Perfusion

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department? 1 Core rewarming with warm fluids 2 Ambulation to increase metabolism 3 Frequent oral temperature assessments 4 Gastric tube feedings to increase fluid volume

1 Core rewarming with warm fluids

A client who has been taking digoxin (Lanoxin) for 20 years is hospitalized. The client exhibits signs of dehydration and laboratory results identify the presence of hypokalemia. The nurse should monitor the client for which clinical finding indicating digoxin toxicity? 1 Constipation 2 Blurred vision 3 Decreased urination 4 Metallic taste in the mouth

2 Blurred vision

The nurse is caring for a client that is admitted with the diagnosis of mild chronic heart failure. The nurse expects to hear what lung sounds? 1 Stridor 2 Crackles 3 Wheezes 4 Friction rubs

2 Crackles Stridor is not heard in chronic heart failure, but with tracheal constriction or obstruction. Wheezes are not heard with chronic heart failure, but with asthma. Friction rubs are not heard with chronic heart failure, but with pleurisy

A client receives a prescription for nitroglycerin (Nitrostat) sublingual as needed for anginal pain. What should the nurse include in the teaching about this medication? 1 To facilitate absorption, drink a large glass of water after taking the medication 2 Place the tablet under the tongue or between the cheek and gum 3 It takes 30 to 45 minutes for the nitroglycerin to achieve its effect 4 If dizziness occurs, take a few deep breaths and lean the head back

2 Place the tablet under the tongue or between the cheek and gum

Digoxin is used to treat what?

cardiac dysrhythmia

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? (Select all that apply.) 1 Sclera 2 Nail beds 3 Lining of eyelids 4 Palms of hands 5 Bony prominences

2 Nail beds 3 Lining of eyelids 4 Palms of hands

A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. The nurse explains that: 1 Steroid hormones have a depressant effect on the spleen and bone marrow 2 Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs 3 Lymph node activity is depressed by radiation therapy used before chemotherapy 4 Dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration

2 Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs

For what client response must the nurse monitor to determine the effectiveness of amiodarone (Cordarone)? 1 Results of fasting lipid profile 2 Presence of cardiac dysrhythmias 3 Degree of blood pressure control 4 Incidence of ischemic chest pain

2 Presence of cardiac dysrhythmias

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? (Select all that apply.) 1 Dependent edema 2 Distended abdomen 3 Polyuria at night 4 Collapsed neck veins 5 Cool extremities

1 Dependent edema 2 Distended abdomen 3 Polyuria at night

Which of the following signs are indications of hydration status during a sickle cell crisis? (Select all that apply.) 1 Turgor of tissue 2 Edema of the ankles 3 Specific gravity of urine 4 Amount of urinary output 5 Texture of mucous membranes

1 Turgor of tissue 5 Texture of mucous membranes

A client with hypertensive heart disease, who had an acute episode of heart failure, is to be discharged on a regimen of metoprolol (Toprol-XL) and digoxin (Lanoxin). The nurse expects that metoprolol, when administered with digoxin, may: 1 Produce headaches 2 Precipitate bradycardia 3 Increase blood pressure 4 Stimulate nodal conduction

2 Precipitate bradycardia

A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results? 1 Anemia 2 Polycythemia 3 Agranulocytosis 4 Thrombocytopenia

2 Polycythemia The body responds to the chronic hypoxia caused by the heart defect by increasing the production of red blood cells (RBCs) in an attempt to increase the oxygen-carrying capacity of the blood.

A client's cardiac monitor shows a PQRST wave for each beat and indicates a rate of 120 beats per minute. The rhythm is regular. The nurse concludes that the client is experiencing: 1 Atrial fibrillation 2 Sinus tachycardia 3 Ventricular fibrillation 4 First-degree atrioventricular block

2 Sinus tachycardia The presence of a P wave before each QRS complex indicates a sinus rhythm; a heart rate greater than 100 regular beats per minute is referred to as tachycardia. Atrial fibrillation has no well-defined P waves, there are 350 or more beats per minute, there are random ventricular beats, and the rhythm is irregular. Ventricular fibrillation is irregular and shows no PQRST configurations. A first-degree atrioventricular block pattern has a prolonged PR interval and is regular.

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? (Select all that apply.) 1 Weight loss 2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea 5 Increased urinary output

2 Unusual fatigue 3 Dependent edema 4 Nocturnal dyspnea

Three weeks after a client gives birth, a deep vein thrombophlebitis develops in her left leg and she is admitted to the hospital for bedrest and anticoagulant therapy. Which anticoagulant does the nurse expect to administer? 1 Clopidogrel (Plavix) 2 Warfarin (Coumadin) 3 Continuous infusion of heparin 4 Intermittent doses of a low molecular weight heparin

3 Continuous infusion of heparin

A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect? 1 Proteinuria 2 Peripheral edema 3 Increased hematocrit 4 Absence of pedal pulses

3 Increased hematocrit Direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood

When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, the nurse explains that: 1 Weekly Z-track injections provide needed control 2 Daily intramuscular injections are required for control 3 Intramuscular injections once a month will maintain control 4 Oral tablets of vitamin B12 taken daily will provide symptom control

3 Intramuscular injections once a month will maintain control

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? (Select all that apply.) 1 Constipation 2 Hypokalemia 3 Irregular pulse rate 4 Change in visual acuity 5 Orthostatic hypotension

3 Irregular pulse rate 5 Orthostatic hypotension

A nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available? 1 ¾ to 1 inch 2 ½ to ¾ inch 3 1 to 1½ inches 4 2 to 2½ inches

4 2 to 2½ inches

The cardiac monitor reveals a series of premature ventricular complexes (PVCs). The nurse anticipates that the client will be receiving a prescription for: 1 Atropine (Atropine Sulfate) 2 Epinephrine (Adrenaline) 3 Sodium bicarbonate (Sodium bicarbonate 5% injection) 4 Amiodarone (Cordarone)

4 Amiodarone (Cordarone) Amiodarone suppresses ventricular activity

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1 Respirations of 10 2 Urine output of 30 ml/hour 3 Lethargy 4 Restlessness

4 Restlessness

An older client tells the nurse, "My legs begin to hurt after walking the dog for several blocks. The pain goes away when I stop walking, but it comes back again when I resume walking." Which condition does the nurse consider as the most likely cause of the client's responses? 1 Spinal stenosis 2 Buerger disease 3 Rheumatoid arthritis 4 Intermittent claudication

Intermittent claudication (pain on mild exertion)

A client at 28 weeks' gestation with previously diagnosed mitral valve stenosis is being evaluated in the clinic. Which sign or symptom indicates that the client is experiencing cardiac difficulties? 1 Systolic murmur 2 Heart palpitations 3 Syncope on exertion 4 Displaced apical pulse

3 Syncope on exertion (fainting)

A nurse is administering erythropoietin (Epogen) three times a week to a client receiving chemotherapy for cancer. Which client response is considered most expected? 1 Elevated liver enzymes 2 Elevated hematocrit level 3 Increase in the white blood cell (WBC) count 4 Increase in Kaposi's sarcoma lesions

2 Elevated hematocrit level

The nurse is caring for a client who has sustained blunt trauma to the forearm. The nurse assesses the client for which early sign of compartment syndrome? 1 Warm skin at site of injury 2 Escalating pain in the fingers 3 Rapid capillary refill in affected hand 4 Bounding radial pulse in the injured arm

2 Escalating pain in the fingers

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion? 1 Arterial spasm 2 Heart muscle ischemia 3 Blocking of the coronary veins 4 Irritation of nerve endings in the cardiac plexus

2 Heart muscle ischemia

A 3½ -year-old child with severe iron-deficiency anemia is seen by a nurse in the clinic. In addition to weakness and fatigue, what should the nurse expect the child to exhibit? 1 Cold, clammy skin 2 Increased pulse rate 3 Increased blood pressure 4 Cyanosis of the nail beds

2 Increased pulse rate

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: 1 Pneumonia 2 Hemorrhage 3 Wound infection 4 Pulmonary embolism

4 Pulmonary embolism

A nurse caring for a client with a myocardial infarction is concerned that the client may develop left ventricular failure. For which clinical manifestation should the nurse assess the client? 1 Weight loss 2 Distended neck veins 3 Paroxysmal nocturnal dyspnea 4 Right upper quadrant tenderness

3 Paroxysmal nocturnal dyspnea

A client undergoes cardiac catheterization via the femoral artery. What is the most important nursing action after the procedure? 1 Provide a bed cradle 2 Check for a pulse deficit 3 Elevate the head of the bed 4 Assess the groin for bleeding

4 Assess the groin for bleeding

An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its effect on the structure of cell walls. I wonder whether it is wise to take it." The nurse concludes the client probably is referring to: 1 A 2 B1 3 C 4 E

4 E

A 4-year-old child is undergoing a diagnostic workup for pulmonic stenosis. The mother asks the nurse about the diagnosis. The nurse bases the response on the fact that pulmonic stenosis is: 1 Narrowing of the valve between the left atrium and left ventricle 2 Hardening of the valve between the right atrium and right ventricle 3 Hardening of the valve between the right ventricle and the arch of the aorta 4 Narrowing of the valve between the right ventricle and the pulmonary artery

4 Narrowing of the valve between the right ventricle and the pulmonary artery

A health care provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive? 1 Omeprazole (Prilosec) 2 Acetaminophen (Tylenol) 3 Docusate sodium (Colace) 4 Pseudoephedrine (Sudafed)

4 Pseudoephedrine (Sudafed)

A client is brought to the emergency department after an automobile collision. The client's blood pressure is 100/60 mm Hg, and the physical assessment suggests a ruptured spleen. For which early clinical indicator of decreased arterial pressure should the nurse assess the client? 1 Warm, flushed skin 2 Increased pulse pressure 3 Lethargy with confusion 4 Reduced peripheral pulses

4 Reduced peripheral pulses

When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart? 1 Heart rate 2 Refractory period 3 Pulmonary pressure 4 Strength of contractions

4 Strength of contractions