Cardiovascular & hematologic disorder ATI 27-42

A nurse at a providers office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicate the client is at risk for heart disease? Select all that apply A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin I 0.02 ng/mL

A. A client who has a total cholesterol level greater than 200 is at increased risk for heart disease C. A client who has an LDL level greater than 130 is at increased risk for heart disease

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for development of a dysrhythmia? Select all that apply A. A client who has metabolic alkalosis B. A client who has a blood potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

A. A client who has an acid base in balance such as metabolic alkalosis is at risk for dysrhythmias D. A client who has lung disease, such as COPD is at risk for dysrhythmias E. A client who has cardiac disease and underwent a stent placement is at risk for Dysrhythmias

A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? Select all that apply A. Cool and clammy foot with capillary refill of 5 seconds B. Observe pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62

A. A cool, clammy foot can be an indication of a few moral hematoma secondary to insertion of the lead wires and should be reported C. Persistent hiccups can indicate lead wire preparation and stimulation of the diaphragm and should be reported

A nurse is reviewing the health record of a client who is being a valuated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? Select all that apply A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for five years D. Weight gain of 10 pounds in the past year E. diastolic murmur present

A. A history of congenital malformations is a risk factor for valvular heart disease C. Hypertension places a client at risk for valvular heart disease E. A murmur indicates turbulent flow, which is often due to valvular heart disease

A nurse is caring for a client who asked why the provider prescribes a daily aspirin. Which of the following responses should the nurse make? A. Aspirin reduces the formation of blood clots that could cause a heart attack B. Aspirin relieve the pain due to myocardial ischemia C. Aspirin dissolves clots that are forming in your coronary arteries D. Aspirin relieves headaches that are caused by other medication

A. Aspirin decreases platelets aggregation that can cause a myocardial infarction

A nurse is planning post operative care for a client following a surgical placement of an endovascular stent graft to repair an aneurysm. Which of the following intervention should the nurse include in the plan of care? Select all that apply A. Assess pedal pulses B. Monitor for an increase in pain below the graft site C. Maintain the client in high Fowlers position D. Monitor the for moral site for bleeding E. Report hourly urine output of 60 ML

A. Assess the pulses distal to the graft site to detect possible occlusion of the graft B. Monitor for an increased pain below the graft site. This can be an indication of graft occlusion or rupture D. Check the for moral insertion site for bleeding and for thrombus formation.

A nurse is reviewing manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following findings should the nurse include in the discussion? Select all that apply A. Cough B. Shortness of breath C. Upper chest pain D. Diaphoresis E. Altered swallowing

A. Cough is a manifestation of the thoracic aortic aneurysm B. Shortness of breath is a manifestation of a thoracic aortic aneurysm E. Difficulty swallowing is a manifestation of a thoracic aortic aneurysm

A nurse educator is receiving expected findings in a client who has right sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? Select all that apply A. Dyspnea B. Client reports of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema

A. Dyspnea is a manifestation of right sided valvular heart disease B. A client reports of fatigue is a manifestation of right sided valvular heart disease E. Peripheral edema is a manifestation of right sided valvular heart disease

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? A. I will notify the airport screeners about my pacemaker B. I will affect to have occasional hiccups C. I will have to disconnect my garage door opener D. I will take my pulse every 2 to 3 days

A. I will notify the airport screeners about my pacemaker

A nurse is caring for a client who has a prescription for an afterload reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypo bulimic D. Distributive

A. Identify that a prescription to reduce afterload will allow the heart to pump more effectively, which is needed for the client who has cardiogenic shock

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? Select all that apply A. Stop the transfusion B. Monitor for hypertension C. Maintain an IV infusion with 0.9% sodium chloride D. Position a client in an upright position with feet lower than the heart E. Administer diphenhydramine

A. Immediately stopped in fusion if an allergic transfusion reaction suspected C. Administer 0.9% Sodium chloride solution through new IV tubing if an allergic transfusion reaction suspected. E. Administer an anti-histamine, such as diphenhydramine, If an allergic transfusion reaction is suspected

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include? Select all that apply A. Avoid taking herbal supplements while taking this medication B. Monitor for the presence of black, tarry stools C. Take this medication when you have pain D. Schedule a weekly PT test E. Limit food sources containing vitamin K while on this medication

A. Instruct the client to avoid herbal supplements while taking clopidogrel Herbal supplements (Garlic, ginger, ginkgo, ginseng) can increase the risk of bleeding. B. Instruct the client to monitor for evidence of G.I. bleed (Abdominal pain, coffee ground emesis, black tarry stools). If this occurs, the client should report this to the provider

A nurse is completing discharge teaching with a client following placement of and ICD. Which of the following information should the nurse include? Select all that apply A. Avoid large magnetic field B. Caution family members that they can receive harmful unexpected shots from the ICD C. Take body temperature at the same time each day D. Wear tight clothing to hold the device in place E. Perform arm stretching exercises to strengthen muscles surrounding the ICD

A. Large magnetic fields can deactivate the device, causing it to be ineffective for dysrhythmias C. The client should take their temperature at the same time each day and report any increases to the provider. This is done to monitor for infection

A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat pericarditis. Which of the following laboratory findings should the nurse report to the provider? A. Platelets 100,000 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 IU/L

A. Long term NSAID therapy can lower platelets. This finding is outside the expected reference range and should be reported to the provider

A nurse is providing discharge teaching for a client who has heart failure and is on fluid restriction of 2000 mL/day. The client asked the nurse how to determine the appropriate amount of fluids they are allowed. Which of the following statements is an appropriate response by the nurse? A. Pour the amount of fluid you drink into an empty 2 L bottle to keep track of how much you drink B. Each glass contains 8 ounces. There are 30 mL per ounce, so you can have a total of eight glasses or cups of fluid each day C. This is the same as 2 quarts or about the same as two pots of coffee D. Take sips of water or ice chips so you will not take into much fluid

A. Porn the amount of fluid consumed into a empty 2 L bottle provides a visual guide for the client as to the amount consumed and how to plan daily intake

A nurse is assessing a client who has splinter hemorrhages of the nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic Endocarditis

A. Splinter hemorrhages in the nail beds and a report of a fever or findings associated with infective endocarditis

A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish stable angina from an MI? A. Stable angina can be relieved with rest and nitroglycerin B. The pain of an MRI results in less than 15 minutes C. The type of activity that causes an MI can be identified D. Stable angina can occur for longer than 30 minutes

A. Stable angina can be relieved by rest and nitroglycerin

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestations are expected findings? Select all that apply A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea

A. Tachypnea is an expected finding in clients who have pulmonary edema B. A persistent cough with pink frothy sputum is an expected finding in a client who has pulmonary edema E. Orthopnea is an expected finding in a client who has pulmonary edema

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40mg PO daily. The nurse should instruct the client to take this medication app which of the following times of the day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime

A. The client should take furosemide, a diuretic, in the morning so that the peak action and duration of the medication occurs during waking hours.

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of the procedure? Select all that apply A. Follow-up ECG B. Energy setting used C. IV fluid intake D. Urinary output E. Skin condition under electrodes

A. The clients ECG rhythm is documented following the procedure B. Energy settings used during the procedure are documented E. The condition of the client skin where electrodes were placed is documented

A nurse educator is reviewing the use of a cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? Select all that apply A. The client demands for oxygen is lowered B. Motion of the heart ceases C. Rewarming of the client takes place D. The clients metabolic rate is increased E. Blood flow to the heart is stopped

A. The use of cardiopulmonary bypass reduces the client demand for oxygen, which reduces the risk of an adequate oxygenation of vital organs B. Motion of the heart ceases during cardiopulmonary bypass to allow for placement of the graft near the affected coronary artery C. The core body temperature is lowered for the procedure, and rewarming then occurs through heat exchangers on the cardiopulmonary bypass machine

A nurse is planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include? Select all that apply A. Use a 10 mL syringe to flush the PICC line B. Apply gentle force it resistant is met during injection C. Cleanse ports with alcohol for 15 seconds prior to use D. Maintain a transparent dressing over the insertion site E. Flushed with 10 mL heparin before and after medication administration

A. Use a 10 ML syringe to flush the pick line to avoid excess pressure that the cause catheter fracture/rupture C. Cleanse insertion ports with alcohol for 15 seconds and allow it to dry bar to use. This action decreases the risk for bacterial contamination D.Maintain a transparent dressing over the insertion site to decrease the risk for infection and allow for visualization. Plan to change the dressing at least every seven days and when wet, loose, or soiled

A nurse is teaching a client who has heart failure and new prescriptions for furosemide and digoxin. Which of the following information should the nurse include? Select all that apply A. Weigh daily, first thing each morning B. Decreased intake of potassium C. Expect muscle weakness while taking digoxin D. Hold digoxin if heart rate is less than 70/min E. Decrease sodium intake

A. Weighing daily when first getting out of bed will assess the client in tracking fluid loss and gain E. Decrease sodium intake to prevent fluid retention, which could worsen heart failure manifestations

A nurse is caring for four clients. Which of the following client should the nurse identify as being at risk of developing rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharyngitis C. Middle aged adults who has lupus erythematosus D. Young adult who recently received a body tattoo

B. A child who has streptococcal pharyngitis is at risk for developing rheumatic fever which could result in rheumatic endocarditis

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates an understanding of the teaching? A. I will be glad to get back to my exercise routine right away B. I will have my prothrombin time checked on a regular basis C. I will talk to my dentist about no longer needing antibiotics before dental exams D. I will continue to limit my intake of foods containing potassium

B. Anticoagulant therapy with warfarin is necessary for the client following placement of mechanical heart valve. The clients prothrombin time will be checked on a regular basis

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh high compression socks. Which of the following actions should the nurse take? A. Elevate the clients legs for 10 minutes, 2 to 3 times daily while wearing stockings B. Apply the stockings in the morning upon awaking and before getting out of bed C. Roll the stockings down to the knees to relieve discomfort of the legs D. Removed the stockings while out of fed for one hour, four times a day to allow the legs to rest

B. Applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less Edematous at this time

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8. Which of the following actions should the nurse plan to take during the first 15 minutes of the transfusion? A. Obtain consent from the client for the transfusion B. Assess for an acute hemolytic reaction C. Explain the transfusion procedure to the client D. Obtain blood cultures specimens to send to the lab

B. Assess for an acute hemolytic reaction during the first 15 minutes of transfusion. This form of a reaction can occur following the transfusion of as little as 10 ML of blood product

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? Select all that apply A. Trace of bloody drainage on the dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb

B. Capillary refill greater than three seconds is outside the expected reference range and should be reported to the provider C. Mottled appearance of the affected extremity is an unexpected findings should be reported to the provider

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7mm Hg & a PAWP of 17mm Hg. Which of the following findings should the nurse expect? Select all that apply A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular vein distention D. Dry mucous membranes E. Hepatomegaly

B. Expect the client to have bilateral crackles in the lungs for an increased CVP and PAWP C. Expect the client to have a jugular vein distention for an increased CVP and PAWP E. Expect the client to have hepatomegaly for an increased CVP and PAWP

A nurse is caring for a client who is receiving warfarin for anticoagulantion therapy. Which of the following laboratory test results indicate to the nurse that the client needs an increase in the dosage? A. aPTT 38 seconds B. INR 1.1 C. PT 22 seconds D. D-Dimer negative

B. INR of 1.1 is within the expected reference range for a client who is not receiving warfarin. However, this value is sub therapeutic for anticoagulation therapy. Expect the client to receive an increased dosage of warfarin until the INR is 2 to 3

A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding for the teaching? A. This test will be performed while I am laying flat on my back B. I will need to stay in bed for about an hour after the test C. This test will determine which anabiotic I should take for treatment D. I will receive a general anesthesia for the test

B. Inform the client of the need to stay on bed rest for 30 to 60 minutes following the test to reduce the risk of bleeding

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the clients heart rate is 46/min and notifies the provider. Which of the following prescriptions might be appropriate for this client? A. Defibrillation B. Pacemaker insertion C. Synchronize cardioversion D. Administration of IV lidocaine

B. Pacemaker insertion

A nurse is screening for client for hypertension. The nurse should identify that which of the following actions by the client increases the risk for hypertension? Select all that apply A. Drinking 8 ounce nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 minutes/mile pace D. Consuming 36oz beer daily E. Getting a massage once a week

B. Popcorn at the movie theater contains a large quantity of sodium and fat, which increases the risk for hypertension. D. Consuming more than 24 ounces beer per day for a mail client or 12 ounces for a female client increases the risk for hypertension.

A nurse is caring for a client who is 4hr post operative following coronary artery bypass grafting (CABG) surgery. The client is able to inspire 200 mL with the incentive spirometer, then declines to try to cough because of fatigue and pain. Which of the following actions should the nurse take? A. Allow the client to rest, and return in one hour B. Administer IV bolus analgesic, and return in 15 minutes C. Document the 200 ML as an appropriate inspired value D. Tell the client coughing after incentive spirometry

B. Providing adequate analgesia and returning in 15 minutes will reduce pain and improve coping effectiveness

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? Select all that apply A. Heart rate 60/min B. Seizure activity C. Respiratory rate of 42/min D. Increased urine output E. Week, thready pulse

B. Seizure activity caused by progressive hypoxia can be present in a client who is in shock C. Tachypnea Is an expected finding for client who is in shock due to the body's attempt to increase oxygen intake E. A weak, thready pulse can be caused by low fluid volume, vasoconstriction, and hypotension is an expected finding in a client who is in shock

A nurse is caring for an older adult client who is to undergo a pre-cutaneous balloon valvuloplasty. The clients family member asked the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? A. This will improve blood flow of the coronary arteries B. This will assist with the ability to perform activities of daily living C. This will prolong the life span of living with this valve disorder D. This will reverse the effects to the damaged area

B. Surgery is indicated for older adult clients when manifestations interfere with activities of daily living

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironoloactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. I should eat a lot more fruits and vegetables, especially bananas and potatoes B. I will report any changes in heart rate to my provider C. I should replace the salt shaker on my table with a salt substitute D. I will decrease the dose of this medication when I no longer have headaches and facial redness

B. Teach the client to monitor their heart rate and report any changes to the provider

A nurse is planning care for a client who has septic shock. Which of the following actions is the primary for the nurse to take? A. Maintain adequate fluid volume with IV infusions B. Administer antibiotics therapy C. Monitor hemodynamic status D. Administer a vasopressor medication

B. The greatest risk to the clients is injury from elimination endotoxins and mediators from bacteria. The priority intervention is to administer antibiotics, which will reduce vasodilation

A nurse is caring for a client who has heart failure and reports increased shortness of breath. Which of the following actions should the nurse take first? A. Obtain the clients weight B. Assist the client into high Fowlers position C. Auscultate lung sounds D. Check oxygen saturation with pulse oximeter

B. Using the airway, breathing, and circulation (ABC) priority approach to the clients care, the first action to take is to assist the client into high Fowlers position. This will decrease venous return to the heart (preload) and help relieve a lung congestion

A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet modifications B. Relaxation exercises C. Smoking cessation D. Taking omega-3 capsules

C. According to the airway, breathing, and circulation (ABC), Priority setting framework, the first step is to recommend the client to stop smoking. Nicotine causes vasoconstriction, elevates blood pressure, and narrows coronary arteries.

A nurse is providing preoperative teaching for a client who requests auto log us teaching for a client who Request autologous donation in preparation for a schedule orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. You should make an appointment to donate blood eight weeks prior to the surgery B. If you need an autologous Transfusion, the blood your brother donates can be used C. You can donate blood each week if you want to hemoglobin is stable D. Any used blood that is donated can be used for other clients

C. Beginning 6 weeks prior to surgery, the client can donate blood each week for autologous transfusion if there HGB and HCT remain stable

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the patient's lower back. Which of the following findings should the nurse suspects? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incision site D. Heart care

C. Bleeding is occurring from the decision site and then joining under the client. The nurse should assess the incision for hematoma, apply pressure, monitor the client, and notify the provider

A nurse in an urgent care clinic is obtaining a history from a client who has type two diabetes mellitus and a recent diagnosis of hypertension. This is the second time in two weeks that the client experienced hypo glycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast

C. Metoprolol can mask the effects of hypoglycemia in clients who have diabetes mellitus

A nurse is completing the admission physical assessment of a client who has mitral valve insufficiency. Which of the following findings should the nurse expect? A. S4 heart sound B. Petechiae C. Neck vein distention D. Splenomegaly

C. Neck vein distention is an expected finding in a client who has pulmonary congestion due to mitral valve insufficiency

A nurse is talking with a client who has class I heart failure and ask about obtaining a ventricular assist device (VAD). Which of the following statements should the nurse make? A. VADs are only implanted during heart transplantation B. A VAD helps to pace the heart C. VADs are used when heart failure is not responsive to medications D. A VAD is useful for clients who also have a chronic lung issue

C. One use for a VAD is to prolong life for a client who has become unresponsive to heart failure medication

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 minutes ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? Select all that apply A. Temperature change from 37°C (98.6) per-transfusion to 37.2°C (99.0) B. Current blood pressure 178/90 C. Heart rate change from 88/min pre-transfusion to 120/min D. Client reports itching E. Client appears flushed

C. Tachycardia is an indication of a febrile transfusion reaction E. A flushed appearance of the client can indicate a febrile transfusion reaction

A newly licensed nurse is observing a cardioversion procedure and here's the team leader call out, "stand clear". This statement indicates which of the following events is occurring? A. The cardioverter is being charged to the appropriate setting B. The team should initiate CPR due to the pulseless electrical activity C. Team members cannot be in contact with equipment connected to the client D. A time out is being called to verify correct protocols

C. Team members cannot be in contact with equipment connected to the client

A nurse is admitting a client who has a suspected occlusion of a graft of the abdominal aorta. Which of the following manifestations should the nurse expect? A. Increase in urine output B. Bounding pedal pulse C. Increase in abdominal girth D. Lower extremities have a irregularly shaped cyanotic areas

C. The client who has a graft embolism can have irregularly shaped cyanotic areas, tenderness, and decreased pulses in the lower extremities due to the occlusion of blood flow from the thrombus.

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147. The client reports a headache and double vision. The client states "I ran out of my diltiazem 3 days ago, and I am unable to purchase more". Which of the following actions should the nurse take first? A. Administer acetaminophen for headache B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive C. Obtain IV access and prepare to administer an IV anti-hypertensive D. Call social services for a referral for financial assistance in obtaining prescribe medication

C. The greatest risk to the patient is injury due to a blood pressure of 266/147, which can be life-threatening and should be lowered as soon as possible. Obtaining IV access will permit administration of an IV hypertensive, which will act more rapidly than the oral route

A nurse on a cardiac unit is reviewing the laboratory findings of a client who has been diagnosed of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK-MB B. Troponin I C. Troponin T D. Myoglobin

C. Troponin T level will still be evident 10 to 14 days a following and MI

A nurse is caring for a client who has a deep vein thrombosis, DVT and has been taking unfractionated heparin for one week. Two days ago, the provider also prescribed warfarin. The client asked the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. I will remind your provider that you already receive heparin B. Your laboratory findings indicate that to anticoagulants were needed C. It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then they happen can be discontinued D. Only one of these medication is being given to treat your deep vein thrombosis

C. Warfarin depressed is synthesis of clotting factors but does not have an affect on clotting factors that are present. It takes 3 to 4 days for the clotting factors that are present to decay and for the therapeutic effects of warfarin to occur.

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medication should the nurse anticipate administering first? A. Methylprednisolone B. Diphenhydramine C. Epinephrine D. Dobutamine

C. When using the airway, breathing, circulation approach to the client care, place the priority on administering epinephrine to the client. This is a rapid acting medication that promotes effective oxygenation and is used to treat anaphylactic shock

A nurse in the emergency department is admitting a client who has a possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A. Administer pain medication as prescribed B. Provide a Warm environment C. Administer IV fluids as prescribed D. Initiate a 12 lead ECG

C. When using the airway, breathing, circulation approach to the clients care, determined that the priority is on administering IV fluids to the client. The client is at risk for an adequate circulatory volume due to profuse sweating related to the pain and feeling of fullness related to the aneurysms and to the possible leaking or rupture of the aneurysms

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates understanding? A. Air should be instilled on into The monitoring system prior to the procedure B. The client should be positioned on the left side during the procedure C. The transducer should be level with the second intercostal space after the line is placed D. A chest x-ray is needed to verify placement after the procedure

D. A chest x-ray is needed to verify placement after the procedure

A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in the left foot C. Then, peeling toenails of the left foot D. Report of intermittent claudication in the affected leg

D. A client who has peripheral arterial disease might report that numbness or burning pain in the extremity ceases with rest (intermittent claudication)

A nurse is caring for a client who has Pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub

D. A friction rub can be hurt during auscultation of a client who has Pericarditis

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should expect a prescription for which of the following laboratory test to assist in confirmation of his diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture

D. A throat culture can review the presence of streptococcus which is the leading cause of rheumatic endocarditis

A nurse is admitting a client who has complete heart block as demonstrated by ECG. The clients heart rate is 34/min and blood pressure is 83/48. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory B. Prepare the client for insertion of a permanent pacemaker C. Obtain a sign informed consent form for a pacemaker D. Apply transcutaneous pacemaker pads

D. Apply transcutaneous pacemaker pads

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts and 18 gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel/AP C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtained vital signs every 15 minutes throughout the procedure

D. Check the Older adult clients vital signs every 15 minutes throughout the transfusion to allow for early detection of fluid overload or other transfusion reactions

A nurse is teaching a client who has a new diagnosis for an aneurysm. The client asked the nurse to explain what causes an aneurysm to rupture. Which of the following assessment should the nurse give? A. This can occur when the wall of an artery becomes thin and flexible B. This can occur when there is turbulence in blood flow in the artery C. It is due to abdominal enlargement D. It is due to hypertension

D. Explain to the client that aneurysm rupture's as a result of hypertension increasing pressure within the arterial wall

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect? A. Iron 90 B. RBC 6.5 million C. WBC 4,800 D. Hgb 10

D. Hgb of 10 is below the expected reference range and is an expected finding of anemia

A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Adema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling Eczema of the lower leg with stasis dermatitis D. Paler on elevation of the limbs, and rubor when the limbs are dependent

D. In a client who has chronic PAD, power is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered.

A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instruction should the nurse include? A. We are tightly fitted insulated socks with shoes when going outside B. Elevate both legs above the heart when resting C. Apply a heat pad to both legs for comfort D. Please both legs in a dependent position while sleeping.

D. Instruct the client to place their legs in a dependent position, such as hanging off the edge of the bed while sleeping. This can alleviate swelling and discomfort of the legs.

Nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? A. A client who is having occasional PVCs on the ECG monitor B. The client has been experiencing vomiting and diarrhea for several days C. A client who has a Graham negative bacteria infection D. A client who has a pulmonary arterial stenosis

D. Obstructive shock results from decreased cardiac function by a non-cardiac cause, such as with pulmonary arterial stenosis or hypertension, or thoracic tumor

A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A. I should place the tablet under my tongue B. I should have my clotting time checked weekly C. I will report a ringing in my ears D. I will call my doctor if my pulse rate is less than 60

D. The client is advised to notify the provider is bradycardia, pulse rate less than 60 occurs

A nurse is teaching a client who is scheduled for coronary angiography. Which of the following statements would the nurse include? A. You should have nothing to eat or drink for four hours prior to the procedure B. You will be given general anesthesia during the procedure C You should not have this procedure done if you are allergic to eggs D. You will need to keep your affected leg straight following the procedure

D. You will need to keep your affected leg straight following the procedure

a cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. which of the following statements by a newly hired nurse indicates understanding of the review? a. "this means the pacemaker fires in an asynchronous pattern." b. "this means the pacemaker firs only when the heart rate is below a certain rate." c. "the pacemaker can automatically adjust to a client's increased activity level. d. "the pacemaker activity is triggered by heart muscle activity."

a. "this means the pacemaker fires in an asynchronous pattern."