MED SURG II HESI (Elsevier)

A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take? .

1. Continue to monitor the client.

A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial response? .

1. Focus on the client's feelings by exploring the reason why the question was asked.

The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in Vitamin K and that should be avoided. What should the nurse include on the list? (Select all that apply.)

1. Spinach 3. Broccoli

The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this occurs?

3. Neck vein distention

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is:

Elevate the head of the bed and obtain vital signs

During chest physiotherapy (CPT), a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next?

1. Interrupt the therapy.

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first? .

2. Instruct the client to remain in bed and notify the health care provider.

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state:

4. "I have trouble breathing when I walk rapidly

A client with arterial insufficiency of both lower extremities is visited by the home health care nurse. An essential nursing intervention is to teach the client to:

4. Check pulses in the legs regularly

The nurse is planning nutritional education for a client with lower extremity arterial disease (LEAD). What diet modifications should the nurse include?

4. Decreasing both cholesterol and saturated fat intake

A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: ."

4. Leakage of red blood cells through the vascular wall."

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis?

4. Put on elastic stockings before arising