ATI CARDIAC STUDY FOR EXAM 1

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding.

1. Verify tube placement 2. . Check the residual feeding contents 3. Administer the feeding 4. Evaluate tolerance of feeding

1. A nurse is caring for a client with peripheral arterial disease (pad). Which of the following symptoms is typically the initial reason clients with pad seek medical attention? A. Intermittent claudication B. Dependent rubor C. Rest pain D. Foot ulcers

A. Intermittent claudication

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. B. Notify the provider who inserted the PICC line. C. Remove the PICC line. D. Apply a cold pack to the client's upper arm.

A. Measure the circumference of both upper arms

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? A. Obtain a pair of slipper-socks for the client. B. Rub the client's feet briskly for several minutes. C. Increase the client's oral fluid intake. D. Place a moist heating pad under the client's feet

A. Obtain a pair of slipper-socks for the client

A nurse is preparing to administer heparin sodium (heparin) to a client who has been receiving anticoagulation therapy at home. Which of the following actions should the nurse take? A. Questioning the medical order B. Contacting the Occupational, Health, and Safety Administration (OSHA) C. Administering the medication as prescribed D. Informing the client of her right to refuse any treatment

A. Questioning the medical order*

A nurse is caring for a male client who has peripheral vascular disease and is taking dietary supplements and has a new prescription for warfarin (coumadin). The nurse should instruct the client to stop which of the following supplements prior to starting the warfarin? (select all that apply) A. Saw palmetto ​B. Echinacea ​C. Glucosamine ​D. Black cohosh ​E. Gingko biloba

A. Saw Palmetto C. Glucosamine E. Gingko bilboa

A nurse is caring for a client who is hospitalized with deep vein thrombosis and has been on IV heparin for 5 days. The provider prescribes oral warfarin (coumadin) without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following is an appropriate nursing response? A. The Coumadin takes several days to work, so the IV heparin will be used until the Coumadin reaches a therapeutic level." B. "I will call the provider to get a prescription for discontinuing the IV heparin today." C. "Both heparin and Coumadin work together to dissolve the clots." D."The IV heparin increases the effects of the Coumadin and decreases the length of your hospital stay."

A. The coumadin takes several days to work, so the iv heparin will be used until the coumadin reaches a therapeutic level"

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching? A. Reaching your goal blood pressure will occur within 2 months." B. "Diuretics are the first type of medication to control hypertension." C. "Limit your alcohol consumption to three drinks a day." D. "Plan to lower saturated fats to 10 percent of your daily calorie intake."

B. "diuretics are the first type of medication to control hypertension"

In preparation for the discharge of a client with peripheral arterial disease (PAD), the nurse should include which of the following instructions? A. Apply a heating pad on a low setting to help relieve leg pain. ​B. Adjust the thermostat so that the environment is warm. ​C. Wear antiembolic stockings during the day. ​D. Rest with the legs above heart level.

B. Adjust the thermostat so that the environment is warm

A nurse is teaching an adult client who has a low literacy level about the subcutaneous administration of a low molecular weight heparin preparation. Which of the following strategies should the nurse use to promote the client's understanding? A. Use technical words and short sentences. ​B. Ask the client to demonstrate the skill. ​C. Provide the client with written, large-print materials. ​Plan for a longer session than usual.

B. Ask the client to demonstrate the skill*

After receiving TPN at 84 ml/hr continuously for five days, a client in a state of confusion pulled out their central line. Prior to notifying the provider, the nurse should start a peripheral iv and do which of the following? A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician. ​B. Change the tubing and filter on the TPN. ​C. Hang an infusion 10% dextrose. D. ​Notify the pharmacy.

B. Change the tubing and filter on the TPN*

A nurse is caring for a client with infective endocarditis. Which of the following is the priority manifestation the nurse should monitor for? A. Anorexia ​B. Dyspnea ​C. Fever ​D. Malaise

B. Dyspnea

A nurse on a medical unit is caring for a client who has infective endocarditis. The nurse should observe this client for manifestations of a common complication of this disorder by monitoring for ​A. a heart murmur. ​B. dyspnea. ​C. fever. ​D. petechiae

B. Dyspnea

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? A. The client will list foods that are high in calcium, which should be avoided. B. The client will walk for 30 min 5 days a week. C. The client will increase calorie intake by 200 cal per day. D. The client will replace cigarettes with smokeless tobacco products.

B. The client will walk for 30min 5 days a week

A nurse is caring for a client diagnosed with thrombophlebitis who has a swollen and inflamed right calf. The client is started on a continuous heparin 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? A. "It usually takes at least two to three days to reach a therapeutic blood level." B. "A pharmacist is the person to answer this question." C. "Heparin does not dissolve clots, it stops new clots from forming." D. "The pill that you will take after this IV will dissolve the clot."

C. "heparin does not dissolve clots, it stops new clots from forming"

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following techniques should the nurse use? ​A. Cleanse the skin with an alcohol swab, insert the needle, and aspirate and inject the heparin. ​B. Cleanse the skin with an alcohol swab, insert the needle, aspirate and inject the heparin, and massage the site. ​C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. ​D. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and aspirate and observe for bleeding.

C. Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? A. Positive Kernig's sign ​B. Positive Homan's sign ​C. Dull, aching calf pain ​D. Soft, pliable calf muscle

C. Dull, aching calf pain

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension? A. High-density lipoprotein (HDL) level of 70 mg/dL B. A diet high in potassium C. Obstructive sleep apnea (OSA) D. Taking benazepril

C. Obstructive sleep apnea (OSA)

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices would be appropriate for the client? A. Surgically placed central catheter B. Implanted infusion port C. Peripherally inserted central catheter D. Arteriovenous fistula

C. Peripherally inserted central catheter

Whenever a nurse is caring for clients who are receiving heparin, which of the following medications should the nurse have on hand in the event of an overdose? ​A. Iron ​B. Glucagon ​C. Protamine ​D. Vitamin K

C. Protamine

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I cant seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? A. Maintaining a semi-Fowler's position as much as possible B. Administering oxygen via nasal cannula at 2 L per min C. Helping the client select a low-salt diet D. Encouraging the client to drink eight glasses of water daily

D. Encourage the client to drink eight glasses of water daily

A nurse is preparing to administer a continuous iv infusion of heparin sodium (heparin). Which of the following actions is appropriate for the nurse to take? A. Administer 50,000 units of heparin by IV bolus. B. Check activated partial thromboplastin time (aPTT) every 4 hr. C. Have Vitamin K (Aquamephyton) available on the nursing unit. D. Use IV tubing specific for heparin sodium when administering the infusion.

D. Use iv tubing specific for heparin sodium when administering the infusion*

A nurse prepares to administer a continuous heparin infusion at 1600 units per hr with 20,000 available heparin units in dextrose 5% in water (d5w) 500 mL. how many per hr should the nurse plan to deliver?

a. 40 mL/hr

1. A client who has deep-vein thrombosis has iv fluid that contains 10,000 units of heparin in 500ml infusing at 1000 units/hr. when calculating the client's intake and output, how much should the nurse document as intake from this infusion in an 8-hr shift?

a. 400*