ATI NCLEX Challenge 5

A nurse is teaching a client who has a new diagnosis of venous insufficiency. Which of the following instructions should the nurse include?

"Use elastic stockings"

A nurse in a cardiac unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP)

A nurse is assessing a client who is taking lisinopril to treat hypertension. Which of the following findings is a priority to report?

Swelling of the tongue

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching?

"I am going to take a stress management class"

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

"I may eat 10 ounces of lean protein each day"

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

"I plan to slow down if I am tired the day after exercising"

A client is teaching a client who has a new prescription for hydrochlorothiazide for management of hypertension. Which of the following instructions should the nurse include?

"Monitor for leg cramps"

A nurse is caring for a client who just had a cardiac catherization. Which of the following nursing interventions should the nurse include in the client's plan of care? (Select all that apply).

- check peripheral pulses in the affected extremity - keep the client's hip and leg extended -have the client remain in bed up to 6 hr

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply).

Hypercholesterolemia, Hypertension, Obesity, Smoking

A nurse is caring for a client who has heart failure and receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?

Hyperuricemia

A nurse is teaching a client who has a new prescription for aspirin to prevent cardiovascular disease. Which of the following instructions should the nurse include in the teaching?

Monitor for tinnitus.

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Perform neurovascular checks with vital signs

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter

A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following statements by the client indicates an adverse effect of the medication?

"I feel nauseated and have no appetite"

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of therapeutic communication response of reflection?

"You seem upset about taking your blood pressure medication"

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse.

5th intercostal space and to the left of the sternum.

A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?

A slice of cheese

A nurse is providing discharge teaching to a client who has a peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Adjust the thermostat so the environment is warm.

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Fatigue

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum

For each assessment finding, click to specify if the assessment finding is consistent with an arterial ulcer, a venous ulcer, or a diabetic ulcer. Each finding may support more than one disease process.

Hair loss: arterial ulcers 1+ posterior tibial pulse: arterial ulcers Pain at ulcer site: arterial and venous ulcers History of hypertension: arterial, venous, and diabetic ulcers Pale wound bed: arterial and diabetic ulcers Defined edges: arterial and diabetic ulcers Skin cool to touch of the affected extremity: arterial and diabetic ulcers

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?

LDL 172 mg/dL

A nurse is assessing a client who had a left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.

Left pedal pulse- Left foot

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?

Measure the client's apical pulse

The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, "I always get a rash when I eat shellfish." Which of the following is the priority nursing action?

Notify the provider of the client's allergy

The nurse reports the 2400 assessment findings to the provider. Which of the following should the nurse anticipate the provider will prescribe? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Obtain an echocardiogram: Anticipated Administer antibiotic therapy: Anticipated Perform strenuous exercise regiment twice daily: Contraindicated Restrict dental hygiene: Contraindicated Obtain blood cultures x3: Anticipated

A nurse is admitting a client who has a history of heart failure. Select the 5 findings that require immediate follow-up.

Vital signs, respiratory assessment, renal function, BNP, ECG results.

A nurse is caring for a client who has heart failure. A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action?

breath sounds, weight, oxygen saturation, blood pressure

A nurse is assessing a client who has heart failure and is prescribed furosemide. Which of the following findings is an adverse effect on this medication?

leg cramps

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

"I eat two eggs for breakfast each morning"

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack"

A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further testing?

"I'll take my heart medications the morning of my test."

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

"Increasing my intake of foods containing trans-fatty acids can lower my risk."

A nurse is caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

Asthma

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

Cardiac dysrhythmias

A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

Cigarette smoking

A nurse is teaching a client about preparing low-fat meals. The nurse should include that which of the following oils contains saturated fat?

Coconut

A nurse is caring for a client who is postoperative following vascular surgery. Which of the following sings should indicate to the nurse that the client has developed a thrombus?

Dull, aching calf pain

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?

Dyspnea

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions?

Heart failure

A nurse is planning to administer digoxin to a client who has heart failure. Which of the following laboratory results is the priority for the nurse to review prior to administering the medication?

Potassium

A nurse is preparing to care for an 84-year-old male client who is being admitted to a medical unit from a provider's office. The nurse reviews the client's medical records to prepare the client's plan of care.

Potential condition: Heart failure Actions to take: Encourage intake of low-sodium diet, Elevate the head of the bed. Parameters to monitor: Urinary output, blood pressure.

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT)

A nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

Radial pulse in the left arm

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

Side of the ankle

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis?

Vertigo

A nurse is admitting a client who has a history of heart failure. Check the 5 findings that require immediate follow-up.

Vital signs, respiratory assessment, renal function, BNP, ECG results

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

impaired tissue perfusion