MARKED ON ATI

a nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find? (SATA) a. hardening along the blood vessel b. absence of a peripheral pulse c. tenderness in the calf d. cool skin on the leg e. increased leg circumference

a, c, e deep-vein thrombosis can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.

a nurse is providing discharge teaching to a client who has a new permanent pacemaker. which of the following statements by the client indicates an understanding of teaching? a. "i should check my heart rate at the same time each day." b. "i dont have to take my antihypertensive medications now that i have a pacemaker" c. "I should keep a pressure dressing over the generator until the incision is healed" d. "I cannot stand in front of our new microwave oven when it is on"

a. "i should check my heart rate at the same time each day."

a nurse is providing information to a client who is scheduled for an exercise electrocardiography test. Which of the following client statements indicates an understanding of the teaching? a. "i will not drink coffee 4 hours prior to my test" b. "I can eat a light meal 1 hour prior to my test" c. "i can have a cigarette up to 30 minutes prior to the test" d. "i willl take my heart medication on the day of the test"

a. "i will not drink coffee 4 hours prior to my test" The client should avoid coffee, alcohol, and caffeine on the day of the test.

a nurse is caring for a client who has an abdominal aortic aneurysm and is scheduled for surgery. the clients vital signs are blood pressure 160/98 mmHg, heart rate 102/min, respirations 22/min and SpO2 95%. which of the following actions should the nurse take? a. administer antihypertensive medication for blood pressure b. monitor to ensure the client's urinary output is 20 ml/hour c. withhold pain medication to prepare the client for surgery d. take the client's vital signs every 2 hours

a. administer antihypertensive medication for blood pressure the nurse should administer antihypertensive medication for elevated blood pressure because hypertension can cause a sudden rupture of the aneurysm due to pressure on the arterial wall.

A nurse is examining the ECG of a client who has hyperkalemia. Which of the following ECG changes should the nurse expect? a. Elevated ST segment b. absent p waves c. depressed ST segments d. varying PP waves

a. elevated ST segment elevated ST segment can indicate hyperkalemia and pericarditis

a nurse is assessing a client who has fluid volume overload from a cardiac disorder. which of the following manifestations should the nurse expect. a. jugular vein distention b. moist crackles c. postural hypotension d. increased heart rate e. fever

a. jugular vein distention b. moist crackles d. increased heart rate the increased venous pressure due to excessive circulating blood volume results in neck vein distention.

A nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which of the following findings should the expect in the client's affected extremity? a. absent pedal pulses b. ankle swelling c. hair loss d. skin atrophy

b. ankle swelling (the nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to poor venous return. other manifestations can include brown pigmentation and cellulitis)

a nurse is assessing a client who had a coronary artery bypass graft for cardiac tamponade. Which of the following actions should the nurse take? a. check for hypertension b. auscultate for loud, bounding heart sounds c. auscultate blood pressure for pulsus paradoxus d. check for pulse deficit

c. auscultate blood pressure for pulsus paradoxus the client who has cardiac tamponade will have pulsus pardoxus when the systolic blood pressure is at least 10 mm Hg higher on expiration than on inspiration. this occurs because of the sudden decrease in cardiac output from the fluid compressing the atria and ventricles.

a nurse is assessing a client who has pericarditis. which of the following manifestations should the nurse expect? a. bradycardia with ST-segment depression b. relief of chest pain with deep inspiration c. dyspnea with hiccups d. chest pain that increases when sitting upright

c. dyspnea with hiccups a client who has pericarditis will experience dyspnea, hiccups, and a nonreproductive cough. these manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade.

A nurse is teaching a client about dietary modifications to control blood pressure. Which of the following food choices should the nurse identify as an indication that the client understands the instructions? a. onion soup and salad b. vegetarian wrap and potato chips c. grilled chicken and salad with fresh tomatoes d. chicken bouillon and crackers

c. grilled chicken and salad with fresh tomatoes (sodium reduction helps control blood pressure)

a nurse is teaching a 70 year old client about risk factors for heart failure. The client has mild asthma, diabetes, and coronary artery disease. Which of the following statements by the client indicates an understanding of teaching? a. "my diabetes will not increase my risk of heart failure" b. "my asthma makes it more likely for me to have heart failure" c. "My age does not increase my risk of heart failure" d. "my coronary artery disease is a risk factor for heart failure"

d. "my coronary artery disease is a risk factor for heart failure" Coronary artery disease is a primary factor for the development of heart failure. Other risk factors include hypertension, cardiomyopathy, tobacco use, family history, and hyperthyroidism

a nurse is assessing a client is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? a. sudden hemoptysis b. acute diarrhea c. frontal headache d. acute confusion

d. acute confusion acute confusion is a manifestation of myocardial infarction in clients age 65 or older. other manifestations can include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue.

A nurse is assessing a client who has an abdominal aortic anuerysum. Which of the following manifestations should the nurse expect? a. midsternal chest pain b. thrill c. pitting edema in lower extremities d. lower back discomfort

d. lower back discomfort

a nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. which of the following actions should the nurse anticipate in the post-procedure plan of care. a. instruct the client about a long-term cardiac conditional program b. administer scheduled dose of acetaminophen c. check for peak laboratory markers of myocardial damage d. monitor for bleeding

d. monitor for bleeding bleeding is a post-procedure complication of PTCA because of the administration of heparin during the procedure and the removal of the femoral (or brachial) sheath. manual pressure or a closure device is used to obtain hemostasis to the site. the client should remain on bed rest until hemostasis is assured.