medsurg tings 1-73 ATI ADULT MED SURG
A nurse is preparing to obtain a sputum specimen from a client. Which of the following nursing actions will facilitate obtaining the specimen?
- Have the client take three deep breaths.
The nurse would record a Mantoux as "positive", when the induration at 48 hours is 5 mm in a client who is
- HIV positive
A client in a hypertensive crisis has sustained B/P of 180/120. The nurse recognizes that the optimum pressure target in the first 2 hrs of reduction therapy is:
135/90
A client in HTN crisis has a sustained BP of 180/120 and is being treated with HTN protocol. The nurse recognizes that the optimum pressure target for the client in the first 2 hours of reduction therapy is:
150/95
The nurse is caring for a client who had PTCA 1 hour ago. Which of the following is a priority assessment at this time?
Bleeding
The nurse is assessing an older client admitted with SOB 3+ bilateral pitting edema, and crackles at bases on auscultation. Which of the following should the nurse assess first?
Blood pressure
A client with severe peripheral arterial disease is having difficulty falling asleep due to pain in their legs. Which of these nursing interventions would be most effective due to prevent these symptoms?
Assist the client to dangle her legs
The RN is teamed with a LPN in caring for a group of clients on the cardiac unit. Which action by the LPN indicated the need by the RN to intervene immediately? The LPN
Assists a client to the bathroom 30 minutes after the client has returned from a cardiac catheterization. (BED REST 2-6 HOURS)
A client has coronary angiography with the entrance site in the left femoral artery. Two hours after the procedure, the nurse in unable to palpate the left pedal pulse. What is the nurse's most appropriate action at the time?
Attempt to locate pulse using a Doppler.
A nurse is caring for a client admitted to the telemetry unit with dysrhythmias and left ventricular failure. Which of the following is a priority assessment for the nurse?
Ausculatate breath sounds
Which intervention suggested to the client with Buerger's disease is aimed at limiting disease progression?
Cease smoking
When the chest tube detaches from the closed-chest drainage system, and the client experiences sudden dyspnea, the nurse should
Reconnect the chest tube to the system
Which statement made by the client with peripheral arterial disease concerning positioning of edematous lower extremities requires further clarification by the nurse?
" I will elevate my legs above the level of my heart."
A nurse is carrying for a client who is receiving treatment for pulmonary tuberculosis (TB) with Rifampin. The nurse evaluate that the client has a good understanding of this medication if the client states
"My urine will look orange because of the medication."
After saying that "everybody always tells me coke is bad for your heart," a young adult client asks the nurse. "What does cocaine do?" The nurse should respond
- "A fight-or-flight reaction occurs when cocaine is used, stressing the heart, often beyond its capacity."
The nurse interprets a Manteux reaction as "0 mm" a negative test for TB. The client tells the nurse "its good to know that I definitely don't have TB". The correct response by the nurse should be
- "A negative test does not always mean that TB is not present."
The nurse is caring for a client with newly diagnosed hypertension. What dietary teaching should be included in the plan of care for this client?
- "Avoid the use of canned or processed foods."
A client recently diagnosed with peripheral arterial disease reports pain in the lower extremities after walking five blocks. Which of the following questions would best assist the nurse in determining in the disease is progressing?
- "Do you feel this pain while resting"?
To determine if a client with complains of pain after walking five blocks is experiencing intermittent claudication, the nurse should ask,
- "Does the pain always occur when you walk that distance?"
A client reports smoking 2 packs of cigarettes per day for 45 years and tells the nurse that his brother died of small cell lung cancer. The client asks the nurse about early symptoms of lung cancer. What is the nurse best response?
- "Early symptoms are nonspecific, consisting of cough and SOB on moderate exertion."
A home care nurse observes oral candidiasis in the client with severe chronic bronchitis. What information should the nurse obtain from the client?
- "How often are you using your steroid inhaler?"
A client was scheduled for bronchoscopy and was given pre-procedure instructions by the RN. Which statements made by the client would indicate need for further teaching?
- "I may swallow the anesthetic sprayed in my throat before the procedure"
A nurse is instructing a client who has stable angina. Which of these client responses would indicate to the nurse that the client has a proper understanding of their conditions?
- "My chest pain can occur if I overexert myself"
A nurse is preparing a client for discharge from the hospital following a myocardial infarction. The nurse determines that further instruction is needed when the client says
- "My heart will be as good as new when I finish a cardiac rehabilitation program."
A physician tells a client that a pneumonia has caused bilateral lobal atelectasis. The client anxiously asks the nurse, "Does that mean my lungs have collapsed?" The most informative response by the nurse would be,
- "No, only a lobe in each side has collapsed but they will inflate as the pneumonia resolves.
What instructions should the nurse provide to a client at risk of deep vein thrombosis who is being discharged home with low-molecular weight heparin?
- "Notify your HCP if your stools appear tarry."
A nurse is telephoned by a client who describes non-radiating substernal chest pain that was precipitated by climbing three flights of stairs. The client has taken one sublingual (SL) nitroglycerin tablet and asks what he should do since the pain is unrelieved. The nurses' best response should be
- "Take another nitroglycerin tablet in five minutes and lie down."
The client with a diagnosis of lung cancer is scheduled to have a liver scan and asks why this procedure is needed. What is the nurse's best response?
- "The treatment for lung cancer is different if it has spread to the liver than if it is only confined to the lungs."
A client with severe chronic bronchitis tells the nurse that eating is difficult, I become so short of breath. What is the nurse's best response?
- "Try using your bronchodilator inhaler about 30 minutes before eating your meal."
A nurse is educating a client who has Raynaud's disease. Which intervention is aimed at preventing complications?
- "Wear warm clothing when exposed to cool temperatures."
A nurse is teaching a client about the medication regimen for the treatment of HTN. Which statement by the client indicates a need for additional teaching?
- "When my blood pressure becomes normal, I won't need to take medication."
A client diagnosed with Active Tuberculosis (TB) asks the nurse about the length of treatment. The nurse bases the response on an understanding that the usual course of drug treatment with active TB is
- 6 months
A nurse in an outpatient clinic meets with three clients to gain information regarding their usual daily routines. The nurse determines that the clients at highest risk for chronic venous disease would be the
- 62- year old overweight client who stands on an assembly line 8 hours a day.
The charge nurse on the medical unit is making assignments for the next shift. Which client should be assigned to the nurse who floated from the surgical unit?
- A 65-year-old client just returned from bronchoscopy and biopsy.
A nurse is obtaining a history from an adult client who has cardiac valve disease. Which of the following questions should be most important for the nurse to ask? "Do you have:
- A childhood history of rheumatic fever?"
A client is scheduled for a thoracentesis to obtain pleural fluid for diagnosis of a large pleural effusion., she asks the nurse to explain what causes the fluid in her lungs. The nurse explains that
- A pleural effusion is not a disease but rather a sign of some other disease
A client with a history of asthma is admitted to the hospital in acute respiratory distress. Which of the following assessment findings would require priority intervention
- ABG: pH 7.32, PaCO2 55 mm Hg, PaO2 60 mm Hg (respiratory acidosis)
For a client who has a diagnosis of peripheral arterial disease, which intervention should the nurse suggest to promote vasodilation?
- Abstaining from smoking - Performing gradually increasing exercises, such as walking.
The health care provider has prescribed to a client with a DVT to be started on oral warfarin while still receiving IV heparin. What is the nurse's best action at this time?
- Administer the medications as prescribed
A nurse is assessing breath sounds with the diaphragm of the stethoscope and hears rhonchi on expiration in both lower lobes. The nurse should reassess
- After the client has coughed.
A client is scheduled to have a bronchoscopy. Which nursing intervention is most appropriate in preparation for this procedure?
- Allow the client nothing by mouth for 4 hours before the procedure.
The nurse makes a diagnosis of impaired gas exchange for a client with COPD in acute respiratory distress, based on the assessment finding of
- An SaO2 of 86%
A nurse is caring for a client considering mechanical mitral valve replacement surgery. An essential determination for the healthcare team to make would be whether the client is able to
- Comply with the lifelong requirement for anticoagulant therapy
The client is 12 hours post op after a thoracotomy for lung cancer. During a portable Chest XR procedure at the bedside, the lower chest tube tubing is accidently pulled out. What is the nurse's best initial action?
- Cover the insertion site with Vaseline or occlusive gauze
A nurse is caring for a client who has a history of hypotension and cardiac failure. In performing a breath sound assessment on the client, the nurse should anticipate the finding of
- Crackles in the lung bases
Following assessment of a client with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance, the nurse bases this nursing diagnosis on the finding of
- Crackles in the right and left lower lobes
A nurse on the telemetry unit is performing an admission assessment on a client admitted with a diagnosis of heart failure. Which of these clinical manifestations would be most significant when assessing a client who has left ventricular failure?
- Crackles to both lung bases
Patient with emphysema respiratory drive is triggered by
- Decreased Oxygen
A client with a medical diagnosis of aortic valve Stenosis (Prolapse) is admitted to the telemetry unit and placed on bed rest with bathroom privileges. Based on an understanding of this disorder, a priority nursing diagnosis should be
- Decreased cardiac output
The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the client with infective endocarditis. This diagnosis is consistent with the assessment finding of
- Decreasing urine output
A client who has mitral stenosis tells the nurse she will not seek treatment for this disorder because she "doesn't really feel that bad." The nurse's best response should be, "Untreated mitral stenosis can result in
- Development of an atrial thrombus."
An emergency room nurse is assessing a client who sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of pneumothorax in this client?
- Diminished breath sounds
For a client admitted with a history of chronic arterial insufficiency, the nurse should anticipate that physical assessment will reveal
- Diminished pedal pulses.
An older client is admitted with a suspected myocardial infarction. Which of these clinical manifestations of myocardial infarction should the nurse expect to see in an older adult?
- Disorientation or confusion
A nurse is caring for a client with a DVT. The nurse should instruct the UAP to make sure to
- Elevate the affected extremity
Nursing care of a client immediately after a PTCA should include:
- Encouraging oral fluids for the client
Which laboratory value indicates to the nurse that the client may have asthma triggered by allergies?
- Eosinophil count of 500 cells/mm (12%) (Normal 30-350 cells/mm 0.0-6.0 %)
During the assessment of the client with severe COPD, the nurse notes jugular vein distension and pedal edema. The nurse further assesses the client for
- Fluid volume excess secondary to right sided heart failure
A client recently diagnosed with PAD is admitted to the medical-surgical unit. The nurse understands that a priority assessment for this client will include
- Foot ulcers and peripheral pulses
To prevent the complication of atelectasis in an older adult client who has a hip fracture, the nurse should
- Frequently reposition the client.
Following discharge teaching, the nurse evaluates the client with pneumonia understands measure to prevent relapse when the client states
- I should continue to do deep-breathing and coughing exercises for at least 6 weeks
A nurse should teach a client who has asthma the technique for pursed-lip breathing because this technique
- Increased pressure in the airway
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
- Ineffective airway clearance
A client who has a chronic cough and blood tinged sputum undergoes a bronchoscopy. Following the bronchoscopy a priority intervention should be to
- Keep the client NPO until the gag reflex returns.
In providing instructions for a client with a new diagnosis of tuberculosis, the nurse should give the highest priority to which nursing diagnosis?
- Knowledge deficit
During an assessment of a client, the nurse notes a heart rate of 48 beats per minute. The nurse further evaluates the client for signs and symptoms related to:
- Light-headedness - Syncope - Fatigue
In managing the care of a client taking isoniazid (INH), it is important for the nurse to monitor which of these laboratory tests?
- Liver function studies
A nurse is assessing a client following a lengthy abdominal surgery. An assessment finding that would indicate a possible complication from the surgery would be
- Localized warmth and tenderness in a lower extremity
While recovering from abdominal surgery a client develops thrombophlebitis. A nurse would assess the client for?
- Localized warmth and tenderness of the leg
An otherwise healthy 28 YO woman has just been diagnosed with stage I HTN. She says she has a glass of wine once or twice week and eats "fast food" frequently because of her busy schedule. Which topic should the nurse plas on including in the client-teaching plan?
- Low-sodium food choices when eating out
Following the removal of a blood sample for an arterial blood gas analysis (ABG) the nurse notes a large hematoma forming at the site of the puncture. Which action taken by the nurse would be most appropriate?
- Maintain manual compression over the puncture site for five minutes.
A client recuperating from a lung resection is encouraged to deep-breathe and cough several times a day and does not need supplemental oxygen. ABG results are PaO2 95 mm Hg, PaCO2 40 mm Hg, and pH 7.35. Which of these should the nurse anticipate in the treatment plan at this time?
- Maintenance of the present course of treatment
The nurse assesses the results of a PaCO2 from an asthmatic patient, the nurse gets this information in relation to
- Measures Ventilation and Perfusion
A nurse caring for a client scheduled to have chest tubes removed. The nurse's most appropriate action should be to
- Medicate for pain ½ hour before removal
The nurse is caring for client on a step down unit. Prior to discharge the nurse will instruct the family of a client who has had a CABG regarding... SATA
- Medication actions and side effects - Physical activity restrictions - Incisional care
Which clinical manifestation in a client with long-standing chronic obstructive pulmonary disease (COPD) alerts the nurse to the possibility of right-sided heart failure?
- Neck vein distension
A client who is being treated for pneumonia has a PaO2 of 75 mm Hg on room air. The most appropriate interpretation of this data by the nurse should be that the client
- Needs supplemental oxygen
A client undergoes a segmental pressure measurements and Ankle-Brachial Index (ABI) in the vascular ultrasound lab. A nurse reviewing the results notes that the ankle pressure is slightly higher than the brachial pressure. How should the nurse interpret these findings?
- No blockage of the peripheral arteries
A nurse is caring for a client admitted to the hospital with a complaint of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states that there is no change in their pain level. Which of these actions should the nurse implement first?
- Notify the HCP.
A nurse is preparing a client who has endocarditis for discharge. The nurse should instruct the client that to avoid further complications the client should
- Notify the dentist when invasive dental procedures are planned.
A nurse notes the mediastinal tubes of a client who is 6 hours post op following CABG surgery have stopped draining. Which action most appropriate for the nurse to take at this time?
- Notify the doctor
A client diagnosed with a community-acquired pneumonia is being admitted to the medical unit. Which nursing intervention has the highest priority?
- Obtain a sputum specimen for culture & sensitivity
While caring for a client with resp disease, the nurse observes that the client's SaO2 drops from 94% to 85% when the client ambulates in the hall. The next best action is to
- Obtain an order for oxygen when the client ambulates
The healthcare provider writes the following orders: Ceftriaxone (Rocephin) 1 g IVPB q12hr, Tylenol for temperature above 102 F, blood cultures x3, CBC, metabolic profile, ECG. When admitting the client who has infective endocarditis, which of these should the nurse do first?
- Obtain the blood cultures.
The nurse identifies a goal of improving nutrition for a client with recent weight loss following an exacerbation of COPD. An appropriate intervention to achieve this goal is
- Order a high calorie, high protein diet divided into six small meals a day
A client with COPD has a barrel chest. The nurse should expect the results of a chest x-ray to reveal
- Over inflation of the alveoli with air
A nurse is assessing the following client with a history of chronic obstructive pulmonary disease. The following X-ray would likely reveal
- Overinflation of the alveoli with air.
A client who has COPD has severe shortness of breath at rest and arterial oxygen tension (PaO2) of 75 mmHg on the most recent ABG. Orders include oxygen via nasal cannula & activity as tolerated. The nurse intervene when noting:
- Oxygen being delivered at 4 L/min via nasal cannula.
A client in moderate to severe respiratory disease is admitted to the medical unit at the hospital. During the admission assessment of the client the nurse should
- Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.
After walking one block a client complains of muscular, cramp-like pain to his lower extremities that is relieved by rest. Based on these clinical symptoms, the nurse should further assess the client for possible
- Peripheral arterial disease
A nurse is teaching a patient who has bronchial asthma. The nurse understands that which of these is a possible consequence of chronic, poorly controlled asthma resulting from inflammatory processes?
- Permanent hyperplasia of bronchial epithelial cells with resultant airway narrowing.
A client who has a MI is admitted to the coronary care unit. The client begins to develop bilateral crackles, an increase in HR from 80 to 102 bpm, and cold, clammy skin. Which of the following actions should the nurse perform at this time? SELECT ALL THAT APPLY
- Place client in semi fowlers - Administer oxygen @ 2 L/min - Notify HCP
A nurse is participating in developing a standard of practice to prevent aspiration pneumonia. Which of these should be included in the standard as a priority?
- Position clients with altered consciousness in lateral positions.
The nurse is speaking to a group about peripheral vascular disorders. The nurse should include factors that may predispose a client to venous disorders including: SELECT ALL THAT APPLY
- Positive family history of venous disorders - Multiple pregnancies - Obesity
A nurse is participating in a community health screening. Which of the following findings presents the highest risk for the development of coronary atherosclerotic heart disease?
- Postmenopausal female - Uncontrolled type 2 diabetes, - Family history of heart disease
The nurse is conducting a musculoskeletal assessment on a client who complains of muscle weakness with cramping. Which of these laboratory values supports this finding?
- Potassium level of 3.0 mEq/L
The nurse teaches the client with COPD how to perform pursed lip breathing, explaining that this technique will assist respiration by SATA:
- Preventing collapse of small airways in the lungs during expiration - Slowing the respiratory rate and giving the client control of respiratory patterns
The charge nurse is making the daily assignment on the cardiac intermediate care unit. Which client is best to assign to a RN who is floated from a general medical-surgical unit for the day? The client
- Receiving intravenous furosemide (Lasix) to treat exacerbation of left ventricular failure
A client is diagnosed with hypertension. Initial nursing assessment reveals a body mass index of 30, reports a sedentary lifestyle, and smoked half a pack of cigarettes daily. For the behavioral change with the most immediate and positive impact on his blood pressure, the nurse should focus on
- Regular exercise.
The nurse assesses a client with emphysema. Which assessment finding would indicate increasing hypoxia?
- Restlessness
1. The nurse is writing an infection control policy for a home health care agency. The nurse should include the information that the rise in TB cases in recent years is related to the
- Rise in HIV infection
When performing cardiac assessment on an apparently healthy adult with mitral regurgitation, the nurse should anticipate auscultating a
- Systolic murmur
A nurse formulating a teaching plan for a client recently diagnosed with active tuberculosis. What pertinent information should the nurse include?
- TB is usually treated with three or more medications to prevent organism resistance.
A nurse is performing a cardiac assessment on a client. In auscultating heart sounds, the nurse hears the closure of the aortic and pulmonic valves. The nurse document this as
- The S2 heart sound
a client who has been diagnosed with TB of the bone tells the nurse that he thought TB was a lung disease. The nurse explains to the client that
- The lungs are the most common site of TB infection but it can spread to other parts of the body through the blood and lymph systems
A client presents to the out patient clinic with a venous ulcer on the left ankle. What additional assessment findings should the nurse expect to be present in this client?
- There is a brownish discoloration of the lower extremity at the ulcer site
A client is being treated for hypertension. Which of the following outcomes demonstrates to the nurse effective management of a client's hypertension?
- There is no indication of target organ damage.
A nurse is caring for a client who has asthma that is triggered by exercise. The most informative response by the nurse should be?
- Use a short acting beta agonist before engaging in exercise
An older adult nursing home resident has a productive cough, fever, chills, and a history of night sweats. A PPD test is negative. What instructions would the infectious disease nurse prepare for nursing staff taking care of this client?
- Use standard precautions and airborne precautions until a chest x-ray shows the client does not have TB.
A nurse is caring for a client with early stages of peripheral venous disease. Which of the following is an expected finding when inspecting the lower extremities?
Edema
Which nursing measure would be a priority in the care plan for a client who has DVT?
Elevating lower extremities
A client who has a history of mitral valve stenosis is admitted for shortness of breath. What pertinent data should the nurse expect from the client regarding a history of mitral valve stenosis? (Strep Throat)
Frequent sore throats or skin infections
A RN and an UAP are caring for four clients on a telemetry floor. Which nursing task would be best for the nurse to delegate to the UAP?
Help position the client who is having a portable x-ray done
A nurse is caring for a client who has been admitted with heart failure after experiencing a MI six months ago. The client asks the nurse how he developed heart failure. The nurse explains the etiology of hear failure after MI as the
Impairment of the contractile function of the ventricle.
A client in a hypertensive crisis has a sustained blood pressure of 200/140 mm Hg and is being treated with hypertensive protocol. The nurse recognizes that the optimum pressure target for the client in the first two hours of reduction therapy is
In the first 2hrs should be 30%
A client with lung cancer is scheduled for surgery and is receiving oxygen at 2L/minute via nasal cannula. The client tells the nurse that the sensation of air hunger is worst. What is the nurse's best first action?
Increase the flow of oxygen.
A client with congestive heart failure is on digoxin therapy. The nurse notes that the digoxin level is 2.6 ng/ml. the nurse should
It is toxic (0.5-2.0 is normal)
A nurse is assessing a client with left sided heart failure and finds bilateral 2+pitting edema of the ankles. Which of the following signs or symptoms should the nurse also anticipate findings?
Jugular venous distention.
A client admitted to the hospital following an MVA 21 days ago has a tracheostomy. The physician orders to cap the tracheostomy for 4 hrs. Which of the following nursing interventions will assist the client to maintain oxygenation?
Keep the balloon deflated while the tracheostomy remained capped.
When preparing a patient for a cardiac catheterization, the patient states that she has allergies to seafood. Which of the following medications may give to her prior to the procedure?
Methylprednisolone (Solu-Medrol)
A nurse assessing an ECG rhythm strip. The p waves and QRS complexes are regular. The PR interval is 0.16 seconds and QRS complexes measure 0.06 second. The overall heart rate 64 BPM. The nurse assesses the cardiac rhythm as
Normal sinus rhythm
What instructions should the nurse provide to a client at risk of DVT who is being discharged home with LMWH?
Notify your HCP if your stools appear tarry."
A nurse is caring for a client with congestive heart failure. A priority assessment at this time would be to
Obtain daily weights.
A client with congestive heart failure has tachypnea, severe dyspnea, and a SaO2 of 84%. The nurse identifies a nursing diagnosis of impaired gas exchange related to increased preload and mechanical failure. An appropriate nursing intervention for this diagnosis is to
Place the client in a high fowler's position with the feet dangling over the bed.
A client with MI is admitted to the coronary care unit. The client begins to develop bilateral crackles, an increase in heart rate from 82 to 102, and cold, clammy skin. Which of the following actions should the nurse implement? All that apply
Place the client in semi-fowler's position, Administer O at 2L/min as ordered, Notify the physician
The nurse has written an outcome goal "demonstrates tolerance for increased activity" for a client diagnosed with congestive heart failure. Which intervention should the nurse implement to assist the client to achieve this outcome?
Plan for frequent rest periods
A nurse is caring for a client with an admitting diagnosis of HF. The medical record contains a notation that the client is orthopneic. The most appropriate nursing intervention to assist with this client's problem would be to
Provide several additional pillows for sleeping.
A nurse is reading a PPD test on the left arm of an inpatient client who was injected with the test material exactly 48 hrs ago. The test area has a 4mm diameter area of induration. What is the nurse's best action?
Re-examine the test site at 72 hours.
A nurse is performing a physical assessment of the distal extremities for a client who has Buerger's disease. The findings most likely to reveal are extremities which are
Reddened and have diminished distal pulses
1. A client with an acute exacerbation of COPD has the following ABG analysis: pH 7.32, PaO2 58 mm Hg, PaCO2 55 mm Hg, HCO3 23 mEq/L, and SaO2 86%. The nurse knows that this client has
Respiratory Acidosis
A nurse is giving discharge instructions to a client who is status post heart valve surgery. Which of the following should the nurse consider a nursing priority?
Taking measures to prevent bleeding due to anticoagulant therapy
After abdominal surgery a client suddenly complains of numbness in the right leg and a "funny feeling" in the toes. The nurse should first
Tell the client to remain in bed and notify the physician
Creatine kinase (CK-MB) and troponin levels are ordered for a client who experienced chest pain and aching for the past four days. The nurse interprets the results with the understanding that
The presence of myocardial damage occurring several days earlier can be validated best by the troponin level
A nurse is working in a community center. For a client diagnosed with HTN who reports being really motivated about losing weight, the nurse should recognize the need for additional teaching when:
Use over the counter appetite suppressants
A client with a diagnosis of valvular heart disease at the cardiac care clinic is meeting with the nurse to review medication management of the disorder. The nurse anticipates that what will be prescribed for this client?
Warfarin Sodium
The nurse is preparing a community presentation for a group of women about risk factors for cardiovascular disease. Which of the following clients is a risk for cardiovascular disease? A woman (SATA)
With elevated LDL levels With abdominal obesity
a nurse receives report at 0730 from the previous shift on a cardiac telemetry unit. Which of the following clients should the nurse plan to assess first?
a 65 year old client admitted last night with MI, history of chronic obstructive pulmonary disease (COPD), morphine sulfate being administered, scheduled for coronary angiography.
a client reports episodes of "palpitations". The HCP prescribes a Holter monitor. The nurse should plan to include which of the following instructions to the client?
keep a record of daily activities
a client who has atherosclerosis is attempting to stop cigarette smoking with the use of a nicotine patch. What specific instructions regarding this therapy should the nurse give to the client?
smoking while using this patch increases the risk of heart attack
A nurse is discussing pre procedure instructions w a client who is scheduled for a resting electrocardiogram (ECG). Which of the following instructions should the nurse give to the client?
you must lie as still as possible during the procedure
A client is admitted to the telemetry unit with a diagnosis of endocarditis. Diagnostic testing reveals a WBC 15,000, temperature of 100.8F, and complains of increasing fatigue for the past two weeks. Further diagnostic testing indicates mitral valve prolapse with regurgitation. The nurse develops a teaching plan for the client explaining the order of the treatment protocol. Which of the following describes the appropriate protocol?
- Antibiotic therapy, valve replacement surgery, anticoagulant therapy
A client who returns to the surgical unit after an arterial revascularization procedure states: "The pain is similar to the pain I felt before the procedure? What should be the nurse's priority action?
- Assess peripheral pulses of the extremity
A client is scheduled for a lung scan. Which of the following nursing interventions is most important to prevent post-procedure complications?
- Assess the renal function of the client.
The client has COPD. Which intervention for airway management should the nurse delegate to the nursing assistant (UAP)?
- Assist client to sit up on side of bed
The nurse is reviewing the ECG strips of a client with mitral stenosis. The nurse realizes as a priority the dysrhythmia of:
- Atrial fibrillation
A nurse is preparing to perform a pulse oximetry when the client states that her painted nails are artificial. Before the assessment the nurse should
- Attach the sensor to the toe
A nurse caring for an older adult client admitted for new-onset confusion notes the following lab results: CBC: wbc- 15,000, HgB 14.1, Hct 42% ABG: pH 7.48, PCO2 32, PO2 78, HCO3 29 Chemistry: BUN 23, Creatinine 0.8 After reviewing these data, a priority assessment for the nurse would be to
- Auscultate for bronchial breath sounds, wheezes, or crackles.
A client who has pneumonia is dyspneic, has a respiratory rate of 26 breaths per minute, and complains of pleuritic pain. After administration of an analgesic, the nurse should first
- Auscultate the client's chest.
The nurse is assessing the INR for a client taking warfarin (Coumadin) for the resolution of a DVT. The INR of the client is 1.2. The primary action for the nurse would be to
- Be aware that the physician needs to be notified to increase the dosage
A nurse should perform a respiratory assessment and monitor for a pneumothorax after which of the following procedures? SELECT ALL THAT APPLY
- Bronchoscopy - Percutaneous lung biopsy
A client has been receiving oxygen per nasal cannula during her hospitalization for emphysema, and the health care provider is now ordering oxygen for use at home. The nurse informs the client that utilizing long term home oxygen therapy
- Can improve the client's prognosis and quality of life
A nurse is giving a community lecture about the increase incidents of lung cancer among women during the past 20 years. The nurse includes that the primary cause for such findings is?
- Cigarette smoking among women increased dramatically 50 years ago.
A nurse evaluates that the intervention carried out to promote airway clearance in the client with COPD are successful, based on finding that the
- Client has effective and productive coughing
During assessment of a client who has severe emphysema exacerbation, the nurse notes jugular vein distension and pedal edema. The best action by the nurse would be to
- Closely monitor the client's intake and output
A client who is experiencing dyspnea comes to a health clinic. Which assessment finding in the client indicates to the nurse that the respiratory problem is chronic?
- Clubbed fingers
Which assessment finding in a client with severe dyspnea indicates to the nurse that the respiratory problem is chronic
- Clubbed fingers
A female client with Reynaud's disease states that she plans to go snow skiing in Switzerland. The nurse should caution the client about the trips potential effect on her disease because of the
- Cold climate of Switzerland.
After administering a Mantoux test to a client on Monday, the nurse would request that the client return for an evaluation on
- Wednesday or Thursday
A nurse evaluates the effectiveness of therapy for a patient with acute asthma exacerbation and severely diminished sounds. This finding indicates that the patient's respiratory function is beginning to improve:
- Wheezing becomes audible (No wheezing is BAD!)
The client with TB asks the nurse when will be considered non-infectious
- When you have THREE negative sputum cultures in a row
As the charge nurse you are making assignment for the next shift. Which client should be assigned a new graduate registered nurse on orientation? The client
- Who needs teaching about use of incentive spirometry.
a client with elevated serum cholesterol has been placed on simvastatin (zocor). The client asks the nurse how this drug will help to lower cholesterol levels. What is the nurse's best response?
-this drug lowers LDL and triglycerides levels
A nurse is caring for a client with a serum potassium level of 6.6 mEq/L. Which of the following characteristics ECG configurations would be most likely to occur in this client?
Abnormal waves
A nurse instructs a new graduate nurse about transferring a patient with a chest tube. Which of these statements, if made by new graduate nurse would indicate the need for further instruction?
Clamp the tube prior to the transfer
When a client with a history of coronary artery disease is at home and experiences chest pain or suspects they are having a heart attack, the HCP will typically advise the client to
- Ingest aspirin
A nurse is providing care to a client who is being treated for HTN crisis. A priority for the nurse would be to monitor the BP carefully during the first 2 hours to prevent:
- Renal ischemia (P.864)
When instruction a client in the proper administration of sublingual nitroglycerin (NTG), the nurse should include in the teaching plan that the client should
- Repeat the dosage every 5 minutes for three times if pain is not relieved
When taking a history from a client, which of these questions should the nurse ask when assessing a client for paroxysmal nocturnal dyspnea?
"Are you waking up SOB?"
Which instruction should be included in the teaching plan for a client being discharged after the CABG surgery?
- Take your pulse before, midway through, and after exercising.
A client who experiences an MI develops left ventricular heart failure. For which sign of poor organ perfusion should the nurse monitor this client?
Urine output of 50 mL in two hours
While ambulating a client on the telemetry unit who has recently experienced a myocardial infarction, the nurse observes diaphoresis and increasing shortness of breath. The most appropriate nursing intervention at this time would be to
- Return the client to bed
In advising a client with higher levels of HDL in proportion to LDL, an appropriate outcome is that this client:
- Is less likely to develop CAD
A nurse should inform a client who is diagnosed with angina that angina pain usually differs from the pain of a myocardial infarction (MI) in that angina pain
- Is often relieved by rest.
A nurse is caring for a client who has an MI. The client reports chest pain and EKG show intermittent premature ventricular contractions. The nurse's first priority for this client would be to:
- Relief of pain and pain management
A nurse is assessing a client who has untreated HTN. Which of the following manifestations should concern the nurse as indicating possible "target organ" damage? Select all that apply
- Retinal changes - BUN 28 and creatinine 1.8 - Headaches
A nurse should determine that teaching regarding a 2 gram sodium diet for a client who has a history of cardiac disease, is effective if the client states,
"I can eat most foods as long as I do not add salt when cooking or at the table."
When assessing a client who is diagnosed with left ventricular heart failure, the nurse interprets which of the following statements the correlate with the diagnosis.
"I cannot climb the stairs in my house without becoming SOB."
A nurse is working a triage station in a busy emergency department. Which of the following client statements would be consistent with an initial nursing diagnosis of impaired circulation related to left ventricular heart failure?
"I cannot walk three blocks without becoming short of breath"
Which of the following statements is an indication that a client needs additional teaching regarding a treatment regimen for heart failure?
"I should only weigh myself once a month and watch for fluid retention."
A nurse determines that additional discharge teaching is needed when the client with chronic congestive heart failure states,
"I should weight myself daily and go on a diet if I gain more than two pounds in two days."
The UAP report to the nurse that a client admitted with a diagnosis of mitral valve prolapsed has a weight gain of 2 pounds since yesterday. The nurse evaluates that the amount of fluid is approximately _____ml.
- 1000
A client one day post op CABG. The client complains of chest pain. Which intervention should the nurse implement first?
- Assess the client's chest dressing and vital signs
A nurse is caring for a client who has had angiography with the entrance site in the left femoral artery. 2 hours after the procedure, the nurse is unable to palpate the left pedal pulse. The priority action at this time would be to:
- Attempt to locate pulse with using a Doppler
A nurse is performing an assessment of the carotid arteries of a client with atherosclerosis. Upon auscultation of the right carotid artery, the nurse hears a swishing sound. What should be the nurse's next most appropriate action?
- Auscultate left carotid artery
A client is admitted with a diagnosis of MI. Which information should the nurse include in the discharge planning?
- Begin walking for short periods every day
A nurse is caring for a client with an admitting diagnosis of acute myocardial infarction. As an appropriate breakfast menu for the client, the nurse should suggest
- Bran flakes with skim milk, apple slices, and orange juice
A client is scheduled for a cardiac catheterization. Which of these actions should the nurse implement? SELECT ALL THAT APPLY
- Check for iodine sensitivity - Verify that written consent has been issued - Withhold food and oral fluids (8-12 Hrs)
In reviewing an electrocardiograph (ECG) tracing from a client undergoing preadmission testing for surgery, the nurse observes the presence of a large, wide Q wave in several leads. The nurse interprets this to mean the client
- Client has had a myocardial infarction in the past
A nurse is developing a teaching plan for a client with congestive heart failure, which of the following outcomes indicates to the nurse that the treatment is effective? Select all that apply
- Clients weight today was 79.5 kg and yesterday eight is 80.2 kg - Auscultated clear lung sounds bilaterally - Able to walk to the bathroom without dyspnea
A nurse is performing a physical assessment on a client who has HTN. Which of the following assessment should the nurse plan to include in the assessment?
- Fundoscopic examination for changes in retinal vessels (The retinas are examined, and laboratory studies are performed to assess possible target organ damage).
A nurse is preparing a client to undergo coronary angioplasty. Which of these assessments should the nurse make before the procedure? Ascertain if the client
- Has allergies to iodine-containing substances
During the initial home visit, the nurse is teaching a client with heart failure how to prevent complications and future hospitalizations. Which of the following statements if made by the client indicates the client's understanding? I will call my health care provider if:
- I become increasingly SOB at rest - I gain 2 pounds in one day - I have to sleep sitting up in a reclining chair
The nurse evaluates the understanding for preoperative teaching with a client scheduled for CABG using a saphenous vein. The nurse determines that additional teaching is needed when the client states
- I will need to remain in the bed for 48 hours after my surgery
A client is at his health clinic for an annual physical exam. After walking for the car to the clinic, he develops a substernal pain. He also reports discomfort in his left shoulder and his jaw, lasting 2 to 3 minutes and then subsiding with rest. His wife indicates that this has occurred frequently over the past few months with similar exertion. This client is most likely experiencing.
- Stable angina
A client is admitted to the telemetry unit with a diagnosis of MI within the last 24 hours. The immediate care plan for this client should include which of the following measures.
- Use of bedside commode for Bowel Movements.
A nurse is developing a teaching plan for parents of school age children. In discussing the long term effects of rheumatic fever, the nurse should plan to discuss the potential complication of:
- Valvular disorders
A client is admitted to the emergency room after developing severe chest pain while mowing the lawn. He has dull pain in the midchest area and a normal ECG. The physician orders a cardiac catheterization with coronary angiography and possible percutaneous transluminal coronary angioplasty (PTCA). The nurse prepares the client for the procedure by explain that it is used to
- Visualize any blockage in the coronary arteries and, if necessary, to dilate an obstructed artery with the use of a small balloon.
When developing an educational plan for a client with a diagnosis of coronary artery disease, the nurse should explain that SELECT ALL THAT APPLY
- Weight reduction can reduce blood pressure - Weight reduction can recue cholesterol - Weight reduction can decrease risk for DM
During the hospitalization of a client with a myocardial infarction, the nurse should plan to start client and family teaching about the disorder
- While the client is in the cardiac care unit (CCU)
A nurse is developing a program for a group of individuals attending a community seminar on atherosclerotic heart disease. Which client is most at risk of developing internal injury leading to atherosclerosis? A client
- With diabetes who smokes one pack of cigarettes/day.
A client diagnosed with essential hypertension asks the nurse to explain how this type of hypertension develops. What is the nurse's best response?
-"There is no known cause for this type of hypertension."
A nurse is participating in a health screening fair to screen for hypertension. Which of the following blood pressure findings for an adult client with no known medical problems should be evaluated further for hypertension? The person with a blood pressure of SELECT ALL THAT APPLY
-124/86 mm Hg -138/78 mm Hg -140/96 mm Hg
A client who has A-Fib is ambulating in the hallway on the coronary step-down unit and suddenly tells the nurse, "I feel really dizzy." After assisting the client to sit down, which of the following interventions should become a priority for the nurse? SELECT ALL THAT APPLY
-Check the client's apical heart rate. -Take the client's blood pressure.
In evaluating a client's ECG tracing, the nurse notes three small squares between the upstroke and downstroke of the QRS complex. The nurse should record the QRS complex as
0.12 seconds
After measuring 3.5 small boxes between the onset of the Q wave and the completion of the S wave, the nurse would record the QRS duration as
0.14 seconds
While caring for a client with angina, the nurse plans interventions that decrease myocardial oxygen demand and promote coronary blood flow. Appropriate interventions are those that primarily prevent
An increase in heart rate
A nurse assessing a client who underwent cardiac catheterization finds the client lying flat on the bed. His temperature is 99.8° F (37.7° C). His blood pressure is 104/68 mm Hg. His pulse rate is 76 beats/minute. She detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry but swollen. What is the most appropriate action for the nurse to take?
A. Contact the physician and report her findings.
A nurse is caring for a client scheduled for a cardiac catheterization. Which of the following information would be of highest priority for the nurse to obtain before the procedure?
Allergy to Iodine or shellfish
A nurse is performing an assessment on a client who had a cardiac catheterization three hours ago. Which of the following findings would require immediate intervention?
Catheterized extremity cold with decreased peripheral pulses.
A nurse is caring for a client who has a history of coronary artery disease. That client asks the nurse how the HCP can find out the extent of the disease process. The nurse explains that the best diagnostic test to determine the location and extent of coronary artery disease would be a/an
Cardiac catheterization
The CK-MB level is markedly elevated in a client with chest pain 12 hours after admission. The nurse interprets this finding as evidence of:
Cellular tissue necrosis
A client is wearing a continuous cardiac monitor (telemetry), which begins to sound the alarm. A nurse notes the absence of electrocardiogram complexes on the screen. The first action by the nurse would be to
Check the client status and lead placement
Along with persistent, crushing chest pain, which clinical manifestation should lead the nurse to suspect the client is experiencing a MI?
Diaphoresis and cool, clammy skin
The nurse is caring for a client who has been diagnosed with cardiovascular disease. Which of these assessment findings is most consistent with a nursing diagnosis of decreased cardiac output related to mechanical failure of heart?
Diminished pedal pulses
A client's telemetry reading shows a P-wave before each QRS complex, a regular PR interval, and the rate is 78. Which of the following actions should the nurse perform next?
Document this as normal sinus rhythm
A nurse is caring for a client following a percutaneous transluminal coronary angioplasty. Which of these interventions should the nurse include in the plan of care?
Encourage oral fluids for the client.
The nurse assesses 2+ pitting edema on the left lower extremity and 3+ pitting edema on the right lower extremity of a client admitted 2 days ago with acute myocardial infarction. Following this assessment, which is the nurse's best next action?
Review the daily weights since admission
When the client with left sided heart failure develops bilateral 2+ pitting edema of the ankles, the nurse should assess that this could be early manifestation of:
Right sided failure (Left-sided HF leads to right sided HF)
A client with an MI has undergone ECG. What changes in the ECG tracing should the nurse expect to see in this client?
ST segment elevation, T wave inversion, abnormal Q wave
A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.20 seconds, and the QRS complexes measure 0.08 seconds. The overall heart rate is 58 beats per minute. The nurse interprets the cardiac rhythm as
Sinus bradycardia
A nurse is a cardiac step-down unit is preparing discharge instructions which include dietary information. Which breakfast food recommendations should be most appropriate for a client with coronary heart disease?
Skim milk, oatmeal, banana, decaffeinated coffee
In developing a standard teaching plan for the outpatient unit where stress testing is performed, the nurse should include information that the
Test may cause the client to experience chest pain.
CK-MB and troponin levels are ordered for a client. The client asks the nurse for the test. The nurse bases the response on the knowledge that:
The presence of myocardial damage occurring several days earlier can be validated best by the troponin level.
A nurse is working in the emergency department (ED) when a client arrives complaining of substernal and left arm discomfort that has been going on for about 3 hours. All of these baseline lab tests are drawn. Which of these lab values will be most useful in determining whether the nurse should anticipate implementing the acute coronary syndrome standards orders?
Troponin
A client is admitted following an acute myocardial infarction to the inferior wall. Which of the following outcomes should indicate to the nurse that tissue perfusion is ineffective?
Urine output of 22 mL/hr for 2 consecutive hours
A charge nurse in a long-term care facility that has RN, LPN/LVN and nursing assistant staff members has developed a plan for ongoing assessment of all residents with a diagnosis of heart failure. Which of these activities included in the plan is most appropriate to delegate to nursing assistant staff?
Weigh all residents with HF each morning.
A nurse is monitoring a client with congestive heart failure. Which of the following would require further evaluation by the nurse?
Weight gain of 1.5 pounds in 24 hours.
A home care nurse is making a routine visit to a client receiving digoxin (lanoxin) in the treatment of heart failure. The nurse should assess the client for
anorexia, nausea, and visual disturbances
A client who is admitted for chest pain asks the nurse the reason for having an exercise stress test. The nurse should explain to a client that an exercise ECG is useful as one means of detecting?
coronary artery disease
