Med- Surg 2nd half
The nurse includes which of the following discharge instructions for a client who had pacemaker insertion?
Use cell phones on the opposite side of insertion site (Instruct patients to place cell phones 6-12 inches away from the pacemaker generator and handheld screening devices used in airports may interfere with the pacemaker)
When assessing whether a 84 year old client is in cardiac arrest, which of the following nursing actions is performed first?
When cardiac arrest occurs consciousness is lost immediately
Which of the following clinical assessment findings is consistent with a client in acute postoperative pain?
elevated blood pressure
The nurse is providing discharge teaching to a client who has an order for prn sublingual nitroglycerin. Which of the following key points should the nurse include in the instruction? Select all that apply.
kept in a dark bottle, renewed every 6 months, placed under a moist tongue and never swallowed and taken q 5 minutes up to 3 doses (call 911 if not effective after 3rd dose) Current practice states to call 911 after the first dose if pain is not relieved
A client presents to the emergency room with complaints of angina after leaving a party. Which statement by the client suggest the etiology of the problem?
'I ate a lot of food during my grandchild's birthday party this evening.'
Which statement by the client indicates that discharge instructions regarding the pacemaker was understood?
'I should avoid lifting weights for at least 2 weeks.' (Avoid raising the hands over the head for 2 weeks or heavy lifting followng the insertion of a cardiac device)
The nurse is preparing a client diagnosed with mitral valve prolapse for discharge. Which of the following statements if made by the client suggests that teaching was effective?
'I should inform all my health care providers of my condition' Mitral valve prolapse increases the risk for infective endocarditis
The nurse is caring for a client with venous insufficiency. Which of the following statements made by the client indicates to the nurse that additional instruction is required prior to discharge?
'I should keep my legs in a dependent position when seated.' (Instruct the patient to lower the extremities below the level of the heart in the setting of arterial insufficiency and to raise the extremity in the setting of venous insufficiency)
The nurse is caring for a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which statement, by the client, indicates the need for further education?
'I'll take my Questran each day at 9 am with meals.'
The nurse is conducting a community health fair to a group of 20 year olds on the prevention of coronary artery disease (CAD). The nurse should include which of the following blood testing recommendations?
.A fasting lipid profile is recommended for all adults 20 years and older every 5 years
A client is admitted with shortness of breath, orthopnea, and dyspnea. During the assessment, the nurse aucultates basilar crackles. Which of the following laboratory values is consistent with this finding?
.An elevated B-type natriuretic peptide (BNP) level
A male client with a history of diabetes is diagnosed with dyslipidemia. Which of the following actions will help reduce the incidence of coronary artery disease? Select all that apply.
.Low density lipoprotein cholesterol should be less than 100 mg/dL (less than 70 mg/dL for high risk patients), total cholesterol less than 200 mg/dL, high density lipoprotein cholesterol greater than 40 mg/dL (males), 50 mg/dL (females) and triglycerides should be less than 150 mg/dL
When evaluating the effectiveness of diltiazem (Cardizem), the nurse should ask the client which of the following questions?
1.'Has your chest pain subsided?'
The nurse instructs the client with Type I diabetes to check blood sugar levels more frequently after being started on metoprolol (Lopressor). Which of the following statements by the client suggests that the rationale for this instruction was understood?
1.'Metoprolol may mask symptoms of hypoglycemia'
A client's electrocardiogram (ECG) shows ST segment elevation myocardial infarction (STEMI). The client wants to know why a percutaneous coronary intervention (PCI) is being scheduled within the hour. Which of the following is the nurse's best response regarding the purpose of the procedure?
1.'We have to identify coronary artery blockages and dilate the vessel'
A client with heart failure is taking digoxin (Lanoxin) daily. When reviewing the electrocardiogram (ECG) for this client, the nurse anticipates which of the following normal changes to the EKG?
1.A longer PR interval
When caring for a client with metabolic syndrome, the nurse assesses which of the following as a priority? Select all that apply
1.Abdominal circumference. 2.Cholesterol level. 3.Blood pressure
The emergency response team has arrived to treat the client in cardiac arrest. After establishing the airway, what is the priority nursing action when ventilating the client?
1.Administer oxygen via 100% bag valve mask
The laboratory calls to report that a client's digoxin level is 2.4 ng/dL. Which of the following findings supports the diagnosis of digoxin toxicity?
1.Apical heart rate of 48
The nurse interviews a client with elevated triglycerides for modifiable risk factors. Which of the following lifestyle choices should the nurse plan to discuss with the client? Select all that apply.
1.Body mass index of 30 2.Sedentary activity level 3.Obtains meals from restaurants
Which of the following key points does the nurse include when teaching an obese, middle-aged female who has heart disease about actions to take to optimize weight? Select all that apply.
1.Body mass index should be 18.5-24.9 2.Engage in aerobic activity 5 times per week
The client presents to the health clinic with a complaint of feeling skipped beats. The electrocardiogram (ECG) shows normal sinus rhythm with occasional premature ventricular contractions (PVCs). The nurse should assess the client's intake of which of the following? Select all that apply.
1.Caffeine 2.Alcohol 3.Tobacco
The nurse is preparing to administer verapamil (Calan) for a client. Which of the following interventions is a priority?
1.Check blood pressure
A client who had a thoracoscopy performed returns to the unit and is requesting breakfast. Which of the following actions is a nursing priority?
1.Check the client's heart rate and blood pressure (.Bleeding is always a risk of angiograpy and procedures ending in oscopy (ex. bronchoscopy)
The nurse receives the following vital signs from an unlicensed care provider on a client who complains of fatigue and is being treated with lanoxin (Digoxin) and furosemide (Lasix): SpO2: 98% on room air; Respirations: 23, BP: 137/88; Pulse: 55; Temp 34.5 C; and Pain 8/10. The nurse should suspect bradycardia due to which of the following?
1.Digoxin toxicity
The electrocardiogram (ECG) rhythm on a client in cardiac arrest shows ventricular fibrillation. Which intervention is most important to the client's survival?
1.Early defibrillation
When educating a client on actions to help prevent episodes of angina, which instructions should the nurse include? Select all that apply.
1.Eat small frequent meals throughout the day 2.Avoid straining with bowel movements
The nurse is reviewing the laboratory report on the client taking lovastatin (Mevacor). Which data finding would the nurse promptly report to the health care provider?
1.Elevated AST and ALT levels
When caring for a client started on nitroglycerin, the nurse instructs the client to rest for 15 minutes after administration and to be aware that which of the following side effects may occur? Select all that apply.
1.Flushed feeling 2.Headache 3.Dizziness
When treating a client who presents with an acute myocardial infarction, which of the following treatments are considered a priority? Select all that apply
1.Giving nitrates 2.Providing 100% oxygen 3.Administering morphine
The nurse is admitting a client with long-term peripheral arterial occlusive disease. Which assessment data is consistent with this disorder?
1.Hairless skin on feet and toes 2.Dependent rubor 3.Deep painful ulcer of toe 4.Leg pain while ambulating
The nurse observes the client in ventricular tachycardia on the cardiac monitor. The client is found unresponsive and lacking a pulse. Which of the following is the treatment of choice?
1.Immediate use of an external defibrillator
After abdominal surgery a client suddenly reports heaviness to the right leg. The nurse notes that the right calf looks bigger than the left calf. What would the nurse do first?
1.Instruct the client to remain in bed and notify the health care provider.
A client who had a total knee replacement two days ago complains of an aching pain to the left leg. The nurse notes that the distal part of the left leg is warm, erythematous and swollen. Which action by the nurse is a priority?
1.Keep the client in bed with the left leg elevated.
The nurse receives orders for a client to be started on atorvastatin (Lipitor). When reviewing the client's past medical history, which condition would the nurse know is a contraindication for this medication.
1.Liver disease
The nurse is caring for a client with heart failure who is receiving furosemide (Lasix). Which interventions should the nurse include in the plan of care when caring for a client on this medication? Select all that apply.
1.Monitor intake and urine output 2.Monitor serum potassium levels 3.Monitor blood pressure
A client presents with severe chest pain unrelieved by three nitroglycerin pills. The nurse understands this client's pain is most likely from which underlying cause?
1.Myocardial ischemia or infarct may occur with blockages or constriction of coronary arteries
The nurse prepares to teach the client with mitral stenosis to avoid activities that increase the heart rate for which of the following reasons?
1.Narrowed valve restricts blood flow from left atrium to left ventricle
The nurse is conducting a health fair to a group of retired nurses with risk factors for coronary artery disease (CAD) including cigarette smoking. The nurse includes which of the following statements on how smoking contributes to the development and severity of CAD? Select all that apply
1.Nicotinic acid in tobacco causes coronary arteries to constrict reducing blood flow 2.Low-density lipoproteins could increase and high-density lipoproteins could decrease 3.Vascular endothelial damage could occur and lead to thrombus formation
The nurse is caring for a client who has right-sided heart failure. Which of the following assessment findings are consistent with this disorder? Select all that apply
1.Nocturia 2.Sacral edema 3.Liver tenderness 4.Fatigue and weakness
The nurse is completing a preoperative assessment on a female client who is scheduled for kidney surgery. Which of the following findings increases the client's risk for deep vein thrombosis? Select all that apply:
1.Obesity 2.Damage to blood vessels 3.Blood pooling in the extremities 4.Crosses legs when sitting
The client asks the nurse how to tell the difference between chest pain from angina or myocardial infarction. Which of the following factors should the client understand is characteristic of stable angina?
1.Pain is typically relieved by rest or nitroglycerin
The client complains of chest pain that worsens when taking a deep breath or ambulating. The nurse asks the client to lean forward and then auscultates the left sternal edge of the fourth intercostal space. Which complication is the nurse assessing the client for?
1.Pericarditis
The client receiving heparin sodium by intravenous (IV) infusion pump following hip replacement surgery begins to vomit coffee-ground emesis. After stopping the infusion, the nurse prepares to administer which of the following medications?
1.Protamine sulfate
The nurse is caring for a client with severe bradycardia and frequent syncopal episodes. The client complains of being too tired to get out of bed or eat. Which of the following is the priority nursing diagnosis?
1.Reduced cardiac output 1.A decrease in cardiac output may result in dizziness, fatigue, chest pain, and palpitations
Metoprolol (Lopressor) is prescribed for a client. The nurse should hold the medication if the client presents with which of the following findings?
1.Sinus bradycardia
The nurse is caring for a client who had an open reduction internal fixation two days ago to repair a right hip fracture. The nurse is concerned that the client may have developed a deep vein thrombosis. Which of the following clinical manifestations best supports the diagnoses.
1.Swelling to the right calf
The client with hyperlipidemia is started on cholestyramine (Questran). Which of the following instructions should the nurse include in the teaching plan?
1.Take medications 1 hour before or 4 hours after Questran
Several clients on a surgical unit have had surgery. Who should the nurse see first after receiving report?
1.Two-days post-operative client with swelling and tenderness in left calf when ambulating
The nurse is preparing a client who had a prosthetic valve replacement for discharge. Which of the following suggestions for preventing complications should be included in the discharge instructions?
1.You will need prophylactic antibiotics before invasive procedures
A nurse in the emergency department is assigned to care for four clients with serious health problems. Which health problem should the nurse identify as the priority?
A client who is having ventricular fibrillations (Ventricular fibrillation causes ineffective quivering of the ventricles and is not compatible with life )
The client returns from surgery for an abdominal aneurysm repair. The client has a history of peripheral vascular disease. Which situation would alert the nurse to a potential complication?
A pedal pulse of + 1 bilaterally
The nurse is completing an assessment on a client with a weak, thready pulse. Which of the following is the priority nursing diagnosis for this client?
A weak thready pulse typically suggests a decrease in cardiac output
The nurse identifies the client as unresponsive. What is the nurse's next priority action?
Activate emergency response team
The nurse is completing an assessment on a client with crushing retrosternal pain with radiation to the neck and jaw. Which nursing diagnosis is the priority?
Acute pain related to ischemic myocardial tissue
The client is scheduled to receive propranolol (Inderal). Which of the following clinical assessment findings would prompt the nurse to hold the scheduled dose of Inderal and contact the health care provider?
Apical pulse 56
When applying compression stockings to a post-surgical client, the nursing actions include which of the following?
Apply compression stockings with legs elevated prior to getting out of bed (Apply compression stockings prior to the patient getting out of bed and remove at night)
A client with a history of atherosclerosis presents to the emergency department and complains of abdominal pain and a hard mass. The nurse should anticipate which of the following conditions?
Atherosclerosis increases the risk for aortic aneurysm
The nurse is providing an inservice for new nurses who working on a telemetry unit. The nurse plans to discuss murmurs and includes which of the following facts about heart sounds.
Atrioventricular (tricuspid and mitral) and semilunar valves (pulmonic and aortic) create the heart sound "lub-dub" and maintain blood flow through the heart in one direction
Prior to administering the client's scheduled dose of hydrochlorothiazide (Microzide), nursing actions include assessment of which of the following? Select all that apply.
Basic metabolic profile Blood pressure
A client's diet is modified to eliminate foods that act as cardiac stimulants. What should the nurse teach this client to avoid? (Select all that apply.)
Black tea, Hot chocolate, Caffeinated energy drinks (Exercise, fever, and catecholamines increase sympathetic stimulation and could result in dysrhythmias)
The nurse is preparing to give isosorbide dinitrate (Isordil) to a client. Which of the following is the priority nursing assessment before the nurse gives the scheduled dose?
Blood pressure
The nurse is caring for a client with chronic venous insufficiency. Which assessment finding is consistent with this disorder?
Brown discolored skin to legs; 1.Peripheral vascular disease is marked by an inability of arterial blood flow to meet the oxygen demand of tissue in the periphery or an impaired ability to bring venous blood flow back to the heart
The nurse is preparing to administer atropine. Which action should the nurse perform prior to administering the medication?
Check heart rate; Atropine (an anticholinergic) is given to block vagal stimulation and increase heart rate during sinus bradycardia
A client who had an echocardiogram just returned to the unit. The echocardiogram showed an increase in the amount of pericardial fluid. The nurse would assess for which of the following clinical manifestations? Select all that apply.
Chest pain Tachypnea Oliguria Dsypnea
The nurse is providing discharge teaching to a client with a history of myocardial infarction who is being sent home on metoprolol. Which of the following instructions has the highest priority?
Continue taking lopressor as prescribed; Worsening angina or myocardial infarction could occur if beta blockers are stopped abruptly
The nurse is caring for a client admitted to the hospital with an abdominal aortic aneurysm. The client admits to smoking two packs of cigarettes each day for over 10 years. Which intervention should the nurse give the highest priority?
Controlling blood pressure is a priority action for an aneurysm
When assessing the heart rate of a client , the nurse uses which of the following methods to measure the number of heartbeats per minute?
Count the number of R waves in 6 seconds, multiply by 10 (Assess heart rate by counting the R-R intervals in 6 seconds and multiply by 10 or count the number of large boxes within the R-R interval and divide 300 by that number)
Which nursing diagnosis is a priority when planning the care for a client with a cardiac dysrhythmia?
Decreased cardiac output (A priority action in the setting of dysrhythmias is to maintain cardiac output)
Surgical procedures could increase a client's risk for complications. When developing a plan of care for a client who had surgery to the vertebral column, the nurse understands that the client has the greatest risk for which of the following complications?
Deep vein thrombosis (Stress increases the risk for hypercoagulation! ; Virchow's triad consists of three risk factors for venous thromboembolism, venous stasis, blood vessel damage, altered coagulation)
The client presents to the emergency department (ED) with crushing substernal chest pain. During the admission process, the client complains of feeling dizzy and then falls to the floor. What is the nurse's next action?
Determine if conscious
When teaching disease management for a client with peripheral vascular disease, which of the following actions should the nurse recommend to the client to help prevent complications from arterial insufficiency?
Do not elevate your legs above the level of your heart (Elevating the legs promotes venous return but is contraindicated with arterial insufficiency)
What is the best rationale for obtaining the automatic external defibrillator (AED) as quickly as possible during a cardiac arrest event?
Early defibrillation by the AED is key to enhancing survival from cardiac arrest
Which of the following clinical assessment findings would prompt the nurse to suspect cardiac tamponade in the client recovering postoperatively from aortic valve replacement? Select all that apply
Elevated central venous pressure (CVP) reading Jugular vein distention Apical pulse 140
A client who has osteoarthritis complains of increased shoulder pain. Which of the following findings best supports inflammation?
Elevated serum C-reactive protein
The nurse teaches a 72-year-old, African American, obese male client with coronary artery disease (CAD) and hypertension about lifestyle modifications. Which of the following are considered modifiable risk factors? Select all that apply.
His weight His diet
When caring for a client with angina, the nurse recognizes the priority nursing intervention is to achieve which of the following outcomes?
Increase oxygen level
The nurse is preparing to administer enalapril to a client who had a myocardial infarction. The nurse understands the primary purpose for enalapril is to
Increase sodium excretion; Angiotensin converting enzymes decrease myocardial infarction mortality by inreasing sodium and fluid excretion and lowering blood pressure which decreases oxygen demand
A 66-year old female reports to the emergency room and is diagnosed with an aortic aneurysm. The nurse assess for which of the following clinical manifestations when determining if the aneurysm has ruptured? Select all that apply
Increased back pain, Drop in blood pressure, Decrease in hematocrit (Severe back pain or abdominal pain, falling blood pressure, and a drop in the hematocrit suggest the aneurysm has ruptured)
When caring for a client following a coronary artery bypass graft surgery, which of the following clinical assessments is suggestive of cardiac tamponade? Select all that apply.
Jugular vein distention. Hypotension. Lightheadedness
A client who had a percutaneous transluminal coronary angioplasty (PTCA) performed just returned to the unit. Which of the following assessment findings suggest complications related to the procedure? Select all that apply.
Large hematoma to groin +3 pedal pulse Patients are at risk for vasospasms, lethal dysrhythmias or cardiac arrest during percutaneous coronary interventions, bleeding and arterial occlusion could occur following the procedure
The nurse is caring for a client who had an acute myocardial infarction. The nurse auscultates crackles bilaterally. Which of the following is consistent with this assessment finding?
Left-sided heart failure
The nurse is assessing the neurovascular status of a client who has just returned from having a cardiac catheterization where the right femoral artery was used. Which action performed by the nurse is appropriate?
Lightly palpate the pulses in the right lower extremity (1.Assess pulses using light palpation)
The nurse is interpreting the electrocardiogram (ECG) rhythm on a client presenting to the emergency department (ED). The nurse notes the presence of Q waves on the ECG strip. The nurse understands that Q waves suggest which of the following?
Myocardial Infarction
A client with a history of coronary artery disease has an order for a vasoconstrictor. The nurse should give highest priority to preventing which of the following complications?
Myocardial infarction
The client presents to the emergency department (ED) with a complaint of indigestion unrelieved by antacids. The nurse concludes that the client may be experiencing a myocardial infarction (MI) based on which of the following findings? Select all that apply:
Nausea SOB at rest anxiety and fear
A client develops a deep vein thrombosis following a total hip replacement and is placed on a continuous heparin infusion. The client has an order for hydromorphone 2mg intramuscular injection every 6 hours for pain. Which of the following actions would the nurse implement?
Obtain an order to change the route of the demerol (Bleeding is a key complication of anticoagulant therapy)
The laboratory calls to report a client's serum potassium level is 6.5 mEq/L. Which of the following findings on the client's electrocardiogram (ECG) is consistent with the client's potassium level?
Potassium is the ion for repolarization (membranes reset). Tall tented t waves occur with hyperkalemia and inverted t waves occur with hypokalemia
The nurse assesses a client who has been prescribed furosemide (Lasix). Which change in the electrocardiogram is consistent with adverse effects from Lasix?
Presence of a U wave; On an EKG, the p wave represents atrial depolarization, the QRS represents ventricular depolarization, the T wave represents ventricular repolarization, the ST segment indicates early ventricular repolarization, U wave is sometimes seen in the setting of hypokalemia
Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?
Protamine sulfate (Prepare to administer vitamin K for coumadin toxicity or protamine sulfate for heparin toxicity)
The client with an anterior wall myocardial infarction (AWMI) is transferred to the cardiovascular intensive care unit. When assessing the client's hemodynamic status, which finding should the nurse report immediately?
Pulmonary Arterty Wedge Pressure (PAWP) 15mm/Hg
A client presents to the emergency department with complaints of chest pain and shortness of breath. The laboratory calls to report an elevated D-dimer. The nurse knows that this test is done to rule out which of the folowing conditions?
Pulmonary embolism A blood D-dimer assay detects if clotting or fibrinolysis is occuring and is used to screen to screen for pulmonary embolism
A client with a history of chronic renal failure presents to the emergency (ED) department with chest pain. The client denies going to hemodialysis for one week. The client's EKG shows peak T waves, and the nurse notices a potassium level of 7.8 mEq/dL. Which action should the nurse take next?
Report diagnostic findings to the physician immediately;1.Cardiac arrest is more likely with hyperkalemia
A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. Which of the following clinical findings require the nurse to notify the practitioner?
Right-sided chest discomfort 4 days postoperatively (Cancer, pregnancy, immobility and clotting disorders increase the risk for deep vein thrombosis and pulmonary embolism)
A client presents with severe chest pain unrelieved by rest or nitroglycerin. The nurse suspects acute myocardial infarction (AMI) when the electrocardiogram (ECG) shows which of the following abnormalities?
ST segment elevation
The nurse is caring for a client with left-sided heart failure who's condition is worsening. Which of the following symptoms should the nurse interpret as clinical manifestations of right-sided heart failure? Select all that apply:
Scrotal edema Jugular vein distention Hepatomegaly
The nurse is caring for a client with chest pain. The electrocardiogram shows ST segment elevation, and the laboratory department calls in an elevated troponin I. The nurse is preparing to administer tissue plasminogen activator. The nurse should monitor the client for which of the following complications?
Signs of bleeding; Bleeding is a significant risk when using thrombolytic therapy
The nurse is caring for a client who had a cocaine overdose. The nurse anticipates which dysrhythmia would be consistent with this situation?
Sinus Tachycardia; Illicit drugs like amphetamines and cocaine can increase the heart rate and lead to dysrhythmias
The nurse recognizes that which of the following laboratory tests may be ordered as part of a screening to identify clients at risk for heart attack or stroke?
Substances (homocysteine) that damage the endothelial lining of afteries increase the risk for thrombus formation and lead to stroke, coronary artery disease and peripheral vascular disease
The nurse is caring for a client diagnosed with heart failure. The client wants to know why an echocardiogram is being done. Which statement by the nurse is most appropriate?
The echocardiogram shows the direction of blood flow through the chambers, the heart size, shape, ventricular function and ejection fraction
