nu 260 quiz 1
14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Midsternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
A
A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at GREATEST risk for the development of acute pericarditis? (SATA) a. 36 year old woman with systemic lupus erythematosus (SLE) b. 42 year old man recovering from coronary artery bypass graft surgery c. 59 year old woman recovering from a hysterectomy d. 80 year old man with a bacterial infection of the respiratory tract e. 88 year old woman with a stage III sacral ulcer
A, B, D
A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. Weight is the best indication that you are gaining or losing fluid b. Daily weights will help us make sure that you're eating properly c. The hospital requires that all clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure
A. Weight is the best indication that you are gaining or losing fluid
10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "I would wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I would participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."
B
12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What action would the nurse take prior to the cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure that a tongue blade is available. d. Position the client on the left side.
B
2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."
B
4. A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity
B
9. A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS™ ANS: A, C, E Dysrhythmias Which priority concept does the nurse
C
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions
C. I must stop halfway up the stairs to catch my breath
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. Your new heart is not connected to the nervous system and is unable to respond to d
C. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes
1. A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How would the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites
D
18. A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How would the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)
D
9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client? a. Make sure that the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 J d. Ensure that everyone is clear of contact with the client and the bed.
D
A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"
a. "Could you walk further than that a few months ago?"
A nurse is working with a client who takes clopidogrel. The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.
a. Ask if the client eats grapefruit.
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."
a. "I can use a heating pad on my legs if it's set on low."
A client is taking warfarin and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."
a. "No, it may interfere with the warfarin."
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics
a. African-American churches
A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.
a. Apply compression stockings. b. Assist with ambulation. d. Offer fluids frequently.
A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count
a. Appropriate hand hygiene before giving care
nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell t
a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires.
A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.
a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion.
A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes.
a. Client is able to decrease blood pressure medications.
A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the wound care nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.
a. Consult with the wound care nurse
A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication f. Wearing a Medic Alert bracelet
a. Dietary restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."
b. "Most people with hypertension do not have symptoms."
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.
b. Apply a warm moist pack
What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options f. Encouraging participation in high impact aerobic activity
b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises
A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.
b. Assess distal pulses and skin color.
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.
b. Assist in finding one change the client can control.
A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.) a. Abdominal tenderness b. Difficulty swallowing c. Changes in bowel habits d. Shortness of breath e. Hoarseness
b. Difficulty swallowing e. Hoarseness
A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.
b. Notify the Rapid Response Team.
A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors
b. Oxygen saturation of 98%
A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.
b. Participate in blood pressure screenings at the mall.
Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best." f. "I will inspect my feet daily."
c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best."
A client asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."
c. "It is hypertension with no specific cause."
A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.
c. Measure for new compression stockings.
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."
d. "My hands shake when I try to do things requiring coordination."
A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to intervene? a. Assesses the client for back pain. b. Auscultates over abdominal bruit. c. Measures the abdominal girth. d. Palpates the abdomen in four quadrants.
d. Palpates the abdomen in four quadrants.
A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary filling of 4 seconds as normal d. Palpating both carotid arteries at the same time
d. Palpating both carotid arteries at the same time
A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring that the consent is signed c. Marking pulses with a pen d. Raising the side rails on the bed e. Recording baseline vital signs
d. Raising the side rails on the bed e. Recording baseline vital signs
Which waveform does the nurse recognize as atrial depolarization when a client is placed on a cardiac monitor? A. P wave B. PR segment C. QRS complex D. T wave
A
A nurse prepares to discharge a client who has heart failure. What questions would the nurse ask to ensure this client's safety prior to discharging home? a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?
A, B, D, C & E
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (SATA) a. Pulmonary crackles b. Confusion c. Pulmonary hypotension d. Dependent edema e. Cough that worsens at night f. Jugular venous distension
A, B, E
A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (SATA) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria
A, B, E, F
A nurse collaborates with assistive personnel to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (SATA) a. Reposition the client every 2 hours b. Teach the client to perform deep-breathing exercises c. Accurately record intake and output d. Use the same scale to weigh the client each morning e. Place the client on oxygen if the client becomes short of breath
A, C, D
A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (SATA) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS
A, C, E
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure b. Document this as a normal finding c. Call the primary health care provider immediately d. Transfer the client to the intensive care unit
A. Assess for symptoms of left-sided heart failure
After teaching a client with congestive hear failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a CORRECT understanding of the teaching related to nutritional intake. (SATA) a. I'll read the nutritional labels on food items for salt content b. I will drink at least 3 L of water each day c. Using salt in moderation will reduce the workload of my heart d. I will eat oatmeal for breakfast instead of ham and eggs e. Substituting fresh vegetables for can
A, D, E
A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at GREATEST risk for the development of left-sided heart failure? a. A 36 year old woman with aortic stenosis b. A 42 year old man with pulmonary hypertension c. A 59 year old woman who smokes cigarettes daily d. A 70 year old man who had a cerebral vascular accident
A. A 36 yer old woman with aortic stenosis
A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take FIRST? a. Assess the client's respiratory status b. Draw blood to assess the client's serum electrolytes c. Administer intravenous furosemide d. Ask the client about current medications
A. Assess the client's respiratory status
A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. Avoid using salt substitutes b. Take your medication with food c. Avoid using aspirin-containing products d. Check your pulse daily
A. Avoid using salt substitutes
A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation
A. Standard Precautions
A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the BEST response by the nurse? a. I can stay if you would like to talk more about this b. You are lucky to have such a devoted daughter c. It is normal to feel as though you are a burden d. Would you like to meet with the chaplain?
A. I can stay if you would to talk more about this
3. A nurse is teaching a client who has premature ectopic beats. Which education would the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium f. Types of aerobic exercise
ABD
2. A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level o
ABE
1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output
ACE
A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. Do you have trouble breathing or chest pain? b. Are you still able to walk upstairs without fatigue? c. Do you awake with breathlessness during the night? d. Do you have new-onset heaviness in your legs?
B. Are you still able to walk upstairs without fatigue?
A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? a. Use a soft-bristled toothbrush and avoid flossing b. Avoid large crowds and people who are sick c. Change positions slowly to avoid hypotension d. Check your heart rate before taking the medication
B. Avoid large crowds and people who are sick
A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. Walk until you become short of breath, then walk back home b. Begin walking 200 feet a day three times a week c. Do not lift heavy weights for 6 months d. Eat plenty of protein to build your strength
B. Begin walking 200 feet a day three times a week
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the BEST response by the nurse? a. The prosthetic valve places you at greater risk for a heart attack b. Blood clots form more easily in artificial replacement valves c. The vein taken from your leg reduces circulation in the leg d. The surgery left a lot of small clots in your heart and lungs
B. Blood clots form more easily in artificial replacement valves
A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
B. Dyspnea on exertion
A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases
B. Friction rub at the left lower sternal border
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for ADDITIONAL teaching? a. I'll be able to carry heavy loads after 6 months of rest b. I will have my teeth cleaned by my dentist in 2 weeks c. I must avoid eating foods high in vitamin K, like spinach d. I must use an electric razor instead of a straight razor to shave
B. I will have my teeth cleaned by my dentist in 2 weeks
After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is MOST important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collaborate with assistive personnel to bathe the client d. Monitor potassium levels and check for signs of hypokalemia
B. Instruct the client to ask for assistance when rising from bed
16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" What is the nurse's best response? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."
C
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. I sleep with four pillows at night b. My shoes fit really tight lately c. I wake up coughing every night d. I have trouble catching my breath
B. My shoes fit really tight lately
11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What intervention would the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 L per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask assistive personnel (AP) to help bathe the client.
C
20. A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 L per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: What action would the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.
C
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side fo the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest b. Provide a neck rub, especially on the left side c. Allow the client to lie in bed with the lights down d. Sit the client up with a pillow to lean forward on
D. Sit the client up with a pillow to lean forward on
A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. Avoid drinking more than 3 quarts (3 L) of liquids each day b. Eat six small meals daily instead of three larger meals c. When you feel short of breath, take an additional diuretic d. Weigh yourself each day while wearing the same amount of clothing
D. Weigh yourself each day while wearing the same amount of clothing
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you c. Do you want to come off the transplant list? d. Would you like more information about advance directives?
D. Would you like more information about advance directives?
13. A nurse prepares to discharge a client with a cardiac dysrhythmia who is prescribed home health care services. Which priority information would be communicated to the home health nurse upon discharge? a. Medication orders for home b. Immunization history c. Religious beliefs d. Nutrition preferences
A
15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone daily to prevent PACs."
A
17. A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."
A
19. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).
A
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (SATA) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue
A, B, C, F
8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. What action would the nurse take next? a. Administer intravenous diltiazem. b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.
B
21. The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, what action would the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.
B
22. After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 08:00 Temperature: 98° F (36.7° C) Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 10:00 Temperature: 98.2° F (36.8° C) Heart rate: 50 beats/mi
B
3. A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily. b. A 50-year-old who is post coronary artery bypass graft surgery. c. A 78-year-old who had a carotid endarterectomy. d. An 80-year-old with chronic obstructive pulmonary disease.
B
5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication would the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol b. Warfarin c. Atropine d. Lidocaine
B
How would the nurse best interpret the electrocardiogram (ECG) of a younger athletic client which shows sinus bradycardia with a rate of 54 beats/min? A. It is the body's attempt to compensate for a decreased stroke volume by decreasing heart rate. B. The sinus bradycardia provides an adequate stroke volume that is associated with cardiac conditioning. C. The client has a rapid filling rate that lengthens diastolic filling time and leads to decreased cardiac output. D. This is a common finding
B
Which normal heart rates does the nurse expect to be initiated by the primary pacemaker of the heart (SA Node) in clients when the heart rate is regular? Select all that apply. A. 55 beats/min B. 62 beats/min C. 74 beats/min D. 86 beats/min E. 98 beats/min F. 110 beats/min
B, C, D, E
A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (SATA) a. Teach the client about energy conservation techniques b. Ensure that the client is prescribed a beta blocker c. Document a discussion about advanced directives d. Confirm that a post-discharge nurse visit had been scheduled e. Consult a social worker for additional resources f. Care transition record transmitted to
B, C, D, F
We have an expert-written solution to this problem! A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia
B. Atrial fibrillation
6. A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis
C
7. A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
C
A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy b. Hold the next dose c. Instruct the client to drink water d. Administer PRN acetaminophen
D. Administer PRN acetaminophen
A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. Avoid taking aspirin or aspirin-containing products b. Increase your intake of foods that are high in potassium c. Hold this medication if your pulse rate is below 80 beats/min d. Do not take this medication within 1 hour of taking an antacid
D. Do not take this medication within 1 hour of taking an antacid
A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."
a. "No, women should only have one beer a day as a general rule."
The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium
a. Assess the client's ankle-brachial index.
A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of lisinopril.
a. Assess the client's lung sounds and oxygenation.
A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client that drugs are safer today than before. d. Warn the client about consequences of noncompliance
a. Assess the reason behind the client's fear.
The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking f. Hyperlipidemia
a. Atherosclerosis d. History of hypertension e. History of smoking f. Hyperlipidemia
The nurse is caring for four hypertensive clients. Which drug-laboratory value combination would the nurse report immediately to the health care provider? a. Furosemide/potassium: 2.1 mEq/L b. Hydrochlorothiazide/potassium: 4.2 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. Torsemide/sodium: 142 mEq/L
a. Furosemide/potassium: 2.1 mEq/L
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.
b. Assess distal pulses every 10 minutes.d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread
b. Baked chicken breast, broccoli, tomatoes
A nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril and needs to use the bathroom. c. Hypertensive client with a blood pressure of 188/92 mm Hg. d. Client who needs pain medication prior to a dressing change of a surgical wound.
b. Client who had a first dose of captopril and needs to use the bathroom.
The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.) a. Elevated low-density lipoprotein (LDL-C) b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) c. Asian ethnicity d. History of smoking e. Blood pressure: 142/92 mm Hg on one occasion a. Elevated low-density lipoprotein (LDL-C)
b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) d. History of smoking
