nursing theroy

The nurse is caring for a patient with aortic regurgitation. Which of the following are clinical manifestations the nurse can expect to document?

Forceful heartbeat more pronounced when laying down. Dyspnea on exertion Fatigue Corrigan Pulse

4.The nurse is caring for a patient with aortic stenosis and notes crackles in the lungs and a cough during her physical assessment. Which complication should the nurse suspect is occurring?

Heart failure

6.A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

125 mL/hr

The nurse is providing discharge teaching to a patient with mitral stenosis. What should the nurse include in the teaching plan?

"Because of your heart condition, the blood flow through our heart is slower and blood may tend to pool in certain areas, which might allow small clots to form."

The nurse is planning care for a patient with pericarditis. The patient

Administer anti-inflammatory medication as ordered.

.The nurse is caring for a patient with pericarditis auscultates muffled heart sounds. The nurse also notes jugular vein distention and a blood pressure of 72/40. The nurse identifies the symptoms as which complication of pericarditis?

Cardiac tamponade

The nurse is auscultating the lungs of a patient with heart failure. Which can the nurse expect to document?

Crackles

A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder?

Dyspnea

A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

Dyspnea

A nurse is preparing to administer atenolol 50 mg PO. The amount available is atenolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 tablet(s)

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 tablet(s)

A nurse is preparing to administer digoxin 1 mg PO to a client. The amount available is digoxin 0.5 mg/tablet. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 tablet(s)

A nurse is preparing to administer potassium chloride 20 mEq. The amount available is potassium chloride liquid 40 mEq/15 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7.5 mL

.A patient with aortic stenosis develops severe dyspnea and chest pain. Which action is should the nurse take first?

Obtain Vital Signs.

The nurse is reinforcing teaching to a client scheduled for an electrocardiogram (ECG). The nurse knows the patient understands the teaching when the patient makes which statement?

"I will have wires connected to my chest, arms, and legs to record the electrical activity of my heart."

9.The nurse is reinforcing teaching to a patient with aortic stenosis. Which statement indicates that the patient correctly understands what happens in aortic stenosis?

"There left ventricle is unable to move blood forward due to a narrowing in the aortic vessel."

7.A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?

"Try to remain still once I have attached the gel pads."

.A nurse is reinforcing teaching about warfarin with a client who has a new onset of atrial fibrillation. Which of the following statements should the nurse include in the teaching?

"Warfarin helps prevent strokes in clients who have atrial fibrillation

The nurse is caring for a group of patients on the telemetry unit. Which patient should the nurse see first?

A patient with atrial fibrillation reporting dyspnea.

The client has aortic stenosis. Which assessment finding indicates the patient is experiencing myocardial oxygen deficiency?

Angina

Which medication class is appropriate when caring for a patient with pericarditis?

Anti-inflammatory

0.A nurse is planning care for a client who has a deep-vein thrombosis (DVT) in the right leg. Which of the following interventions should be included in the plan of care?

Apply compression stockings.

A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. Which of the following actions should the nurse anticipate when notifying the provider of this finding?

Arrange for a venous duplex ultrasound.

The nurse is reinforcing discharge teaching to a patient with infective endocarditis. Which topics will the nurse be sure to include in the teaching? (Select All that Apply)

Brushing teeth with a soft-bristle toothbrush. Avoiding biting nails. Avoiding applying ointment to cuts. Reporting fever and chills to the HCP. Instruction on proper hand washing.

.A nurse is collecting data from a client who requires bed rest and has developed thrombophlebitis. Which of the following findings should the nurse expect when examining the client's leg?

Edema

A nurse is contributing to the care plan of a client who is postoperative and has an increased risk for deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Encourage fluid intake. Apply elastic compression stockings. Encourage frequent leg exercises. Measure thighs.

The nurse is caring for a patient with pulmonary edema. Which position should the nurse place the patient?

Fowler's

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following findings should the nurse expect?

Frothy sputum

.A nurse is collecting data from a client who has splinter hemorrhages in the nail bed and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders?

Infective endocarditis

A nurse is planning to perform an electrocardiogram (ECG) for a client who has a history of coronary heart disease. Which of the following actions should the nurse take? (Select all that apply.)

Inspect the electrode pads. . Use alcohol to wipe the skin before placing the electrodes. Instruct the client to breath normally. Administer an analgesic prior to the procedure. Rationale:Keep the client NPO after midnight

A nurse is assisting with the plan of care for a client who has a new deep-vein thrombosis (DVT) in his leg. Which of the following interventions should the nurse include in the plan?

Keep the client's affected leg elevated.

A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?

Monitor daily weight

A nurse is contributing to the plan of care for a client who is admitted with a deep vein thrombosis (DVT) of the left leg. Which of the following interventions should the nurse include in the plan?

Monitor platelet levels

During data collection, what findings should the nurse expect to see in a patient demonstrating symptoms of heart failure? (Select all that apply)

Orthopnea Dry cough Edema Respiratory crackles

A nurse is collecting data from a client who has pericarditis. Which of the following findings should the nurse expect?

Pericardial Friction Rub

The nurse is reviewing a patient chart who was involved in a motor vehicle collision 3 days ago where the patients chest hit the steering wheel. Which symptom indicates the presence of pericarditis?

Pericardial friction rub

.A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Peripheral edema

A nurse is reinforcing teaching about the prevention of deep vein thrombosis (DVT) with a group of newly licensed nurses. Which of the following interventions should the nurse include in the teaching?

Place sequential compression devices bilaterally.

.The nurse is contributing to the plan of care for a patient with heart failure. What should be the major goal of nursing management for this patient?

Reduce the workload of the heart.

Which intervention is appropriate for the nurse to implement for a patient with aortic regurgitation?

Schedule activities with periods of rest

A nurse is collecting data from a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Shortness of breath while lying down

The nurse is sitting at the desk writing her shift notes and notes a patient's cardiac rhythms shows asystole. Which action should the nurse take first?

Start cardiopulmonary resuscitation (CPR) immediately

A patient with mitral regurgitation asks what the problem means. What should the nurse explain to the patient?

There is back flow of blood into the left atrium".

8.The nurse is teaching a caregiver about prevention of paroxysmal nocturnal dyspnea. Which topic should be included in the teaching

Use pillows to sleep upright.

The nursing is assessing a patient who underwent valve replacement surgery. Which finding indicating a complication of valve replacement surgery, should the nurse report to the physician?

Wet lung sounds

During a home visit of a patient with heart failure and diabetes, the patient tells the nurse "I feel strange". Data collection reveals the following: blood pressure 172/96 mm Hg, pulse 118 beast/min, respirations 21/min, heart rhythm regular, and course crackles in the lung fields. What action should the nurse take?

Consult the registered nurse (RN).

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

Encourage increased fluid intake.

The nurse enters a patients room and finds him coughing up pink, frothy sputum. Which action should the nurse take?

Notify the health care provider (HCP)

.The nurse is caring for a post operative patient who has been on bed rest for 2 days. The patient suddenly develops dyspnea, tachypnea, restlessness, and chest pain. The patient tells the nurse, "I feel like I am going to die". Which action should the nurse take?

Notify the health care provider (HCP) immediately.

The nurse is caring for a patient with heart failure. The patient asks the nurse what he can do stay out of the hospital. What response is appropriate?

You should maintain an exercise routine to remain physically, follow dietary and fluid restrictions, refrain from smoking, and follow your medication regimen to help manage your condition."