Unit 4 PrepU

The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?

"Are you only able to breathe when you are sitting upright?"

Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation?

Anticoagulant

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia?

Atropine

A nurse is checking laboratory values on a client who has crackles in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which laboratory value does the nurse expect to be abnormal?

B-type natriuretic peptide (BNP)

A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next?

Begin cardiopulmonary resuscitation

A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How will the nurse intervene?

Instruct the client to sit for several minutes before standing.

The nurse is educating a patient at risk for atherosclerosis. What nonmodifiable risk factor does the nurse identify for the patient?

Positive family history

An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed Chlorothiazide and Benazepril. What will the nurse monitor this client for?

Postural hypotension and resulting injury

A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?

acute pulmonary edema.

A triage nurse in the emergency department suspects that a 78-year-old patient is experiencing severe digoxin toxicity with significant cardiac arrhythmia. If the nurse is correct, which action is likely to be taken?

The patient will be given digoxin immune fab.

The client has just been diagnosed with a arrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm?

The sinoatrial (SA) node initiates the impulse.

A client with heart failure asks, "Why am I taking a 'water pill' when it's my heart that is having a problem?" While educating the client about the Frank-Starling mechanism, which explanation is most appropriate to share?

"Since your heart is not pumping efficiently, the kidneys are getting less blood flow; therefore, the kidneys are holding on to sodium and water."

Which question would be most important for a nurse to ask a female client who is starting on an angiotensin II receptor blocker for hypertension?

"When was your last menstrual period?"

A nurse is discussing with a nursing student how to accurately measure blood pressure. What statement by the student indicates an understanding of the education?

A cuff that is too small will give a false high blood pressure.

The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle?

Atrial depolarization

The nurse is monitoring a patient in the postanesthesia care unit (PACU) following a coronary artery bypass graft, observing a regular ventricular rate of 82 beats/min and "sawtooth" P waves with an atrial rate of approximately 300 beat/min. How does the nurse interpret this rhythm?

Atrial flutter

A community health nurse is conducting a workshop for unlicensed care providers who work in a chain of long-term care facilities. The nurse is teaching the participants about the signs and symptoms of stroke. What signs and symptoms should the nurse identify? Select all that apply. Epistaxis (nosebleed) Confusion Sudden numbness Sudden ear pain Visual disturbances

Confusion Sudden numbness Visual disturbances

A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply. Coronary artery disease Myocardial infarction Pancreatitis Tension pneumothorax Stroke

Coronary artery disease Myocardial infarction Stroke

How often should neurologic assessments and vital signs be taken initially for the patient receiving tissue plasminogen activator (tPA)?

Every 15 minutes

The nurse is caring for a client with accelerated hypertension. Which body system would the nurse assess to identify early signs of blood pressure progression?

Eyes

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to do perform which action?

Form understandable words and comprehend spoken words

The nurse reads an athletic client's electrocardiogram. What finding will be consistent with a sinus bradycardia?

Heart rate of 42 beats per minute (bpm).

The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client?

Immediate defibrillation

A client is brought to the emergency department with reports of a bad headache and an increase in blood pressure. The blood pressure reading obtained by the nurse is 260/180 mm Hg. What is the therapeutic goal for reduction of the mean blood pressure?

Reduce the blood pressure by 20% to 25% within the first hour of treatment.

Which finding indicates that hypertension is progressing to target organ damage?

Retinal blood vessel damage

An emergency department nurse is awaiting the arrival of a client with signs of an ischemic stroke that began 1 hour ago, as reported by emergency medical personnel. The treatment window for thrombolytic therapy is which of the following?

Three hours

The nurse is assessing a client with symptomatic bradycardia. What medication does the nurse anticipate will be ordered by the healthcare provider to treat the bradycardia?

atropine

What is the term for the ability of the cardiac muscle to shorten in response to an electrical impulse?

contractility

During an initial assessment, the nurse measures the client's apical pulse and compares it to the peripheral pulse. The difference between the two is known as pulse:

deficit.

Hypertension is defined as "sustained elevations in systolic or diastolic blood pressures that exceed prehypertension levels." What are some of the consequences of hypertension that make it such a health menace in the United States?

hypertension places people at risk for heart disease, heart failure, stroke, and kidney disease.

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate?

international normalized ratio (INR)

The nurse analyzes a 6-second electrocardiogram (ECG) tracing. The P waves and QRS complexes are regular. The PR interval is 0.18 seconds long, and the QRS complexes are 0.08 seconds long. The heart rate is calculated at 70 bpm. The nurse correctly identifies this rhythm as

normal sinus rhythm.

Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through:

ophthalmic examination.

When the nurse observes that the client's heart rate increases during inspiration and decreases during expiration, the nurse reports that the client is demonstrating

sinus arrhythmia.