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A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Irregular

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

Hacking cough

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

The client should hold his cell phone on the side opposite the ICD.

A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

Vitamin K

A nurse is caring for a client who is on warfarin therapy for atrial fibrillation. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?

Vitamin K

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?

"A headache is an expected adverse effect of the medication."

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

"DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

"Heparin does not dissolve clots. It stops new clots from forming."

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

"I eat two eggs for breakfast each morning."

A nurse is performing an ECG on a client who is experiencing chest pain. Which of the following statements should the nurse make?

"I will need to apply electrodes to your chest and extremities."

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?

"I'll take my heart medications the morning of my test."

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

"Increasing my intake of foods containing trans-fatty acids can lower my risk."

A nurse is preparing a client for magnetic resonance imaging (MRI) of the heart and great vessels. Which of the following instructions should the nurse include about this test?

"It requires removing metal objects like jewelry."

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?

"Place the tablet under your tongue, and then take a small sip of water."

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

"Take one tablet at the first indication of chest pain."

A nurse is providing teaching to a client who is taking warfarin about monitoring its therapeutic effects. Which of the following explanations should the nurse provide about the international normalized ratio (INR) test?

"The INR is a standardized test that eliminates the variations between laboratories reports in prothrombin times."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

"These tests help determine the degree of damage to the heart tissues."

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

"Use elastic stockings."

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A systolic murmur

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

Abnormally prominent U wave

A nurse on a telemetry unit is caring for a client who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the client states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?

Administer another nitroglycerin tablet.

A nurse is caring for a client who has Wernicke-Korsakoff psychosis as a result of chronic alcohol use disorder. Which of the following interventions should the nurse anticipate?

Administration of thiamine

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following =laboratory findings should the nurse expect to be altered?

Albumin

A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective?

Albumin 4.2 g/dL

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

Amylase

A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instructions should the nurse include in the teaching?

Apply the transdermal patch in the morning.

A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave?

Atrial depolarization

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

Atropine

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

Attach the leads for a 12-lead ECG.

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions?

Beans

A client who has a history of myocardial infarction (MI) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

antiplatelet aggregate

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

Change the IV tubing every 24 hr.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

Cigarette smoking

A nurse is caring for a client who has a history of alcohol use disorder and reports bruising and frequent nosebleeds. The nurse should recognize that this client in manifesting which of the following conditions?

Cirrhosis

A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?

Decreased blood pressure

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Dependent rubor

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Dextrose 10% in water

A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide?

Do not use salt substitutes while taking this medication.

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?

Dyspnea

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

Eat foods that contain plenty of potassium.

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

Edema

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30° to 45°

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Fatigue

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations?

Fatigue

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

Frothy sputum

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication?

Grapefruit juice

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

Have the client lie flat in bed.

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart failure

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

Hepatomegaly

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as a complication of this therapy?

Hyperglycemia

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Hypotension

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

Hypovolemia

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

Increased respiratory rate

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

Increased urine output

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Leg pain at rest

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

MRI of the chest

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?

Measure the client's apical pulse.

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Median vein in the forearm

A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial acute phase to manage the client's pain and anxiety?

Morphine

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

Muffled heart sounds.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

Reduce the client's intake of protein.

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching?

Obstruction of the bile duct

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Obtain a 12-lead ECG.

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

Obtain an EKG.

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

Oliguria

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Pacemaker spikes before each QRS complex

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

Packed RBCs

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate?

Pantoprazole 80 mg IV bolus twice daily

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

Perform a 12-lead ECG

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect?

Petechiae

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider?

Potassium 2.3 mEq/L

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching?

Practice effective hand hygiene.

A nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving lidocaine IV at 2 mg/min. When the client asks the nurse why he is receiving that medication, the nurse should explain that it has which of the following actions?

Prevents dysrhythmias

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects?

Protamine sulfate

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT)

A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, blood pressure 110/79 mm Hg, and apical heart rate 112/min. Which of the following interventions is the nurse's priority?

Provide the client with supplemental oxygen at 5 L/min via facemask.

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

QT interval

The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Radial pulse in the left arm

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG?

Reduction of T-wave amplitude

A nurse is teaching self-management to a client who has hepatitis B. Which of the following Instructions should the nurse include in the teaching?

Rest frequently throughout the day.

A nurse is preparing a client for placement of a catheter for total parenteral nutrition. Which of the following access sites should the nurse plan to prepare for catheter insertion?

Right subclavian vein

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Shakiness and diaphoresis

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

Spironolactone

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

Systolic blood pressure is increased

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave falls before the QRS complex.

A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?

The client follows a low-fat diet to reduce cholesterol.

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider?

The client has a history of bronchial asthma.

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

The laboratory values are prolonged.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

The third heart sound (S3)

A nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction (MI). Which of the following laboratory tests should the nurse expect the provider to prescribe?

Troponin

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Troponin I

A nurse is caring for a client who came to the emergency department reporting chest pain. The provider suspects a myocardial infarction. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client?

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

A nurse is providing discharge teaching for a client who has a new prescription for warfarin. Which of the following instructions should the nurse include in the teaching?

Use an electric razor while on this medication.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Withhold oral fluids and food.

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

indicates turbulent blood flow through a valve.


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