three times the intake in the same period. Vital signs are within normal limits and stable. Intravenous fluids are running at 50 mL/hr. Femoral insertion site dressing is intact. Distal pulses are palpable and strong. The nurse should recognize that the discrepancy between the client's intake and output represents a physiologic response to which of the following?

Dye utilized for the study

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

A nurse is preparing educational material for a client who has a thrombocytopenic disorder. Which of the following information should the nurse include?

Notify the dentist of condition prior to invasive procedure

​A client who has angina pectoris tells the nurse in the emergency department that he took three nitroglycerin (Nitrostat) tablets sublingually just before coming to the hospital. The nurse should expect to identify which of the following findings? (Select all that apply.)

Tightness in the chest Shortness of breath ​Indigestion

A nurse is assisting with the care of a client following surgery who has antiembolism stockings in place. Which of the following is the purpose for this device?

To prevent venous stasis

An older adult client with a history of myocardial infarction (MI) comes to the emergency department reporting bilateral calf pain. He states that it started 2 weeks ago when he began a more advanced stretching and exercise regimen. The client also states that he has been having indigestion for the past 24 hr. Which of the following is the nurse's priority action?

Obtaining an ECG for the client

A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding?

Oliguria

A nurse is caring for a client who enters the emergency department of severe chest pain. Which of the following interventions should the nurse implement to determine if the client is experiencing a myocardial infarction?

Perform a 12-lead ECG

A client tells the nurse at an outpatient clinic that he has leg pains that begin when he walks but cease when he stops walking. Which of the following disorders should the nurse suspect?

Peripheral vascular problems in both legs

A nurse is assessing a client's wife on how to take a blood pressure. Which of the following actions by the wife indicates a need for further instruction?

Place the client arm above the level of the heart

A client is requesting information regarding serum troponin test. Which of the following is the nurse's best response?

"The slightest elevation in troponin levels will prompt treatment to prevent complications of cardiovascular disease."

A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition?

"DIC is caused by abnormal coagulation involving fibrinogen"

A nurse has received shift report and is preparing her assignment. Which of the following client's should the nurse assess first?

A client who was admitted for chest pain with a troponin level of 0.6 ng/mL and complaining of indigestion

While reading a client's ECG tracing, the nurse should understand that the P wave reflects which of the following cardiac electrical activities?

Atrial depolarization

A nurse is caring for a client who has a cardiopulmonary arrest. The emergency response team will administer which of the following medications during cardiopulmonary resuscitation (CPR) if the client's restored rhythm is symptomatic bradycardia?

Atropine

The nurse is helping with the admission of a client from the emergency department. The client is prescribed clopidogrel bisulfate (Plavix). Which of the following precautions should the nurse anticipate?

Bleeding

A nurse is caring for a client who has mild dementia and reports taking the over-the-counter supplement gingko biloba. Which of the following should the nurse instruct the client to report immediately to the provider?

Bleeding gums

A nurse is obtaining vital signs on a client who is 3 days postoperative following a coronary artery bypass graph surgery (CABG), and notes that the client has an irregular radial pulse of 92/min. Which of the following actions should the nurse take first?

Count the apical heart rate for 1 minute

A nurse collecting data from a newborn finds an apical pulse of 130/min. Which of the following is the appropriate nursing action?

Document this as an expected finding

A client who is 7 days postpartum calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

Elevate her leg

A nurse is talking with a client who is about to undergo hip arthroplasty. The nurse explains that the surgeon will prescribe anticoagulant therapy to prevent deep-vein thrombosis postoperatively. The nurse should explain that the client will not require frequent clotting time determinations because the surgeon plans to prescribe which of the following medications?

Enoxaparin (Lovenox)

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back and shoulder, shortness of breath and nausea. Which of the following actions should the nurse perform first?

Ensure a patent airway

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back and shoulder, shortness of breath and nausea. Which of the following actions should the nurse perform first?

Ensure a patent airway.

A client comes to the emergency department via ambulance to report severe radiating chest pain and shortness of breath. The client appears restless, frightened, and slightly cyanotic. The provider prescribes oxygen by nasal cannula at 4 L/min stat, cardiac enzyme levels, IV fluids, and a 12-lead ECG. Which of the following actions should the nurse take first?

Initiate oxygen therapy.

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client feeling reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Irregular pulsations

A nurse is about to administer warfarin (Coumadin) to a client who has atrial fibrillation. When the client asks what this medication will do, which of the following is an appropriate nursing response?

It prevents strokes in clients who have atrial fibrillation.

A nurse is caring for a client who is 1 wk postpartum and notes unilateral leg edema with associated pain and a low-grade temperature. The nurse should advise the client to avoid which of the following?

Massaging the painful area of the leg

A nurse is caring for a client who receives digoxin (Lanoxin). Before administering this medication, which of the following actions should the nurse take?

Measure the client's apical pulse

A nurse is caring for a client in the critical care unit following a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following findings supports this suspicion?

Muffled heart sounds.

A nurse in a clinic is caring for a client who has a prescription for digoxin (Lanoxin). Which of the following statements by the client indicates the client is experiencing digoxin toxicity?

My vision seems yellow

A nurse is assessing a client who has an acute myocardial infarction (MI). Which of the following clinical manifestations should the nurse expect to find? (Select all that apply.)

Nausea Tachycardia Diaphoresis

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings should make the nurse suspect deep-vein thrombosis?

Unilateral leg edema

A nurse is assessing a client who has a vitamin K deficiency. Which of the following indicates the nurse understands the effects of Vitamin K?

Vitamin K reverses warfarin toxicity.

A nurse is caring for client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tab. The client's current vital signs are: blood pressure 144/96, heart rate 54/min, respirations 18/min, and temperature 98.6 F. Which of the following actions should the nurse take?

Withhold the digoxin dose for decreased pulse rate

A nurse is reinforcing teaching with an older adult client who has just undergone insertion of a permanent pacemaker. The nurse should emphasize that a sign of pacemaker malfunction the client should report to the provider is

fatigue

A nurse is reinforcing teaching with a client who has angina pectoris about starting therapy with nitroglycerin (Nitrostat). The nurse should remind the client to take the medication

at the first indication of chest pain

A nurse in an intensive care unit is caring for a client who had an acute myocardial infarction (MI) and had cardiac enzymes drawn. The nurse should know that the results of the cardiac enzyme studies help determine the

degree of damage to the myocardium.

To evaluate a client following cardiac catherization with a left antecubital insertion site, the nurse should palpate the

radial pulse in the left arm

A nurse is caring for a male client who has peripheral vascular disease and is taking dietary supplements and has a new prescription for warfarin (Coumadin). The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (Select all that apply.)

​Saw palmetto Glucosamine Gingko biloba