MED SURG chapters 36,37,38 & 40
The nurse is concerned that an older adult client with heart failure is developing pulmonary edema. What manifestation alerts the nurse to further assess the client for this complication? a. Confusion b. Dysphagia c. Sacral edema d. Irregular heart rate
A
A client with pericarditis is admitted to the cardiac unit. What assessment finding does the nurse expect in this client? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regularly gallop rhythm d. Coarse crackles in bilateral lung bases
B
A client with systolic dysfunction has an ejection fraction of 38%. The nurse assesses for which physiologic change? a. Increase in stroke volume b. Decrease in tissue perfusion c. Increase in oxygen saturation d. Decrease in arterial vasoconstriction
B
A client is admitted with early-stage heart failure. Which assessment finding does the nurse expect? a. A decrease in blood pressure and urine output b. An increase in creatinine and extremity edema c. An increase in heart rate and respiratory rate d. A decrease in respirations and oxygen saturation
C
The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management? a. Pedal edema is not present in the lower legs. b. No complaints of sexual dysfunction occur. c. No indication of renal impairment is present. d. The blood pressure reading is 148/94 mm Hg.
C
The nurse is caring for a client with peripheral arterial disease. What priority nursing intervention does the nurse perform to promote vasodilation? a. Increase the client's exercise regimen daily. b. Apply a heating pad to the affected limb. c. Administer an aspirin on a daily basis. d. Educate the client to abstain from smoking.
D
A nurse notes that the PR interval on a client's electrocardiograph (ECG) tracing is 0.14 second. What action does the nurse take? a. Assess serum cardiac enzymes. b. Administer 1 mg epinephrine IV. c. Administer oxygen via nasal cannula. d. Document the finding in the client's chart.
D
The nurse is monitoring a client who has returned to the unit after arterial revascularization. The client reports pain in the affected limb that is similar to the pain experienced before the procedure. What is the nurse's best action? a. Assess the peripheral pulses in the limb. b. Elevate the affected extremity on pillows. c. Administer pain medication as prescribed. d. Place a warm blanket on the operative limb.
A
The nurse is providing care to a client with infective endocarditis. What infection control precautions does the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation
A
A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
A
A client's cardiac status is being observed by telemetry monitoring. The nurse observes a P wave that changes shape in lead II. What conclusion does the nurse make about the P wave? a. It originates from an ectopic focus. b. The P wave was replaced by U waves. c. It is from the sinoatrial (SA) node. d. Multiple P waves are present.
A
The nurse is recovering a client with peripheral arterial disease who has just undergone percutaneous transluminal angioplasty. What complication does the nurse monitor for in the immediate postprocedure period? a. Bleeding b. Aspiration c. Hypertensive crisis d. Chest pain
A
A client's electrocardiograph (ECG) tracing shows a run of sustained ventricular tachycardia. What is the nurse's first action? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).
A
An older adult client is admitted with fluid volume excess. Which diagnostic study does the nurse facilitate as a priority? a. Echocardiography b. Chest x-ray c. T4 and thyroid-stimulating hormone (TSH) d. Arterial blood gas
A
An older adult client with heart failure states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? a. "Would you like to talk about this more?" b. "You're lucky to have such a devoted daughter." c. "You must feel as though you are a burden." d. "Would you like an antidepressant medication?"
A
The nurse assesses a client and notes the presence of an S3 gallop. What is the nurse's best intervention? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.
A
The nurse incorporates dietary teaching into the plan for a client with a low-density lipoprotein (LDL) level of 158 mg/dL. What dietary instruction by the nurse is most appropriate? a. "You should keep your saturated fat intake below 10% of your total calories." b. "This result is normal, so continue your current dietary practices." c. "Your total cholesterol intake should be less than 300 mg/day." d. "You should restrict protein sources to fish and chicken only."
A
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? a. Middle-aged woman with aortic stenosis b. Middle-aged man with pulmonary hypertension c. Older woman who smokes cigarettes daily d. Older man who has had a myocardial infarction
A
The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions? a. "I will give my canned soups to the food pantry." b. "I'm going to miss my evening glass of wine." c. "I will mostly use salt substitutes for flavoring." d. "I can have regular coffee only in the morning."
A
The nurse is caring for a client with severe heart failure. What is the best position in which to place this client? a. High Fowler's, pillows under arms b. Semi-Fowler's, with legs elevated c. High Fowler's, with legs elevated d. Semi-Fowler's, on the left side
A
A client asks the nurse why it is important to be weighed every day if he has right-sided heart failure. What is the nurse's best response? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. "The hospital requires that all inpatients be weighed daily." d. "You need to lose weight to decrease the incidence of heart failure."
A
A client experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. What instruction does the nurse include in the client's teaching plan? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take quinidine (Cardioquin) daily to prevent PACs."
A
A client has an epicardial pacemaker. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiograph (ECG) tracing. How does the nurse interpret this event? a. Loss of capture b. Ventricular fibrillation c. Failure to sense d. A normal tracing
A
A client has been admitted to the acute care unit for an exacerbation of heart failure. Which is the nurse's priority intervention? a. Assess respiratory status. b. Monitor electrolyte levels. c. Administer intravenous fluids. d. Insert a Foley catheter.
A
A client in severe heart failure has a heparin drip infusing. The health care provider prescribes nesiritide (Natrecor) to be given intravenously. Which intervention is essential before administration of this medication? a. Insert a separate IV access. b. Prepare a test bolus dose. c. Prepare the piggyback line. d. Administer furosemide (Lasix) first.
A
A client is experiencing sinus bradycardia with hypotension and dizziness. What medication does the nurse administer? a. Atropine (Atropine) b. Digoxin (Lanoxin) c. Lidocaine (Xylocaine) d. Metoprolol (Lopressor)
A
A client with a history of myocardial infarction calls the clinic to report the onset of a cough that is troublesome only at night. What direction does the nurse give to the client? a. "Please come into the clinic for an evaluation." b. "Increase your fluid intake during waking hours." c. "Use an over-the-counter cough suppressant." d. "Sleep on two pillows to facilitate postnasal drainage."
A
A client with heart failure is due to receive enalapril (Vasotec) and has a blood pressure of 98/50 mm Hg. What is the nurse's best action? a. Administer the Vasotec. b. Recheck the blood pressure. c. Hold the Vasotec. d. Notify the health care provider.
A
A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? a. Place the client in a high Fowler's position. b. Perform nasotracheal suctioning of the client. c. Auscultate the client's heart and lung sounds. d. Place the client on a 1000 mL fluid restriction.
A
A client with heart failure is prescribed enalapril (Vasotec). What is the nurse's priority teaching for this client? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily."
A
A client with hypercholesterolemia and atherosclerosis is prescribed nicotinic acid (Niaspan). Which instruction does the nurse provide the client? a. "This medication may make you flush." b. "Take this medication on an empty stomach." c. "You will not need to change your diet with this medication." d. "Take this medication when you experience chest pain."
A
A client with ischemic heart disease has an electrocardiograph (ECG) tracing that shows a PR interval of 0.24 second. What is the nurse's best action? a. Document the finding in the chart. b. Measure blood pressure. c. Notify the health care provider. d. Administer oxygen.
A
The nurse is working with clients at a health fair. Which teaching takes priority to reduce the risk of atherosclerosis? a. Instructing a diabetic client not to smoke or use any tobacco b. Teaching diet changes to a client with elevated cholesterol levels c. Suggesting limiting alcohol to an older client with hypolipidemia d. Encouraging exercise to an obese client who lives a sedentary lifestyle
A
The nurse is evaluating the laboratory results for a client with heart failure. What results does the nurse expect? (Select all that apply.) a. Hematocrit (Hct), 32.8% b. Serum sodium, 130 mEq/L c. Serum potassium, 4.0 mEq/L d. Serum creatinine, 1.0 mg/dL e. Proteinuria f. Microalbuminuria
A, B, E, F
The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. S3/S4 summation gallop f. Cough worsens at night
A,B,E,F
A client has a consistently regular heart rate of 128 beats/min. Which related physiologic alterations does the nurse assess for? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Increase in blood pressure d. Decrease in blood pressure e. Increase in urine output
A,D
A client with unstable ventricular tachycardia is receiving amiodarone by intravenous infusion. The nurse notes that the client's heart rate has decreased from 68 to 50 beats/min. The client is asymptomatic. What is the nurse's priority intervention? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer a precordial thump. d. Place the client in a side-lying position.
B
A client has a heart rate averaging 56 beats/min with no adverse symptoms. What activity modifications does the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm (100° F)." b. "Avoid bearing down or straining while having a bowel movement." c. "Avoid strenuous exercise, such as running, during the late afternoon." d. "Limit your intake of caffeinated drinks to no more than 2 cups per day."
B
A client has been diagnosed with Cushing's syndrome. What assessment does the nurse perform to detect vascular complications associated with this illness? a. Auscultation of heart and lung sounds b. Assessment of blood pressure c. Daily weight using the same scale d. Monitoring of urine output every 24 hours
B
A client is being discharged home after a heart transplant with a prescription for cyclosporine (Sandimmune). What priority education does the nurse provide with the client's discharge instructions? a. "Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick." c. "Change positions slowly to avoid hypotension." d. "Check your heart rate before taking the medication."
B
A client was admitted for a permanent pacemaker insertion. What priority instruction does the nurse include in the client's discharge teaching? a. "Do not submerge your pacemaker, take only showers." b. "Report pulse rates lower than your pacemaker setting." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having an MRI."
B
A client who has had a prosthetic valve replacement asks the nurse why he must take anticoagulants for the rest of his life. What is the nurse's best response? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves." c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs."
B
A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. What is the nurse's interpretation of this information? a. The aneurysm clotted and is obstructing blood flow. b. The aneurysm is expanding and is preparing to rupture. c. The client feels the inflammation of the aneurysm. d. This is a normal sensation associated with an AAA.
B
A client with hyperlipidemia who is being treated with dietary fat restrictions and an exercise program asks the nurse why his serum lipid levels are still elevated. What activity by the nurse is most appropriate? a. Developing a very low-fat diet that the client will adhere to b. Explaining familial tendencies in hyperlipidemia c. Referring the client to a registered dietitian for weight loss d. Educating the client on antihyperlipidemic medications
B
A client with myocardial ischemia is having frequent early, wide ventricular complexes seen on the cardiac monitor. Which medication does the nurse administer? a. Lanoxin (Digoxin) b. Amiodarone (Cordarone) c. Dobutamine (Dobutamine) d. Atropine sulfate (Atropisol)
B
A client with ventricular tachycardia (VT) is unresponsive and has no pulse. The nurse calls for assistance and a defibrillator. What is the nurse's priority intervention while waiting for the defibrillator to arrive? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation. c. Start an 18-gauge IV in the antecubital. d. Ask the client's family about code status.
B
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention? a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.
B
The nurse is administering captopril (Capoten) to a client with heart failure. What is the priority intervention for this client? a. Administer this medication before meals to aid absorption. b. Instruct the client to ask for assistance when arising from bed. c. Give the medication with milk to prevent stomach upset. d. Monitor the potassium level and check for symptoms of hypokalemia.
B
The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath."
B
The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with? a. Diabetic foot ulceration b. Peripheral arterial disease c. Peripheral venous disease d. Deep vein thrombosis
B
The nurse is assessing a client with a history of heart failure. What priority question assists the nurse to assess the client's activity level? a. "Do you have trouble breathing or chest pain?" b. "Are you able to walk upstairs without fatigue?" c. "Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?"
B
The nurse is assessing clients at a community clinic. Which client does the nurse assess most carefully for atrial fibrillation? a. Middle-aged client who takes an aspirin daily b. Client who is dismissed after coronary artery bypass surgery c. Older adult client after a carotid endarterectomy d. Client with chronic obstructive pulmonary disease
B
The nurse is assisting the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client? a. Cheese omelet, skim milk, whole wheat toast, coffee b. Skim milk, oatmeal, banana, orange juice, coffee c. Whole wheat French toast, a side of bacon, coffee d. Blueberry muffin, orange juice, decaffeinated coffee
B
The nurse is caring for a client with atrial fibrillation. What manifestation most alerts 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
The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Atropine) d. Lidocaine (Xylocaine)
B
The nurse is caring for a client with mitral valve stenosis. What clinical manifestation alerts the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
B
The nurse is discharging a client home following mitral valve replacement. What statement indicates that the client requires further education? a. "I will be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by the dentist in 2 weeks." c. "I will avoid eating foods high in vitamin K, like spinach." d. "I will use an electric razor instead of a straight razor to shave."
B
The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? a. "Walk until you become short of breath and then walk back home." b. "Gather everything you need for a chore before you begin." c. "Pull rather than push or carry items heavier than 5 pounds." d. "Take a walk after dinner every day to build up your strength."
B
The nurse is providing discharge instructions for a client with an implantable cardioverter-defibrillator (ICD). What statement by the client indicates a good understanding of the instructions? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I can't perform activities that increase my heart rate." d. "Now I can discontinue my antidysrhythmic medication."
B
The nurse is reviewing the menu selections of a client who has ordered a low-cholesterol diet. What meal items does the nurse question? a. Vegetarian wrap b. Cheesesteak sandwich c. Fruit salad with yogurt d. Grilled fish sandwich
B
The nurse notes that the client's apical pulse is displaced to the left. What conclusion can be drawn from this assessment? a. This is a normal finding. b. The heart is hypertrophied. c. The left ventricle is contracted. d. The client has pulsus alternans.
B
The nurse observes a prominent U wave on the client's electrocardiograph (ECG) tracing. What is the most appropriate action for the nurse to take? a. Document the finding as a normal variant. b. Review the client's daily electrolyte results. c. Move the crash cart closer to the client's room. d. Call for an immediate electrocardiogram.
B
A client is recovering after an embolectomy. What clinical manifestations consistent with compartment syndrome does the nurse watch for? a. Elevated temperature and excessive diaphoresis b. Loss of sensation and pallor near the surgical site c. Swelling, pain, and tension of the affected limb d. Increased pulse and warmth below the surgical site
C
A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurse's best response? a. "Injury to the arteries causes them to spasm, reducing blood flow to the extremities." b. "Excess fats in your diet are stored in the lining of your arteries, causing them to constrict." c. "A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow." d. "Excess sodium causes injury to the arteries, reducing blood flow and eventually causing obstruction."
C
A client with chronic peripheral arterial disease and claudication tells the nurse that burning pain often awakens him from sleep. What is the nurse's interpretation of this change? a. The client has inflow disease. b. The client has outflow disease. c. The client's disease is worsening. d. The client's disease is stable.
C
A client with high cholesterol is beginning treatment with simvastatin (Zocor). What priority instruction does the nurse give this client? a. "Increase your intake of dietary fiber to minimize constipation." b. "Take this drug on an empty stomach to promote absorption." c. "Report any muscle tenderness to your health care provider." d. "You may experience flushing of the skin with this medication."
C
A client with third-degree heart block is admitted to the telemetry unit. The nurse observes wide QRS complexes on the monitor with a heart rate of 35 beats/min. What priority assessment does the nurse perform? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
C
A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention? a. Take the client's apical pulse for 1 full minute before drug administration. b. Place the client in Trendelenburg position to facilitate blood flow to the heart. c. Educate the client to sit on the side of the bed for a few minutes before rising. d. Instruct the client to drink 3 L of fluid daily when taking this medication.
C
The client's heart rate increases slightly during inspiration and decreases slightly during expiration. What action does the nurse take? a. Evaluate for a respirator disorder. b. Assess the client for chest pain. c. Document the finding in the chart. d. Administer antidysrhythmic drugs.
C
The nurse has administered adenosine (Adenocard). What is the expected therapeutic response? a. Increased intraocular pressure b. A brief tonic-clonic seizure c. A short period of asystole d. Hypertensive crisis
C
The nurse is assessing a client in an outpatient clinic. Which client statement alerts the nurse to possible left-sided heart failure? a. "I have been drinking more water than usual." b. "I have been awakened by the need to urinate at night." c. "I have to stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."
C
The nurse is assessing a client's understanding of his hypertension therapy. What client statement indicates a need for further teaching? a. "If I lose weight, I might be able to reduce my blood pressure medication." b. "If my blood pressure stays under control, I will reduce my risk for a heart attack." c. "When my blood pressure is normal, I will no longer need to take medication." d. "When getting out of bed in the morning, I will sit for a few moments then stand."
C
The nurse is assessing the client's electrocardiography (ECG). What does the P wave on the ECG tracing represent? a. Contraction of the atria b. Contraction of the ventricles c. Depolarization of the atria d. Depolarization of the ventricles
C
The nurse is caring for a client admitted for myocardial infarction. The client's monitor shows frequent premature ventricular contractions (PVCs). What dysrhythmia does the nurse remain alert for? a. Sinus tachycardia b. Rapid atrial flutter c. Ventricular tachycardia d. Atrioventricular junctional rhythm
C
The nurse is caring for a client diagnosed with aortic stenosis. What assessment finding does the nurse expect in this client? a. Bounding arterial pulse b. Slow, faint arterial pulse c. Narrowed pulse pressure d. Elevated systolic pressure
C
The nurse is caring for a client on a cardiac monitor. The monitor shows a rapid rhythm with a "saw tooth" configuration. What physical assessment findings does the nurse expect? a. Presence of a split S1 and wheezing b. Anorexia and gastric distress c. Shortness of breath and anxiety d. Hypertension and mental status changes
C
The nurse is caring for a client with a complete heart block (third-degree atrioventricular [AV] block). What is the nurse's priority intervention? a. Perform a cardioversion. b. Assist with carotid massage. c. Begin external pacing. d. Administer adenosine (Adenocard) IV.
C
The nurse is caring for a client with a temporary pacemaker. The client's bedside monitor shows a spike followed by a QRS complex. What is the nurse's best action? a. Remove the pacemaker; it is not needed. b. Decrease the threshold of the pacemaker. c. Document the finding in the client's chart. d. Set the pacemaker to the synchronous mode.
C
The nurse is providing care for a client with hypertension. What priority physical assessment does the nurse include in examination of this client? a. Skin examination for telangiectasia b. Otoscopic examination of the inner ear c. Funduscopic examination of the retina d. Neurologic examination of the cranial nerves
C
The nurse is providing discharge education to a client with hypertrophic cardiomyopathy (HCM). What priority instruction will the nurse include? a. "Take your digoxin at the same time every day." b. "You should begin an aerobic exercise program." c. "You should report episodes of dizziness or fainting." d. "You may have only two alcoholic drinks daily."
C
The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client? a. Absence of hair on the left lower extremity b. Skin surrounding the ulcer mottled but blanchable c. Brownish discoloration of the lower extremity d. Cold and gray-blue lower extremity
C
The nurse reminds the client who has received a heart transplant to change positions slowly. Why is this instruction a priority? a. Rapid position changes can create shear and friction forces, which can tear out internal vascular sutures. b. The new vascular connections are more sensitive to position changes, leading to increased intravascular pressure. c. The new heart is denervated and is unable to respond to decreases in blood pressure caused by position changes. d. The recovering heart diverts blood flow away from the brain when the client stands, increasing the risk for stroke.
C
The physician is about to perform carotid sinus massage on a client with supraventricular tachycardia. What equipment is most important for the nurse to have ready? a. Emesis basin b. Magnesium sulfate c. Resuscitation cart d. Padded tongue blade
C
The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? a. Decrease in oxygen saturation from 98% to 95% b. Respiratory rate change from 22 to 28 breaths/min c. Systolic blood pressure change from 136 to 96 mm Hg d. Increase in heart rate from 86 to 100 beats/min
C
A client has been admitted to the intensive care unit with worsening pulmonary manifestations of heart failure. What is the nurse's best action? a. Place the client in a high Fowler's position. b. Begin cardiopulmonary resuscitation (CPR). c. Promote rest and minimize activities. d. Administer loop diuretics as prescribed.
D
A client is taking triamterene-hydrochlorothiazide (Dyazide) and furosemide (Lasix). What assessment finding requires action by the nurse? a. Cough b. Headache c. Pulse of 62 beats/min d. Potassium of 2.9 mEq/L
D
A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? a. "Avoid drinking more than 3 quarts of liquids each day." b. "Eat six small meals daily instead of three larger meals." c. "When you feel short of breath, take an additional diuretic." d. "Weigh yourself daily while wearing the same amount of clothing."
D
A client with atherosclerosis is attempting to stop cigarette smoking with the use of a nicotine patch. Which statement by the client indicates a good understanding of smoking cessation education? a. "Abruptly discontinuing this patch can cause high blood pressure." b. "Abruptly discontinuing this patch can cause nausea and vomiting." c. "Smoking while using this patch increases the risk of respiratory infection." d. "Smoking while using this patch increases the risk of a heart attack."
D
A client with end-stage heart failure is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." What is the nurse's best response? a. "Would you like to speak with a priest or chaplain?" b. "I will consult a psychiatrist to speak with you." c. "Do you want to come off the transplant list?" d. "Would you like information about advance directives?"
D
After reviewing the client's chart upon admission to the unit, the nurse consults the health care provider about a new order for lovastatin (Mevacor). What triggered the nurse's action? a. Blood glucose of 182 mg/dL b. History of peptic ulcers c. History of high cholesterol d. Elevated liver enzymes
D
The client who just started taking isosorbide dinitrate (Imdur) reports a headache. What is the nurse's best action? a. Titrate oxygen to relieve headache. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen.
D
The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse? a. Measurement of abdominal girth b. Observation of abdominal wall movement c. Auscultation of any area of the abdomen d. Palpation of the abdominal midline area
D
The nurse identifies a client's rhythm to be a sustained supraventricular tachycardia. What medication does the nurse administer? a. Atropine (Atropine) b. Epinephrine (Adrenalin) c. Lidocaine (Xylocaine) d. Diltiazem (Cardizem)
D
The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating a client? a. Make sure the defibrillator is set to the synchronous mode. b. Deliver a precordial thump to the upper portion of the sternum. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that all personnel are clear of contact with the client and the bed.
D
The nurse is caring for a client who develops compartment syndrome after an embolectomy for peripheral arterial disease. What is the nurse's best action? a. Perform passive range-of-motion exercise to improve distal blood flow. b. Prepare the client for return to the operative suite for surgical correction. c. Medicate the client for pain and place the client in a knee-chest position. d. Loosen the dressing and elevate the extremity to the level of the heart.
D
The nurse is educating a client before a right leg atherectomy. What priority education does the nurse provide? a. "You may use the bathroom after the procedure." b. "You will be sedated for 6 hours after the procedure." c. "You will not need to take a daily aspirin anymore." d. "You may be on heparin during the procedure."
D
The nurse is obtaining the admission health history for a young adult who presents with fever, dyspnea, and a murmur. What priority data does the nurse inquire about? a. Family history of coronary artery disease b. Recent travel to Third World countries c. Pet ownership, especially cats with litter boxes d. History of a systemic infection within the past month
D
The nurse is recovering a client after insertion of an implantable cardioverter-defibrillator (ICD). What complication must the nurse intervene for immediately? a. 2/4 bilateral peripheral edema b. Heart rate of 56 beats/min c. Temperature of 96° F (35.5° C) d. Muffled heart sounds
D
The nurse is starting a client on digoxin (Lanoxin) therapy. What intervention is essential to teach this client? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min." d. "Do not take this medication within 1 hour of taking an antacid."
D
When analyzing a client's electrocardiograph (ECG) tracing, the nurse observes that not all QRS complexes are preceded by a P wave. What is the nurse's interpretation of this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
D
