Cardiac ATI

The client developed a tolerance to the medication.

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios would the nurse document as the explanation for this situation? The client not been taking the medication properly. The client is experiencing episodes of confusion. The client has become addicted to the medication. The client developed a tolerance to the medication.

b. Speech alterations Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A nurse assesses a client with atrial fibrillation. Which manifestation should 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. Turn off oxygen therapy. For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

d. Maintain the airway. The client is at risk for respiratory obstruction.Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the client has a patent airway.

A nurse in an emergency department is caring for a client who has deep partial-and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? a. Initiate fluid resuscitation. b. Medicate for pain. c. Insert an indwelling urinary catheter. d. Maintain the airway.

Sensitive to touch Wound blanches with pressure Blisters

A nurse is caring for a preschooler who has a partial-thickness burn on her right forearm. Which of the following findings should the nurse expect? Dry surface Sensitive to touch Wound blanches with pressure Intact epidermis Blisters

d. Swallow the capsules whole. The client should swallow the capsules whole and not chew or crush them or place them under the tongue.

A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include? a. Take 1 capsule at the onset of anginal pain. b. Stop taking the medication if side effects are troublesome. c. the medication with meals. d. Swallow the capsules whole.

C.Ask the patient to lay on his left side. If the nurse is having difficulty hearing the heart sounds, ask the patient to lean forward or roll to his or her left side. This will make the sounds more audible for auscultation. The first heart sound is low pitched and is best her at the apex of the heart. Asking the patient to hold their breath for 15 seconds is not appropriate and while it will decrease respiratory noise, it will not make the heart sounds more audible as with positioning or correct auscultation location.

The nurse is assessing a patient's heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate? A.Listen at the base of the heart. B.Listen only for higher pitched sounds. C.Ask the patient to lay on his left side. D.Ask the patient to hold their breath for 15 seconds.

C. "I'm glad I don't need to change my diet. Salads are my favorite food."

The primary health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which statement made by the client indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider" C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

B. Tobacco use D. High-fat diet F. Obesity

A 48-year-old female client having an annual physical asks the nurse about her risk for developing a myocardial infarction (MI). The nurse discusses risk factors with the client. Which modifiable risk factors will the nurse assess to guide the client's teaching plan? Select all that apply. A. Older age B. Tobacco use C. Female D. High-fat diet E. Family history F. Obesity

a. Offer to remain with the client for awhile. The nurses presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the clients blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the clients safety. Telling a confused client that everything is being done is not the most helpful response.

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the clients bed. d. Tell the client everything possible is being done.

a. Alert and oriented, answering questions Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion. Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain does not indicate therapeutic effect. The IV site is normal. The urine output is normal, but only minimally so.

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug? a. Alert and oriented, answering questions b. Client denial of chest pain or chest pressure c. IV site without redness or swelling d. Urine output of 30 mL/hr for 2 hours

A. Increasing pallor B. Increasing thirst D. Increasing heart rate E. Increasing respiratory rate H. Decreasing urine output

A client who is in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which ones does the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

Prevents dysrhythmias

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 2mg/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 Slows intestinal motility Dissolves blood clots Relieves pain

Hyperkalemia

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. The nurse should expect which of the following laboratory findings in this client? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin

Inspect the mouth for signs of inhalation injuries.

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face and both forearms. Which of the following is the priority action the nurse should take? Insert an indwelling urinary catheter. Inspect the mouth for signs of inhalation injuries. Administer intravenous pain medication. Draw blood for a complete blood cell (CBC) count

b. Atrial fibrillation Atrial fibrillation causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit.

A nurse is an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? a. First-degree AV block b. Atrial fibrillation c. Sinus bradycardia d. Sinus tachycardia

Erythema

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? Blistering Erythema Eschar Absence of pain

c. Irregular With atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions and thus an irregular pulse.

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect? a. Slow b. Not palpable c. Irregular d. Bounding

A small, translucent papule with rolled borders

A nurse is assessing a client who has basal cell carcinoma on her nose. the nurse should expect which of the following findings? A multi-colored lesion with irregular borders A small, translucent papule with rolled borders A crusted lesion with indurated margins A small macule with dry yellow scale

b. Muscle weakness Myopathy is an adverse effect of this medication. Signs of myopathy include muscle aches, tenderness, and muscle weakness

A nurse is assessing a client who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the recognize as a potential adverse effect? a. Urinary retention b. Muscle weakness c. Orthostatic hypotension d. Blurred vision

b. A 50-year-old who is post coronary artery bypass graft surgery Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse is assessing clients on a medical-surgical unit. Which client should 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

Location of the burn

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns? Age of the client Associated medical history Location of the burn Cause of the burn

b. Suppress respiratory effort Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor lung compliance.

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? a. Decrease chest wall compliance b. Suppress respiratory effort c. Induce sedation d. Decrease respiratory secretions

c. Measure the client's apical pulse. Digoxin decreases the heart rate, so the nurse should count the apical pulse for at least 1 min before administering. The nurse should hold the medication and notify the provider if the client's heart rate is below 60/min or if a change in heart rhythm is detected.

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? a. Offer the client a light snack. b. Measure the client's blood pressure. c. Measure the client's apical pulse. d. Weigh the client.

The hematocrit (Hct)

A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication? The leukocyte count The platelet count The hematocrit (Hct) The erythrocyte sedimentation rate (ESR)

"I feel nauseated and have no appetite."

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates and adverse effect of the medication? "I can walk a mile a day." "I've had a backache for several days." "I am urinating more frequently." "I feel nauseated and have no appetite."

Cryosurgery Electrosurgery Radiation therapy Micrographic surgery

A nurse is caring for a client who has questions concerning the various treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following treatments should the nurse include in the discussion. (SATA) Cryosurgery Electrosurgery Radiation therapy Topical corticosteroids Micrographic surgery

d. 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? a. Epinephrine b. Atropine c. Protamine d. Vitamin K

b. Perform neurovascular checks with vital signs. The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances.

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take? a. Instruct the client to perform range-of-motion exercises to his lower extremities. b. Perform neurovascular checks with vital signs. c. Ambulate the client 1 hr following the procedure. d. Restrict the client's fluid intake.

b. "I should leave the patch in place until it is time for the next dose." Clients should have a period of 10 to 12 hr without the patch on to reduce the risk for nitrate tolerance.

A nurse is providing teaching to a client who has a new prescription for transdermal nitroglycerin paste. Which of the following statements by the client indicates the need for further teaching? a. "I should measure the dosage on the supplied paper." b. "I should leave the patch in place until it is time for the next dose." c. "I should get up slowly when I stand." d. "I might have a headache when I first start taking this medication."

a. Wash the affected area with soap and water before applying cream. The client should wash the affected area with soap and water and dry it thoroughly before applying the cream.

A nurse is providing teaching to a client who has a skin infection and a new prescription for gentamicin topical cream. Which of the following instructions should the nurse provide? a. Wash the affected area with soap and water before applying cream. b. Increase intake of fluids while using this medication. c. The medication might cause temporary blurred vision. d. Apply the cream to large areas around the infection.

A. Protein

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D

"Aloe vera can act as a laxative."

A nurse is teaching a client about the uses of aloe vera. Which of the following information should the nurse include in the teaching? "Aloe vera can cause drowsiness when taken with an antidepressant." "Aloe vera can act as a laxative." "Aloe vera can help decrease moderate blood pressure." "Aloe vera can be taken to prevent migraine headaches."

a. Clean the skin and clip hairs if needed. To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP 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.

B.Triglycerides 168 mg/dL C.HDLs 40 mg/dL Triglycerides that are elevated signal increased risk for CAD and would be anticipated in a patient diagnosed with CAD. Low HDL values indicate an increased risk for CAD and would be anticipated in a patient with CAD. The other values are normal values. These values would likely be elevated in a patient with CAD.

A patient has recently been admitted with a diagnosis of coronary artery disease. What lab assessments would the nurse anticipate? (Select all that apply.) A.Cholesterol 120 mg/dL B.Triglycerides 168 mg/dL C.HDLs 40 mg/dL D.CRP 0.8 mg/dL E.Lipids 600 mg/dL

C. Chest pain associated with ECG changes E. Chest pain relieved only by opioids F. Chest pain associated with shortness of breath

The nurse is assessing a client with chest pain. Which symptoms assessed by the nurse would be most indicative of myocardial infarction? Select all that apply. A. Substernal chest discomfort associated with exertion B. Chest pain that is relieved with rest. C. Chest pain associated with ECG changes D. Chest pain relieved with nitroglycerin E. Chest pain relieved only by opioids F. Chest pain associated with shortness of breath G. Chest pain that lasts less than 10 minutes

c. Level of consciousness A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light- headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the clients level of consciousness is the priority.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

D. Serum lactate and serum potassium levels are declining.

Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99° F (37.2° C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.

c. Report of chest heaviness Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of dopamine. While taking dopamine, the oxygen requirements of the heart are increased due to increased myocardial workload, and may cause ischemia. Without knowing the clients previous blood pressure or pedal pulses, there is not enough information to determine if these are an improvement or not. A urine output of 32 mL/hr is acceptable.

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately? a. Blood pressure of 98/68 mm Hg b. Pedal pulses 1+/4+ bilaterally c. Report of chest heaviness d. Urine output of 32 mL/hr

A."Smoking is a major risk factor for coronary artery disease and peripheral vascular disease." Cigarette smoking is a major risk factor for CVD, specifically coronary artery disease (CAD) and peripheral vascular disease (PVD). The other options are inappropriate.

A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate? A."Smoking is a major risk factor for coronary artery disease and peripheral vascular disease." B."You are correct, smoking only hurts the lungs." C."The primary impact of smoking is only on the heart." D."What concerns you most about smoking?"

Cardiac Output

Amount of blood pumped from left ventricle per minute Heart rate × Stroke volume

Morphine Oxygen Nitrate Aspirin

M.O.N.A.

Oxygen Heparin Beta blocker Aspirin Thrombolytics Morphine Ace Inhibitor Nitrate

O.H.B.A.T.M.A.N.

a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures Assessing and identifying clients at risk for shock is probably the most critical action the nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique, and removing IV lines and catheters are also important actions to prevent shock. Monitoring laboratory values does not prevent shock but can indicate a change.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.) a. Assessing and identifying clients at risk b. Monitoring the daily white blood cell count c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

a. Anaerobic metabolism c. Hypotension The common manifestations of shock, no matter the cause, are directly related to the effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function, and increased perfusion are not manifestations of shock.

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.) a. Anaerobic metabolism b. Hyperglycemia c. Hypotension d. Impaired renal perfusion e. Increased perfusion

a. High glucose is common in shock and needs to be treated. High glucose readings are common in shock, and best outcomes are the result of treating them and maintaining glucose readings in the normal range. Medications and IV solutions may raise blood glucose levels, but this is not the most accurate answer. The stress of the illness has not made the client diabetic.

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best? a. High glucose is common in shock and needs to be treated. b. Some of the medications we are giving are to raise blood sugar. c. The IV solution has lots of glucose, which raises blood sugar. d. The stress of this illness has made your spouse a diabetic.

c. Short period of asystole Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should 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

a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition Immobility, decreased thirst response, diminished immune response, and malnutrition can place the older adult at higher risk of developing shock. Overhydration is not a common risk factor for shock.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

a. Discontinue the existing IV line. The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? a. Discontinue the existing IV line. b. Initiate a new IV line in the other extremity. c. Apply a hot pack to the irritated site. d. Determine if the client needs to continue IV therapy.

C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago.

With which client should the nurse remain alert for the possibility of sepsis and septic shock? A. 41-year-old man who sustained closed depression fractures of the face when hit with a baseball B. 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove several large fibroid tumors. C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago. D. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate cancer.

a. Bringing the client warm blankets d. Reorienting the client as needed e. Sitting with the client for reassurance The student can bring the client warm blankets, reorient the client as needed to decrease anxiety, and sit with the client for reassurance. The client should be NPO at this point, so hot tea is prohibited. Massaging the legs is not recommended as this can dislodge any clots present, which may lead to pulmonary embolism.

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.) a. Bringing the client warm blankets b. Giving the client hot tea to drink c. Massaging the clients painful legs d. Reorienting the client as needed e. Sitting with the client for reassurance

"Black cohosh should not be taken during pregnancy."

A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching? "Black cohosh should not be taken during pregnancy." "Black cohosh helps relieve headache pain." "Black cohosh increases the risk for bleeding." "Black cohosh is a stimulant."

b. Initiate cardiopulmonary resuscitation (CPR). The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event.

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, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status.

Administer IV fluids.

a nurse in an emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? Clean and dress the wound. Administer pain medication. Administer a tetanus booster. Administer IV fluids.

"The area surrounding the insertion site feels warm to the touch."

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? "The infusion rate has stopped but the tubing is not kinked." "The area surrounding the insertion site feels warm to the touch." "There is fluid leaking around the insertion site." "There is no blood return when the tubing is aspirated."

c. The burned area is red in color with eschar present. This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? a. The burned area is black in color and pain is absent. b. The burned area is pink in color with blisters present. c. The burned area is red in color with eschar present. d. The burned area is yellow in color with severe edema.

Airway obstruction

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? Airway obstruction Infection Fluid imbalance Paralytic ileus

c. Protamine Protamine reverses the effects of heparin and is used in the event of an overdose.

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose? a. Iron b. Glucagon c. Protamine d. Vitamin K

a. Client with a blood pressure change of 128/74 to 110/88 mm Hg This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the clients pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

The nurse gets the hand-off report on four clients. Which client should the nurse assess first? a. Client with a blood pressure change of 128/74 to 110/88 mm Hg b. Client with oxygen saturation unchanged at 94% c. Client with a pulse change of 100 to 88 beats/min d. Client with urine output of 40 mL/hr for the last 2 hours

c. Schedule periods of exercise and rest during the day. Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters 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 unlicensed assistive personnel to help bathe the client.

b. Warfarin (Coumadin) Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

"Large incisions will be made in the eschar to improve circulation."

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? "Large incisions will be made in the eschar to improve circulation." "This procedure involves placing the client into a shower and removing the dead tissue." "A piece of healthy skin will be removed from an unburned area and grafted over the burned area." "Dead tissue will be non-surgically removed."

b. Check the value of the client's current platelet count The nurse should recognize that the bleeding is likely due to the adverse effect of the chemotherapy and needs to be evaluated further. Bleeding gums is a sign of thrombocytopenia (decreased platelet count) secondary to bone marrow suppression, which can be life-threatening in a client who is receiving chemotherapy.

A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums? a. Explain to the client that this is an expected adverse effect b. Check the value of the client's current platelet count c. Instruct the client to use an electric toothbrush d. Have the client make an appointment to see the dentist

b. Headache c. Nausea d. Tachycardia e. Diaphoresis Headache: Chest pain and sometimes jaw, back, and shoulder pain are manifestations of an acute MI. Nausea and vomiting are manifestations of an acute MI. Tachycardia and dysrhythmias are manifestations of an acute MI. Tachycardia can also occur as a result of the client's anxiety.Diaphoresis: Profuse sweating and anxiety are manifestations of an acute MI.

A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infarction (MI). Which of the following manifestations should the nurse expect to find for a client experiencing a acute MI? (SATA) a. Orthopnea b. Headache c. Nausea d. Tachycardia e. Diaphoresis

d. 54 percent Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA totaling 54%.

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area? a. 9 percent b. 18 percent c. 36 percent d. 54 percent

a. Troponin I b. Troponin T d. CPK e. Myoglobin Troponin I is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. Troponin T is a myocardial muscle protein that is released when there is injury to cardiac muscle. Levels are elevated as early as 2 to 3 hr following a myocardial infarction. CPK, or creatine phosphokinase, is an enzyme that is elevated in the presence of muscle injury. Although CPK is not specific for myocardial damage, it is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction. A CPK isoenzyme, CK-MB, is specific to cardiac muscle and a significant elevation in this isoenzyme indicates a myocardial infarction has occurred. Elevation of myoglobin indicates myocardial injury. Myoglobin levels will significantly increase within approximately 3 hours following myocardial infarction. This test is used in conjunction with other diagnostic tests to support a diagnosis of myocardial infarction.

A nurse in the emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory test are used to diagnose a myocardial infarction (MI)? (SATA) a. Troponin I b. Troponin T c. Plasma low-density lipoproteins (LDL) d. CPK e. Myoglobin

b. "A headache is an expected adverse effect of the medication." The vasodilation nitroglycerin induces increases blood flow to the head and typically results in a headache.

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? a. "A headache is an indication of an allergy to the medication." b. "A headache is an expected adverse effect of the medication." c. "A headache indicates tolerance to the medication." d. "A headache is likely due to the anxiety about the chest pain."

c. Initiate oxygen therapy. The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

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? a. Attach the leads for a 12-lead ECG. b. Obtain a blood sample. c. Initiate oxygen therapy. d. Insert the IV catheter.

a. Defibrillation The greatest risk to the client is death from a lack of cardiac output. Ventricular fibrillation is a lethal rhythm in which the ventricles are in a quivering pattern and there is no atrial activity. Defibrillation is essential to resolve ventricular fibrillation promptly and convert the rhythm to restore cardiac output. The nurse should follow defibrillation with cardiopulmonary resuscitation and repeated defibrillation, if necessary, to convert the ventricular fibrillation into a sustainable rhythm.

A nurse is caring for a client who develops a ventricular fibrillation rhythm. The client is unresponsive, pulseless and apneic. Which of the following actions is the nurse's priority? a. Defibrillation b. Airway management c. Epinephrine administration d. Amiodarone administration

Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose.

A nurse is caring for a client who has an infection for gentamicin intermittent IV bolus every 8 hr. A peak and trough is required with the next dose. Which of the following actions should the nurse take to obtain an accurate gentamicin serum level? Draw a trough level at 0900 and a peak level at 2100. Draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose. Draw a peak level at 0900 and a trough level at 2100.

a. Headache Headache is a common adverse effect of ondansetron. Analgesic relief is often required.

A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemotherapy-induced nausea. For which of the following adverse effects should the nurse monitor? a. Headache b. Dependent edema c. Polyuria d. Photosensitivity

Decreased blood pressure

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 Increase of HDL cholesterol Prevention of bipolar manic episodes Improved sexual function

c. Pacemaker spikes before each QRS complex The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.

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? a. Pacemaker spikes after each QRS complex b. Pacemaker spikes before each P wave c. Pacemaker spikes before each QRS complex d. Pacemaker spikes with each T wave

Pour tepid water over the burns.

A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take? Apply ice to the burns. Place the child in a tub of cool water. Pour tepid water over the burns. Cover the burns with a blanket.

b. Lactate: 6 mmol/L A lactate level of 6 mmol/L is high and is indicative of possible shock. A creatinine level of 0.9 mg/dL is normal. A sodium level of 150 mEq/L is high, but that is not related directly to shock. A white blood cell count of 11,000/mm3 is slightly high but is not as critical as the lactate level.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider? a. Creatinine: 0.9 mg/dL b. Lactate: 6 mmol/L c. Sodium: 150 mEq/L d. White blood cell count: 11,000/mm3

b. Heart rate When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? a. BP b. Heart rate c. Urine output d. Weight

d. Lactated Ringer's

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? a. Dextrose 5% in water b. Dextrose 5% in 0.9% sodium chloride c. 0.9% sodium chloride d. Lactated Ringer's

Hypotension

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? Hyperthermia Hypotension Ototoxicity Muscle pain

a. "Place the tablet under your tongue, and then take a small sip of water." A client who takes a sublingual medication should place it under his tongue. A sip of water can help the medication dissolve.

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pertoris. Which of the following instructions should the nurse include? a. "Place the tablet under your tongue, and then take a small sip of water." b. "The medication can take up to 15 minutes to take effect." c. "Avoid taking the medication prior to exercising." d. "Stop taking the medication and notify your provider if you develop a headache."

b. "The pacemaker can be checked from home by using the telephone." The initial pacemaker check is performed at the clinic. Following this initial examination, follow-up pacemaker checks can happen remotely from the client's home. Using a telephone transmitting device, the client can transmit basic information electronically from the pacemaker to the clinic. The client will return to the clinic annually for a more thorough pacemaker check.

A nurse is providing teaching to a client who has a permanent pacemaker and has just had the initial pacemaker check. Which of the following client statements should the nurse recognize as an understanding of the teaching? a. "I will take my pulse weekly." b. "The pacemaker can be checked from home by using the telephone." c. "My pacemaker will need reprogramming if I stand too close to a microwave oven." d. "The next pacemaker check will be when the batteries need to be replaced."

d. "I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting." If 1 nitroglycerin tablet does not relieve the client's pain, he should access emergency services and then take 2 more tablets at 5-min intervals if he still has pain.

A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching? a. "I'll dial 911 if I still have pain after taking 3 nitroglycerin tablets 5 minutes apart." a. "I'll dial 911 if I still have pain after taking 4 nitroglycerin tablets over a 20-minute period." c. "I'll dial 911 when I have pain and then take the nitroglycerin tablets." d. "I'll dial 911 if 1 nitroglycerin tablet does not relieve my pain, and then take up to 2 more tablets 5 minutes apart while waiting."

a. Apply the patch to a hairless area and rotate sites is correct. b. Apply a new patch each morning c. Remove the patch for 10 to 12 hr daily Hair can interfere with the adhesion of the patch. Rotating sites helps prevent skin irritation.Therapeutic preventive effects of transdermal nitroglycerin patches begin 30 to 60 min after application and last up to 14 hr. is correct. Removing the patches for 10 to 12 hr each day helps prevent tolerance to the medication.

A nurse is providing teaching to a client who has stable angina and a new prescription for transdermal nitroglycerin. Which of the following instructions should the nurse include? (SATA) a. Apply the patch to a hairless area and rotate sites. b. Apply a new patch each morning. c. Remove the patch for 10 to 12 hr daily. d. Apply the patch to dry skin and cover the area with plastic wrap. e. Apply a new patch at the onset of anginal pain.

b. "You should avoid grapefruit juice. "Grapefruit inhibits the drug-metabolizing enzyme CYP3A4 which slows the metabolism of simvastatin. This can cause an increase in serum simvastatin. Potential adverse effects include elevated liver enzymes, and rhabdomyolysis.

A nurse is teaching a client who has a new prescription for simvastatin. Which of the following instructions should the nurse include? a. "You should expect brown-colored urine." b. "You should avoid grapefruit juice." c. "You should monitor for ringing in the ears." d. "You should take the medication in the morning."

b. Apply the transdermal patch in the morning. The client should apply the patch every morning and leave it in place for a 12 to 14 hr, then remove it in the evening.

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? a. Apply a new transdermal patch once a week. b. Apply the transdermal patch in the morning. c. Apply the transdermal patch in the same location as the previous patch. d. Apply a new transdermal patch when chest pain is experienced.

c. "Take one tablet at the first indication of chest pain." The client should take nitroglycerin as soon as he feels pain, pressure, or tightness in his chest and not wait until his chest pain is severe.

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? a. "Take this medication after each meal and at bedtime." b. "Take one tablet every 15 min during an acute attack." c. "Take one tablet at the first indication of chest pain." d. "Take this medication with 8 ounces of water."

a. "I will avoid drinking grapefruit juice." Grapefruits and grapefruit juice can reduce metabolism of atorvastatin, which increases the risk for toxicity.

A nurse is teaching a client who is taking atorvastatin daily. Which of the following statements by the client indicates an understanding of the teaching? a. "I will avoid drinking grapefruit juice." b. "I should take this medication without food." c. "I should expect my stools to turn clay-colored." d. "It is not necessary to have routine lab tests done."

c. Fatigue Pacemaker malfunction causes bradycardia and a drop in cardiac output. This can cause hypoxia, with classic manifestations of weakness, fatigue, and dizziness.

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 manifestation? a. Increased urine output b. Rapid pulse c. Fatigue d. Sneezing

a. "These tests help determine the degree of damage to the heart tissues." Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels.

A nurse is teaching the partner of 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 makes regarding cardiac enzymes studies? a. "These tests help determine the degree of damage to the heart tissues." b. "Cardiac enzymes will identify the location of the MI." c. "These tests will enable the provider to determine the heart structure and mobility of the heart valves." d. "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

a. Administer another nitroglycerin tablet. Administration guidelines for sublingual nitroglycerin indicate that it is appropriate to administer another tablet 5 min after the first one if the client is still reporting pain.

A nurse on a telemetry unit is caring who has unstable angina and is reporting chest pain with 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? a. Administer another nitroglycerin tablet. b. Initiate a peripheral IV. c. Call the Rapid Response Team. d. Obtain an ECG.

c. An excess amount of doxorubicin can lead to cardiomyopathy. Doxorubicin is an antineoplastic antibiotic used in the treatment of various cancers. Irreversible cardiomyopathy with congestive heart failure can result from repeated doses of doxorubicin, and prolonged use can also cause severe heart damage, even years after the client has stopped taking it. The maximum cumulative dose a client should receive is 550 mg/m2 or 450 mg/m2 with a history of radiation to the mediastinum.

A nurse on an oncology unit is preparing to administer doxorubicin to a client who has a breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is the verification necessary? a. An excess amount of doxorubicin can lead to myelosuppression. b. Exceeding the lifetime cumulative dose limit of doxorubicin might cause extravasation. c. An excess amount of doxorubicin can lead to cardiomyopathy. d. Exceeding the lifetime cumulative dose limit of doxorubicin might produce red tinged urine and sweat.

d. Ensure that everyone is clear of contact with the client and the bed. To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure 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 joules. d. Ensure that everyone is clear of contact with the client and the bed.

a. Until your incision is healed, do not submerge your pacemaker. Only take showers. b. Report any pulse rates lower than your pacemaker settings. e. Do not lift your left arm above the level of your shoulder for 8 weeks. The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients 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 of your shoulder for 8 weeks.

b. Drink fluids on a regular schedule. Preventing dehydration in older adults is important because the age-related decrease in the thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a regular schedule will help keep them hydrated without the influence of thirst (or lack of thirst). Telling clients not to get dehydrated is important, but not the best answer because it doesnt give them the tools to prevent it from occurring. Older adults should seek attention for lacerations, but this is not as important an issue as staying hydrated. Taking medications as prescribed may or may not be related to hydration.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock? a. Do not get dehydrated in warm weather. b. Drink fluids on a regular schedule. c. Seek attention for any lacerations. d. Take medications as prescribed.

b. Slow the amiodarone infusion rate. IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the clients heart rate.

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: 0800 Temperature: 98 F 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: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.