MS Week 4 ATI

A systolic murmur

While auscultating a clients heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this findings as which of the following?

Provide information about how to reduce risk factors of hypertension.

A 46-year-old African American man is in an outpatient clinic for a physical examination. His bp is 126/84mm Hg, his BMI is 24, and he reports no previous medical problems Which of the following actions should the nurse take?

Carotid

A nurse is collecting data about a clients circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

25gtt/min

A nurse is preparing to administer 0.9% sodium chloride (NS) 100mL IV to infuse over 4hr. The drip factor of the manual IV tubing is 60gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?(Round the answer to the nearest whole number)

Check the clients respiratory rate and lung sounds.

During a change-of-shift report, a nurse sees that a clients IV bag of 0.9% sodium chloride has 900mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Two arteries and one vein

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborns umbilical cord?

Call the emergency response team.

A nurse enters a clients room and finds the client pulseless. The nurse knows the clients family has requested do-not-resuscitate(DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take?

Kale

A nurse in a clinic is reviewing teaching about food choices with a client who has recently begun taking warfarin. The nurse should instruct the client to limit combustion of which of the following foods?

Heart failure.

A nurse in a providers office is collecting data from a client who reports dyspnea and fatigue The nurse determines that the client also has tachycardia and edema. Which of the following disorders should the nurse suspect?

Exercise ECG stress test

A nurse is reviewing the prescription for a newly admitted client who is to undergo cardiac testing. For which of the following procedures should the nurse verify that the client has given written informed consent?

Cellular hypoxia

A nurse is caring for a client who has a hemoglobin of 10.8g/dL and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following?

located on the inner ankle, behind the malleolus(end of the tibia)

A nurse is monitoring a clients peripheral circulation. Identify where the nurse should palpate to check posterior tibial pulse?

Ventricular gallop

A nurse is collecting data about a clients cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

125mL/hr

A nurse is assisting with care of a client who has a prescription for 3,000mL of intravenous fluid over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

Atrial fibrillation

A nurse is assisting with collecting data on a client who is on a continuous ECG monitor. The clients ECG tracing shows no identifiable P waves and an irregular ventricular rate. The nurse should recognize the client is experiencing which of the following cardiac dysrhythmias?

Dyspnea

A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder?

"DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is assisting with the care of a client who has septic shock and is at risk for disseminated intravascular coagulation(DIC). Which of the following nursing statements indicates an understanding of the condition?

Protamine

A nurse is assisting with the care of a client who is receiving heparin by IV infusion. Which of the following medications should the nurse have available in the event of an overdose?

Stop the transfusion.

A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, "My heart is racing." The nurse notes that the clients face has become flushed, Which of the following actions should the nurse take first?

Prothrombin time (PT)

A nurse is caring for a client who has a new prescription for warfarin. The nurse should use the result of which of the following diagnostic test to monitor the effect of this therapy?

atropine

A nurse is caring for a client who has a prescription for metoprolol. The nurse measures the clients vital signs and notes that the clients apical heart rate is 49/min. The nurse should prepare to administer which of the following?

Vitamin K

A nurse is caring for a client who has been taking warfarin and has a prothrombin time of 30 seconds. Which of the following medications should the nurse anticipate the provider to prescribe?

Patent ductus arteriosus

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with the increased pulmonary blood flow?

Dysrhythmias

A nurse is caring for an older adult client who reports occasional constipation. The nurse should informs the client that straining while defecating can cause which of the following?

Drop in systolic BP more than 10mm Hg on inspiration.

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Count the apical pulsations for a full minute.

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Over the apex of the heart, at the anatomical landmarks of the 5th intercostal space and below the left nipple line 7.6cm(about 3in) to the left of the sternum.

A nurse is collecting a clients apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse.

The client uses garlic as a daily dietary supplement.

A nurse is collecting data from a client who has a prosthetic aortic valve and takes warfarin daily at bedtime. Which of the following data is the priority finding for the nurse to report to the provider?

Irregular

A nurse is collecting data from a client who has atrial fibrillation. When documenting the quality of the clients pulse, which of the following terms should the nurse use?

Drinking orange juice regularly

A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the clients heartburn?

Dyspnea on exertion

A nurse is collecting data from a client who has mitral stenosis. which of the following findings is a manifestation of this condition?

High white blood cell count(WBC)

A nurse is collecting data from a client who has osteomyelitis following a compound fracture of the right lower leg. Which of the following findings should the nurse expect?

Peripheral edema

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Displaced fundus from the midline

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings requires immediate intervention by the nurse?

Irregular pulsations

A nurse is collecting data from a client who is receiving continuous monitoring that is indicating premature ventricular contractions (PVCs). Which of the following findings should the nurse expect when assessing the client?

Digoxin

A nurse is collecting data from a client who reports a sudden onset of shortness of breath, fatigue, and dizziness. Electrocardiography indicates the client is experiencing atrial fibrillation. Which of the following medications should the nurse expect to administer?

Feverfew

A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell the client can increase anticoagulation effect and thus increase risk for bleeding?

Dyspnea

A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

Monitor daily weight

A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?

5.6mL

A nurse is preparing to administer amoxicillin 30mg/kg/day divided dose every 12hr to a toddler who weighs 33lb. Available is amoxicillin 200mg/5mL suspension. How many mL should the nurse administer every 12hr?(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)

"Try to remain still once I have attached the gel pads."

A nurse is preparing to perform a 12-lead electrocardiogram ECG. Which of the following instructions should the nurse provide to the client?

"I will eat cantaloupe for my morning snack."

A nurse is reinforcing discharge teaching with a client about dietary sources of potassium. Which of the following statements by the client indicates an understanding of the teaching?

A client who is African-American

A nurse is reinforcing health screening education with a group of client. The nurse should recognize that which of the following clients has greatest risk for hypertension?

The client should use an electric razor while on this medication.

A nurse is reinforcing teaching for a client who has a new prescription for warfarin. Which of the following information should the nurse include?

"This is a standardized test, so it eliminates the variations different laboratories report in prothrombin times."

A nurse is reinforcing teaching with a client who is taking warfarin about monitoring its therapeutic effect. The nurse should issue which of the following statements about the providers use of the international normalized ratio(INR)?

Soybean oil

A nurse is reinforcing teaching with a client who wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?

Atrial depolarization

A nurse is reinforcing teaching with a newly licensed nurse about reading a clients ECG tracing. The nurse should include in the teaching that the P wave represents which of the following cardiac electrical activities?

OT interval

A nurse is reinforcing teaching with a newly licensed nurse about reading a clients ECG tracing. The nurse should include in the teaching that which of the following ECG components represent the time it takes for ventricular depolarization and depolarization?

"This indicated turbulent blood flow through a valve."

A nurse is reinforcing teaching with an older adult client who has been newly diagnosed with a heart murmur. Which of the following statement should the nurse make?

Elevated T-cell count

A nurse is reviewing the laboratory report of a client who is receiving treatment for a high fever and viral infection. Which of the following findings should the nurse expect?