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A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation

A. Standard Precautions Pt w/ infective endocarditis does not pose a threat of transmitting the causative organism. Standard Precautions would be used; others not necessary.

The nurse working with oncology clients understands that interacting factors affect cancer development. Which factors does this include? (SATA) a. Exposure to carcinogens b. Genetic predisposition c. Immune function d. Normal doubling time e. State of euploidy

A, B, C The three interacting factors needed for cancer development are exposure to carcinogens, genetic predisposition, and immune function.

A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (SATA) a. A sore throat that does not heal b. Changes in menstrual patterns c. Indigestion or trouble swallowing d. Near-daily abdominal pain e. Obvious change in a mole f. Frequent indigestion

A, B, C, E, F The seven warning signs for cancer be remembered with acronym CAUTION: Changes in bowel or bladder habits; A sore throat that does not heal; Unusual bleeding or discharge; Thickening or lump in the breast or elsewhere; Indigestion or difficulty swallowing; Obvious change in wart or mole; and Nagging cough or hoarseness. Abdominal pain is not a warning sign.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (SATA) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue

A, B, C, F Clinical findings of heart transplant reject include: SOB, fatigue, fluid gain, abdominal bloating, new-onset bradycardia, HYPOtension, afib/aflutter, decreased activity tolerance, and decreased EF.

A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at GREATEST risk for the development of left-sided heart failure? a. A 36 year old woman with aortic stenosis b. A 42 year old man with pulmonary hypertension c. A 59 year old woman who smokes cigarettes daily d. A 70 year old man who had a cerebral vascular accident

A. A 36 yer old woman with aortic stenosis Cause of LV failure include mitral or aortic valve disease, CAD, and HTN. Pulmonary HTN and chronic cig smoking are risk factors for RV failure. A CVA does not increase risk of HF.

A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at GREATEST risk for the development of acute pericarditis? (SATA) a. 36 year old woman with systemic lupus erythematosus (SLE) b. 42 year old man recovering from coronary artery bypass graft surgery c. 59 year old woman recovering from a hysterectomy d. 80 year old man with a bacterial infection of the respiratory tract e. 88 year old woman with a stage III sacral ulcer

A, B, D Acute pericarditis most commonly associated with acute exacerbations of systemic connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the cardiac sac after cardiac surgery or a MI; and with infective organisms, including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and pressure injuries do not increase risk.

A nurse prepares to discharge a client who has heart failure. What questions would the nurse ask to ensure this client's safety prior to discharging home? a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? c. Will you be able to afford your oxygen therapy? d. What spiritual beliefs may impact your recovery? e. Are you able to accurately weigh yourself at home?

A, B, D, C & E??? To ensure safety upon discharge, the nurse would assess for structural barriers to functional ability, such as stairs. Nurse would assess pt's available social support (family, friends, home health services). Pt beliefs about and ability to adhere to meds and tx including daily weight would also be reviewed. Other q's do not specifically address pt safety upon discharge?

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (SATA) a. Pulmonary crackles b. Confusion c. Pulmonary hypotension d. Dependent edema e. Cough that worsens at night f. Jugular venous distension

A, B, E Left-sided HF occurs w/ decrease in contractility of heart or increase in afterload. Most signs will be in respiratory - crackles, confusion (decreased O2), and cough. RV HF = pulmonary hypotension, edema, and JVD.

A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (SATA) a. Hematocrit: 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 Hematocrit of 32.8% is low (should be 42.6) indicating dilutional ratio of RBCs to fluid (too much fluid). Serum sodium low bc hemodilution. Microalbuminuria and proteinuria are present, indicating decerase in renal filtration. These are early warning signs of decreased compliance of heart. K levels normal, creatinine normal.

A nurse collaborates with assistive personnel to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (SATA) a. Reposition the client every 2 hours b. Teach the client to perform deep-breathing exercises c. Accurately record intake and output d. Use the same scale to weigh the client each morning e. Place the client on oxygen if the client becomes short of breath

A, C, D The AP should reposition the client every 2 hours to improve oxygenation and prevent atelectasis. The AP can also accurately record intake/output, and use same scale to weigh pt each AM before breakfast. APs are not qualified to teach or asses the need for and provide O2 therapy.

A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (SATA) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS

A, C, E Management of obstructive HCM includes administering negative inotropic agents such as beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil). Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in pts with obstructive HCM. Strenuous exercise is also prohibited. Echo, radionuclide imaging, and angiocardiography during cardiac cath are performed to diagnose different cardiomyopathies. The CardioMEMS device is used with clients who have HF.

After teaching a client with congestive hear failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a CORRECT understanding of the teaching related to nutritional intake. (SATA) a. I'll read the nutritional labels on food items for salt content b. I will drink at least 3 L of water each day c. Using salt in moderation will reduce the workload of my heart d. I will eat oatmeal for breakfast instead of ham and eggs e. Substituting fresh vegetables for canned ones will lower my salt intake f. Salt substitutes are a good way to cut down on sodium in my diet

A, D, E Nutritional therapy for CHF focused on decreasing sodium and water retention to decrease heart workload. Pt taught to read labels, omit table salt and foods high in sodium (ham and canned foods), and limit water intake to a normal 2 L/day. Salt subs typically contain K so although not banned pt would have to have renal function and serum K monitored while using them - safer to avoid

The nurse learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (SATA) a. Differentiated function b. Large nucleus-to-cytoplasm ratio c. Loose adherence d. Nonmigratory e. Specific morphology f. Orderly and specific growth

A, D, E, F Normal cells have the characteristics of differentiated function, nonmigratory, specific morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and well-regulated growth.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure b. Document this as a normal finding c. Call the primary health care provider immediately d. Transfer the client to the intensive care unit

A. Assess for symptoms of left-sided heart failure The presences of an S3 gallop is an early diastolic filling sound indicative of increasing LV pressure and LV failure. The other actions are not warranted.

A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take FIRST? a. Assess the client's respiratory status b. Draw blood to assess the client's serum electrolytes c. Administer intravenous furosemide d. Ask the client about current medications

A. Assess the client's respiratory status Assessment of respiratory and oxygenation status is the most important nursing intervention for the prevention of complications. Monitoring electrolytes, administering diuretics ad asking about current meds are important but not as important.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is MOST important? a. Assessing the IV site and blood return every hour b. Educating the client on side effects c. Monitoring the client for nausea d. Providing warm packs for comfort

A. Assessing the IV site and blood return every hour Intravenous chemotherapy can cause local tissue destruction if it extravasates into the surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The most important intervention is prevention, so the nurse would check hourly to ensure the IV site is patent, or frequently depending on facility policy. Education and monitoring for side effects such as nausea are important for all clients receiving chemotherapy. Warm packs may be helpful for some drugs, whereas for others ice is more comfortable. The nurse would monitor the site and check for blood return to prevent injury from infiltration or extravasation.

A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. Avoid using salt substitutes b. Take your medication with food c. Avoid using aspirin-containing products d. Check your pulse daily

A. Avoid using salt substitutes ACE inhibitors such as enalapril inhibit excretion of potassium. Hyperkalemia can be a life threatening side effect, and clients should be taught to limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors do not need to be taken with food and have no impact on the pt's pulse rate. Aspirin is often prescribed with ACE inhibitors and is not contraindicated.

A client is receiving rituximab. What assessment by the nurse takes PRIORITY? a. Blood pressure b. Temperature c. Oral mucous membranes d. Pain

A. Blood pressure Rituximab can cause infusion-related reactions, including hypotension, so monitoring blood pressure is the priority. Other complications of this drug include fever with chills/rigors, headache and abdominal pain, shortness of breath, bronchospasm, nausea and vomiting, and rash. Assessing the client's temperature and for pain are both pertinent assessments, but do not take priority over the blood pressure. Oral mucous membrane assessment is important for clients with cancer, but are not specific for this treatment.

The nurse caring for oncology clients knows that which form of metastasis is the most common? a. Bloodborne b. Direct invasion c. Lymphatic spread d. Via bone marrow

A. Bloodborne Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads, although cancer can occur in the bone marrow.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is BEST? a. Call the client at home the next day to review teaching b. Give the client information about a cancer support group c. Provide all the preoperative instructions in writing d. Reassure the client that surgery will be over soon

A. Call the client at home the next day to review teaching Clients are often overwhelmed at a sudden diagnosis of cancer and may be more overwhelmed at the idea of a major operation so soon. This stress significantly impacts the ability to understand, retain, and recall information. The nurse would call the client at home the next day to review the teaching and to answer questions. The client may or may not be ready to investigate a support group, but this does not help with teaching. Giving information in writing is important (if the client can read it), but in itself will not be enough. Telling the client that surgery will be over soon is giving false reassurance and does nothing for teaching.

The nurse working with oncology clients understands that which age-related change increases the older client's susceptibility to infection during chemotherapy? a. Decreased immune function b. Diminished nutritional stores c. Existing cognitive deficits d. Poor physical reserves

A. Decreased immune function As people age, there is an age-related decrease in immune function, causing the older adult to be more susceptible to infection than other clients. Not all older adults have diminished nutritional stores, cognitive dysfunction, or poor physical reserves.

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The client is symptomatic but refuses blood transfusions. What medication does the nurse prepare to administer? a. Epoetin alfa b. Filgrastim c. Mesna d. Dexrazoxane

A. Epoetin alfa The client's hemoglobin is very low, so the nurse prepares to administer epoetin alfa, a colony-stimulating factor that increases the production of red blood cells. Filgrastim is for neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents. Dexrazoxane helps protect the heart from cardiotoxicity from other agents.

A nurse cares for an older adult client with heart failure. The client 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 BEST response by the nurse? a. I can stay if you would like to talk more about this b. You are lucky to have such a devoted daughter c. It is normal to feel as though you are a burden d. Would you like to meet with the chaplain?

A. I can stay if you would to talk more about this Depression can occur in pts with HF, esp older adults. Having pt talk about feelings will help focus on actual problem. Open-ended statements allow pt to respond safely and honestly. Other options minimize pt concerns and do not allow nurse to obtain more information to provide pt centered care.

The nurse has educated a client on precautions to take with thrombocytopenia. What statement by the client indicates a need to review the information? a. I will be careful if I need enemas for constipation b. I will use an electric shaver instead of a razor c. I should only eat soft food that is either cool or warm d. I won't be able to play sports with my grandkids

A. I will be careful if I need enemas for constipation The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers. This statement would indicate the client needs more information. The other statements are appropriate for the thrombocytopenic client.

A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is BEST? a. Maybe; preservatives, dyes, and preparation methods may be risk factors b. No; research studies have never shown those things to cause cancer c. There are other things you can do that will more effectively lower your risk d. Yes; preservatives and dyes are well known to be carcinogens

A. Maybe; preservatives, dyes, and preparation methods may be risk factors Dietary factors related to cancer development are poorly understood, although dietary practices are suspected to alter cancer risk. Suspected dietary risk factors include low-fiber intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say that other things can lower risk more effectively, but this does not give the client concrete information about how to do so, and also does not answer the client's question.

A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is MOST important? a. Request an order for serum electrolytes and uric acid b. Increase the client's IV infusion rate c. Instruct assistive personnel to strain all urine d. Administer an IV antiemetic

A. Request an order for serum electrolytes and uric acid This client's reports are consistent with tumor lysis syndrome, for which he or she is at risk due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures, and altered mental status. The nurse would notify the primary health care provider and request an order for serum electrolytes. Hydration is important in both preventing and managing this syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to strain the client's urine and the client may need an antiemetic, but first the nurse would assess the situation further by obtaining pertinent lab tests.

A nurse cares for a client with right-sided HF. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? 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 clients be weighed daily d. You need to lose weight to decrease the incidence of heart failure

A. Weight is the best indication that you are gaining or losing fluid Daily weights needed to document fluid retention or loss. 1 L of fluid = 2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other responses do not address the importance of monitoring fluid retention/loss.

A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (SATA) a. Teach the client about energy conservation techniques b. Ensure that the client is prescribed a beta blocker c. Document a discussion about advanced directives d. Confirm that a post-discharge nurse visit had been scheduled e. Consult a social worker for additional resources f. Care transition record transmitted to next level of care within 7 days of discharge

B, C, D, F National quality measures aim to decrease HF readmission by proper prep for discharge. These measures include: 1. beta blocker prescribed for LV dysfunction at discharge; 2. post-discharge follow-up appt scheduled w/in 7 days of discharge w/ documentation of location, date, and time; 3. care transition record transmitted to next level of care w/in 7 days of discharge; 4. documentation of discussion of advance directives/advance care planning with a HCP; 5. documentation of execution of advance directives w/in the medical record; and 6. post-discharge eval of pt for symptom assessment and tx adherence within 72 hours of discharge (by phone, office visit, home visit)

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (SATA) a. Demonstrating breast self-examinations to women b. Instructing people on the use of chemoprevention c. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer e. Teaching teens the dangers of tanning booths f. Educating adults about healthy eating habits

B, C, E, F Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer. Secondary prevention includes screening and early diagnosis. Primary prevention activities include teaching people about chemoprevention, providing approved vaccinations to prevent cancer, teaching teens the dangers of tanning beds, and educating adults on eating habits to reduce the risk of getting cancer. Breast examinations and screening for cervical cancer are secondary prevention methods.

A nurse learns that which of the following is the single biggest risk factor for developing cancer? a. Exposure to tobacco b. Advancing age c. Occupational chemicals d. Oncovirus infection

B. Advancing age The single biggest risk factor for developing cancer is advancing age. As one ages, immunity decreases and exposures increase. Tobacco use is the single most preventable cause of cancer. Exposure to chemicals and oncoviruses cause fewer cancers.

A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. Do you have trouble breathing or chest pain? b. Are you still 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. Are you still able to walk upstairs without fatigue? Pts with hx of HF generally have negative findings, such as SOB and fatigue. Nurse needs to determine whether pt's activity is same or worse, or whether pt identifies a decrease in activity level. Trouble breathing, chest pain, breathlessness at night, and peripheral edema are symptoms of HF but don't provide data that can determine extent of HF.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia

B. Atrial fibrillation Afib is a clinical manifestation of mitral valve regurg/stenosis. PVCs and bradycardia are not associated with valvular problems but usually identified in pts with electrolyte imbalances, MI, and sinus node problems. Sinus tach is a manifestation of aortic regurg due to decrease in CO.

A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? 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. Avoid large crowds and people who are sick Heart transplant pts must take immunosuppressant therapy for rest of life. Nurse would teach pt to avoid crowds and sick ppl to reduce risk of becoming ill. Meds do not place pt at risk for bleeding, orthostatic hypotension, or changes in HR. Orthostatic hypotension from the denervated heart is generally only a problem in immediate postop period.

A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. Walk until you become short of breath, then walk back home b. Begin walking 200 feet a day three times a week c. Do not lift heavy weights for 6 months d. Eat plenty of protein to build your strength

B. Begin walking 200 feet a day three times a week A pt with HF would be taught to conserve energy and given an exercise plan. PT should begin walking 200-400 feet a day 3x a week. Pt should not walk until becoming SOB bc may not make it back home. Lifting restriction specific to pt after valve replacement. Protein helps build strength, not specific to HF.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the BEST response by the nurse? 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. Blood clots form more easily in artificial replacement valves Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of clots. The other responses are inaccurate.

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is MOST appropriate? a. Avoid getting salt water on the radiation site b. Do not expose the radiation area to direct sunlight c. Have a wonderful time and enjoy your vacation! d. Remember you should not drink alcohol for a year

B. Do not expose the radiation area to direct sunlight The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy has been completed. The nurse would inform the client to avoid sun exposure to this area. This advice continues for 1 year after treatment has been completed. The other statements are not appropriate.

The nurse learning about cellular regulation understands that which process occurs during the S phase of the cell cycle? a. Actual division (mitosis) b. Doubling of DNA c. Growing extra membrane d. No reproductive activity

B. Doubling of DNA During the S phase, the cell must double its content through DNA synthesis. Actual division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1 phase. During the G0 phase, the cell is working but is not involved in any reproductive activity.

A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert 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. Dyspnea on exertion Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other S&S do not relate.

A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down b. Friction rub at the left lower sternal border c. Presence of a regular gallop rhythm d. Coarse crackles in bilateral lung bases

B. Friction rub at the left lower sternal border PT with pericarditis may present with a pericardial friction rub at left lower sternal border. This sound is the result of friction from inflamed pericardial layers when they rub together. Other assessments not related.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for ADDITIONAL teaching? a. I'll be able to carry heavy loads after 6 months of rest b. I will have my teeth cleaned by my dentist in 2 weeks c. I must avoid eating foods high in vitamin K, like spinach d. I must use an electric razor instead of a straight razor to shave

B. I will have my teeth cleaned by my dentist in 2 weeks Pts with defective or repaired valves at high risk for endocarditis. Pt with valve surgery should avoid dental procedures for 6 months bc of risk for endocarditis. When undergoing mitral valve replacement surgery, the pt needs to be on anticoagulant therapy to prevent vegetation forming on the new valve. Pts on anticoagulant therapy would be instructed on bleeding precautions including using an electric razor. If pt is prescribed warfarin, the pt should avoid foods high in vitamin K. Pt recovering from open-heart valve replacements should not carry anything heavy for 6 months while the chest incision and muscle heal.

After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is MOST important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption b. Instruct the client to ask for assistance when rising from bed c. Collaborate with assistive personnel to bathe the client d. Monitor potassium levels and check for signs of hypokalemia

B. Instruct the client to ask for assistance when rising from bed Hypotension is a side effect of ACE inhibitors such as captopril. Pts with a fluid volume deficit should have their volume replaced or start at a lower dose of the drug to minimize this effect. The nurse would instruct the client to seek assistance before arising from bed to avoid injury from postural hypotension. ACE inhibitors do not need to be taken w/ food. Collab with AP to provide hygiene is not a priority. The pt would be encourage to complete ADLs as independently as possible. The nurse would monitor for hyperkalemia, not hypokalemia, especially if the pt has renal insufficiency secondary to HF.

A client has a platelet count of 9800/mm3 (9800x10^9/L). What action by the nurse is MOST appropriate? a. Assess the client for calf pain, warmth, and redness b. Instruct the client to call for help to get out of bed c. Obtain cultures as per the facility's standing policy d. Place the client on protective Isolation Precautions

B. Instruct the client to call for help to get out of bed A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent injury, the client would be instructed to call for help prior to getting out of bed. Calf pain, warmth, and redness might indicate deep vein thrombosis, not associated with low platelets. Cultures and isolation relate to low white cell counts.

A nurse assesses a client admitted to the cardiac unit. Which statement 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. My shoes fit really tight lately Signs of systemic congestion occur with right-sided HF. Fluid is retained, pressure builds in the venous system, and peripheral edema develops. Left-sided HF symptoms include respiratory symptoms - orthopnea, coughing, and difficulty breathing all could be results.

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is MOST appropriate? a. Are you getting adequate rest and sleep each day? b. It is normal to be fatigued even for months afterward c. This is not normal and I'll let the primary health care provider know d. Try adding more vitamins B and C to your diet

B. it is normal to be fatigued even for months afterward Radiation-induced fatigue can be debilitating and may last for months after treatment has ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client (and family) understands this is normal.

A nurse is learning the difference between normal cells and benign tumor cells. What information does this include? a. Benign tumors grow through invasion of other tissue b. Benign tumors have lost their cellular regulation from contact inhibition c. Growing in the wrong place or time is typical of benign tumors d. The loss of characteristics of the parent cells is called anaplasia

C. Growing in the wrong place or time is typical of benign tumors Benign tumors are basically normal cells growing in the wrong place or at the wrong time. Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact inhibition. Anaplasia is a characteristic of cancer cells.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. I have been drinking more water than usual b. I am awakened by the need to urinate at night c. I must stop halfway up the stairs to catch my breath d. I have experienced blurred vision on several occasions

C. I must stop halfway up the stairs to catch my breath Pts with left-sided HF report weakness/fatigue while performing ADLs, as well as difficulty breathing, or "catching their breath". This occurs as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and blurred vision are not related to HF.

A nurse has taught a client about dietary changes that can reduce the chances of developing cancer. What statement by the client indicates the nurse needs to provide ADDITIONAL teaching? a. Foods high in vitamin A and vitamin C are important b. I'll have to cut down on the amount of bacon I eat c. I'm so glad I don't have to give up my juicy steaks d. Vegetables, fruit, and high-fiber grains are important

C. I'm so glad that I don't have to give up my juicy steaks To decrease the risk of developing cancer, one should cut down on the consumption of red meats and animal fat. The other statements are correct.

A client is receiving rituximab and asks how it works. What response by the nurse is BEST? a. It causes rapid lysis of the cancer cell membranes b. It destroys the enzymes needed to create cancer cells c. It prevents the start of cell division in the cancer cells d. It sensitizes certain cancer cells to chemotherapy

C. It prevents the start of cell division in the cancer cells Rituximab prevents the initiation of cancer cell division. The other statements are not accurate.

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. Rapid position changes can create shear and friction forces, which can tear out your internal vascular sutures b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness c. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk of stroke when you stand up

C. Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes Bc new heart is denervated, the baroreceptor and other mechanisms that compensate for BP drops caused by position changes do not function. This allows orthostatic hypotension to persist in postop period. Other statements false.

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy b. Hold the next dose c. Instruct the client to drink water d. Administer PRN acetaminophen

D. Administer PRN acetaminophen The vasodilating fx of nitrates frequently cause pts to have headaches in the initial period of therapy. The nurse would inform the pt about this side effect and offer a mild analgesic, such as acetaminophen. The pt's headache is not related to hypoxia or dehydration so O2 or H2O would not help. The pt needs to take the med as prescribed to prevent angina; the med wouldn't be held.

A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. Avoid taking aspirin or aspirin-containing products b. Increase your intake of foods that are 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. Do not take this medication within 1 hour of taking an antacid GI absorption of digoxin is erratic. Many meds, especially antacids, interfere with its absorption. Pts are taught to hold their digoxin for bradycardia; a heart rate of 80 beats/min is too high for this cut off. Potassium and aspirin have no impact on digoxin absorption.

A nurse is assessing a client with glioblastoma. What assessment is MOST important? a. Abdominal palpation b. Abdominal percussion c. Lung auscultation d. Neurologic examination

D. Neurologic examination A glioblastoma arises in the brain. The most important assessment for this client is the neurologic examination.

A nurse asks the staff development nurse what "apoptosis" means. What response is BEST? a. Growth by cells enlarging b. Having the normal number of chromosomes c. Inhibition of cell growth d. Programmed cell death

D. Programmed cell death Apoptosis is programmed cell death. With this characteristic, organs and tissues function with cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having the normal number of chromosomes is euploidy. Inhibition of cell growth is contact inhibition.

A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment. Which action by the nurse is BEST? a. Ensure the client is placed in protective isolation b. Have pregnant visitors stay 6 feet from the client c. No special action is necessary to care for this client d. Read the policy on handling radioactive excreta

D. Read the policy on handling radioactive excreta This type of radioisotope is excreted in body fluids and excreta (urine and feces) and would not be handled directly. The nurse would read the facility's policy for handling and disposing of this type of waste. The other actions are not warranted.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side fo the neck. Which nonpharmacologic comfort measure would the nurse implement? a. Apply an ice pack to the client's chest b. Provide a neck rub, especially on the left side c. Allow the client to lie in bed with the lights down d. Sit the client up with a pillow to lean forward on

D. Sit the client up with a pillow to lean forward on Pain from acute pericarditis may worsen when pt lays supine. Nurse would position pt in a comfortable position, usually upright and leaning slight forward. An ice pack and neck rub will not relieve pain. Dimming lights will not help

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes PRIORITY? a. Helping clients adjust to their appearance b. Reassuring clients that this change is temporary c. Referring clients to a reputable wig shop d. Teaching measures to prevent scalp injury

D. Teaching measures to prevent scalp injury All of the actions are appropriate for clients with alopecia. However, the priority is client safety, so the nurse would first teach ways to prevent scalp injury.

A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the client's chart that the cancer classification is T(IS)N0M0. What does the nurse conclude about his client's cancer? a. The primary site of the cancer cannot be determined b. Regional lymph nodes could not be assessed c. There are multiple lymph nodes involved already d. There are no distant metastases noted in the report

D. There are no distant metastases noted in the report T(IS) stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0 stands for no distant metastasis.

Which statement about carcinogenesis is ACCURATE? a. An initiated cell will always become clinical cancer b. Cancer becomes a health problem once it is 1 cm in size c. Normal hormones and proteins do not promote cancer growth d. Tumor cells need to develop their own blood supply

D. Tumors need to develop their own blood supply Tumors need to develop their own blood supply through a process called angiogenesis. An initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to occur for it to become a health problem.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the client's oral chemotherapy medications. What action by the nurse is MOST appropriate? a. Crush the medications if the client cannot swallow them b. Give one medication at a time with a full glass of water c. No special precautions are needed for these medications d. Wear personal protective equipment when handling the medications

D. Wear personal protective equipment when handling the medications During the administration of oral chemotherapy agents, nurses must take the same precautions that are used when administering IV chemotherapy. This includes using personal protective equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not needed.

A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? a. Avoid drinking more than 3 quarts (3 L) 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 each day while wearing the same amount of clothing

D. Weigh yourself each day while wearing the same amount of clothing Pts with HF are instructed to weight themselves daily to detect worsening HF early and avoid complications. Other signs include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload increases symptoms of HF. The pt would be taught to eat a heart healthy diet, balance intake and output to prevent dehydration and overload, and take meds as prescribed. The most important discharge teaching is daily weights as this provides the best data related to fluid retention.

A nurse cares for a client with end-stage heart failure who 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." How would the nurse respond? a. Would you like to speak with a priest or chaplain? b. I will arrange for a psychiatrist to speak with you c. Do you want to come off the transplant list? d. Would you like more information about advance directives?

D. Would you like more information about advance directives? Pt is verbalizing a real concern/fear about negative outcomes of surgery. This anxiety itself can have negative effects on the outcome because of SNS stimulation. The best action is to allow pt to verbalize concern and work toward positive outcome without making pt feel as though concerns are not valid. Pt needs to feel some control over future. Nurse personally provides care to address the pt's concerns instead of immediately calling for the chaplain or psychiatrist. Nurse would not jump to conclusions and suggest taking pt off transplant list, which is the best tx option.

A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b. "Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?"

a. "Could you walk further than that a few months ago?"

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

a. "I can use a heating pad on my legs if it's set on low."

A client is taking warfarin and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

a. "No, it may interfere with the warfarin."

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."

a. "No, women should only have one beer a day as a general rule."

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics

a. African-American churches

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

a. Apply compression stockings. b. Assist with ambulation. d. Offer fluids frequently.

A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

a. Appropriate hand hygiene before giving care

A nurse is working with a client who takes clopidogrel. The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

a. Ask if the client eats grapefruit.

nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations. f. Arrange for an amputee to come visit the client.

a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion.

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium

a. Assess the client's ankle-brachial index.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of lisinopril.

a. Assess the client's lung sounds and oxygenation.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client that drugs are safer today than before. d. Warn the client about consequences of noncompliance

a. Assess the reason behind the client's fear.

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking f. Hyperlipidemia

a. Atherosclerosis d. History of hypertension e. History of smoking f. Hyperlipidemia

A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes.

a. Client is able to decrease blood pressure medications.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the wound care nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

a. Consult with the wound care nurse

A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication f. Wearing a Medic Alert bracelet

a. Dietary restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.) a. Elevated low-density lipoprotein (LDL-C) b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) c. Asian ethnicity d. History of smoking e. Blood pressure: 142/92 mm Hg on one occasion

a. Elevated low-density lipoprotein (LDL-C) b. Decreased levels of high-density lipoprotein cholesterol (HDL-C) d. History of smoking

The nurse is caring for four hypertensive clients. Which drug-laboratory value combination would the nurse report immediately to the health care provider? a. Furosemide/potassium: 2.1 mEq/L b. Hydrochlorothiazide/potassium: 4.2 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. Torsemide/sodium: 142 mEq/L

a. Furosemide/potassium: 2.1 mEq/L

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."

b. "Most people with hypertension do not have symptoms."

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

b. Apply a warm moist pack

What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options f. Encouraging participation in high impact aerobic activity

b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.

b. Assess distal pulses and skin color.

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

b. Assess distal pulses every 10 minutes. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.

b. Assist in finding one change the client can control.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

b. Baked chicken breast, broccoli, tomatoes

A nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril and needs to use the bathroom. c. Hypertensive client with a blood pressure of 188/92 mm Hg. d. Client who needs pain medication prior to a dressing change of a surgical wound.

b. Client who had a first dose of captopril and needs to use the bathroom.

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.) a. Abdominal tenderness b. Difficulty swallowing c. Changes in bowel habits d. Shortness of breath e. Hoarseness

b. Difficulty swallowing e. Hoarseness

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

b. Notify the Rapid Response Team.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

b. Oxygen saturation of 98%

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store.

b. Participate in blood pressure screenings at the mall.

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. "A good abrasive pumice stone will keep my feet soft." b. "I'll always wear shoes if I can buy cheap flip-flops." c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best." f. "I will inspect my feet daily."

c. "I will keep my feet dry, especially between the toes." d. "Lotion is important to keep my feet smooth and soft." e. "Washing my feet in room-temperature water is best."

A client asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."

c. "It is hypertension with no specific cause."

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

c. Measure for new compression stockings.

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first? a. Dry, itchy, peeling skin b. Serum calcium of 9.2 mg/dL c. Serum potassium of 2.8 mEq/L d. Weight gain of 0.5 lb (1.1 kg) in 1 day

c. Serum potassium of 2.8 mEq/L TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse would assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving cancer treatments, and the nurse would assess that client next because of the potential for discomfort and infection. This calcium level is normal. TKIs can also cause weight gain, but the client with the low potassium level is more critical.

An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "I'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d. "My hands shake when I try to do things requiring coordination."

d. "My hands shake when I try to do things requiring coordination."

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to intervene? a. Assesses the client for back pain. b. Auscultates over abdominal bruit. c. Measures the abdominal girth. d. Palpates the abdomen in four quadrants.

d. Palpates the abdomen in four quadrants.

A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary filling of 4 seconds as normal d. Palpating both carotid arteries at the same time

d. Palpating both carotid arteries at the same time

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring that the consent is signed c. Marking pulses with a pen d. Raising the side rails on the bed e. Recording baseline vital signs

d. Raising the side rails on the bed e. Recording baseline vital signs