Cardiovascular

A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take? 1. Continue to monitor the client. 2. Notify the health care provider. 3. Ensure that a defibrillator is close by. 4. Administer lidocaine intravenously as per protocol.

1. Continue to monitor the client.

A nurse is assessing an older adult client. Which clinical findings are expected responses to the aging process? (Select all that apply.) 1. Slowed neurological responses 2. Lowered intelligence quotient 3. Long-term memory impairment 4. Forgetfulness about recent events 5. Reduced ability to maintain an erection

1. Slowed neurological responses 4. Forgetfulness about recent events 5. Reduced ability to maintain an erection

A client with varicose veins is scheduled for sclerotherapy. What clinical finding does the nurse expect to identify when assessing the lower extremities of this client? 1. Pallor 2. Ankle edema 3. Yellowed toenails 4. Diminished pedal pulses

2. Ankle edema **Ankle edema results from venous pooling with increased hydrostatic pressure; fluid moves from intravascular to interstitial spaces.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiological effect of nicotine should the nurse explain to the group? 1. Constriction of the superficial vessels dilates the deep vessels. 2. Constriction of the peripheral vessels increases the force of flow. 3. Dilation of the superficial vessels causes constriction of collateral circulation. 4. Dilation of the peripheral vessels causes reflex constriction of visceral vessels

2. Constriction of the peripheral vessels increases the force of flow.

A client has edema in the lower extremities during the day, which disappears at night. With which medical problem does the nurse conclude this clinical finding is consistent? 1. Pulmonary edema 2. Myocardial infarction 3. Right ventricular heart failure 4. Chronic obstructive lung disease

3. Right ventricular heart failure

The nurse is conducting a nutrition class for a group of clients with congestive heart failure (CHF). It would be most important for the nurse to explain the importance of: 1. Restricting fluid intake 2. Choosing fresh or frozen vegetables instead of canned ones 3. Eating a low-calorie diet to reduce weight 4. Recognizing which products are high in cholesterol

2. Choosing fresh or frozen vegetables instead of canned ones **The key principle to teach CHF clients is the importance of decreasing sodium in their diet and which foods contain sodium.

A nurse is caring for a client who has a prescription for a diuretic, 2-gram sodium diet, and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) level 42 mg/dL and creatinine 1.1 mg/dL. Considering the assessment findings, what is the most appropriate intervention by the nurse? 1. Sending the client's urine for analysis 2. Expecting an increase in the oral fluid intake 3. Placing the client on strict intake and output measurements 4. Notifying a nutritionist/dietitian so that sodium can be restricted further

2. Expecting an increase in the oral fluid intake

A client with a history of hypertension develops dyspnea on exertion. What does the nurse conclude is the most likely cause of the client's dyspnea? 1. Cor pulmonale 2. Left heart failure 3. Bronchial spasms 4. Right ventricular failure

2. Left heart failure

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 **Nail beds lose their pink coloration because of reduced hemoglobin. A reduced amount of hemoglobin decreases pink color of the lining of the eyelids. Palms of the hands will become pale because of the decreased hemoglobin.

A client develops heart failure. Which response should the nurse expect when assessing the client? 1. Weight loss 2. Peripheral edema 3. Decreased heart rate 4. Increased urinary output

2. Peripheral edema

A health care provider prescribes enoxaprarin (Lovenox) 30 mg subcutaneously daily. To ensure client safety, which measure would the nurse take when administering this medication? 1. Remove air pocket from prepackaged syringe before administration 2. Rub site after administration 3. Push over two minutes 4. Administer in the abdomen

4. Administer in the abdomen

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? 1. Gabapentin (Neurontin) 2. Midazolam HCI (Versed) 3. Alprazolam (Xanax) 4. Aspirin (ASA)

4. Aspirin (ASA)

A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home? 1. No further drainage from the incisions 2. Increased edema in the leg that provided the donor graft 3. Mild incisional pain and tenderness for three to four weeks 4. Extreme fatigue and a mild fever occurring for several weeks

2. Increased edema in the leg that provided the donor graft

A client is admitted to the hospital for an emergency cardiac catheterization. What is the most common adaptation that the client is most likely to complain about after this procedure? 1. Fear of dying 2. Skipped heartbeats 3. Pain at the insertion site 4. Anxiety in response to intensive monitoring

3. Pain at the insertion site

A nurse is auscultating a client's heart sounds. Which valves close when the first heart sounds are produced? 1. Mitral and tricuspid 2. Aortic and tricuspid 3. Mitral and pulmonic 4. Aortic and pulmonic

1. Mitral and tricuspid

Which responses should a nurse expect a client experiencing hypoglycemia to exhibit? (Select all that apply.) 1. Nausea 2. Palpitations 3. Tachycardia 4. Nervousness 5. Warm, dry skin 6. Increased respirations

2. Palpitations 3. Tachycardia 4. Nervousness

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk factor for the development of a pulmonary embolus? 1. Atrial fibrillation 2. Forearm laceration 3. Migraine headache 4. Respiratory infection

1. Atrial fibrillation

A client is receiving hydrochlorothiazide (HCTZ). What should the nurse monitor to best determine the effectiveness of the client's hydrochlorothiazide therapy? 1. Blood pressure 2. Decreasing edema 3. Serum sodium level 4. Urine specific gravity

1. Blood pressure

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm Hg, and the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1. 72 mm Hg 2. 90 mm Hg 3. 100 mm Hg 4. 130 mm Hg

1. 72 mm Hg

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? (Select all that apply.) 1. Absence of hair on the toes 2 . Superficial ulcer with irregular edges 3. Pitting edema of the lower extremities 4 . Reports of pain associated with exercising 5 . Increased pigmentation of the medial malleolus area

1. Absence of hair on the toes 4 . Reports of pain associated with exercising

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? 1. Cataracts 2. Esophagitis 3. Kidney failure 4. Diabetes mellitus

3. Kidney failure

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? (Select all that apply.) 1. Anxiety 2. Chest pain 3. Irregular pulse 4. Fear of losing control 5. Feelings of depersonalization

1. Anxiety 2. Chest pain 3. Irregular pulse

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? 1. Arteriolar constriction occurs. 2. The cardiac workload decreases. 3. Contractility of the heart decreases. 4. The parasympathetic nervous system is triggered.

1. Arteriolar constriction occurs. **The early compensation of shock is cardiovascular and is reflected in changes in pulse, blood pressure, and pulse pressure; blood is shunted to vital organs, particularly the heart and brain.

A beta-blocker, atenolol (Tenormin), is prescribed for a client with moderate hypertension. What information should the nurse include when teaching the client about this medication? (Select all that apply.) 1. Change positions slowly 2. Take the medication before going to bed 3. Count the pulse before taking the medication 4. Mild weakness and fatigue are common side effects 5. It is safe to take concurrent over-the-counter (OTC) medications

1. Change positions slowly 3. Count the pulse before taking the medication 4. Mild weakness and fatigue are common side effects

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? 1. Pain subsides as a result of arteriole and venous dilation 2. Pulse rate increases because the cardiac output has been stimulated 3. Sublingual area tingles because sensory nerves are being triggered 4. Capacity for activity improves as a response to increased collateral circulation

1. Pain subsides as a result of arteriole and venous dilation **Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain.

A client with heart failure is digitalized and placed on a maintenance dose of digoxin (Lanoxin) 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? 1.Diuresis and decreased pulse rate 2.Increased blood pressure and weight loss 3. Regular pulse rhythm and stable fluid balance 4.Corrected heart murmur and decreased pulse pressure

1.Diuresis and decreased pulse rate

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding? 1.Oliguria 2. Bradypnea 3. Pulse deficit 4. High potassium levels

1.Oliguria

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? (Select all that apply.) 1. Raw carrots 2. Boiled spinach 3. Sweet potatoes 4. Brussels sprouts 5. Asparagus spears

2. Boiled spinach 3. Sweet potatoes

Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client? 1. Hirsutism 2. Bradycardia 3. Restlessness 4. Hypertension

2. Bradycardia

When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? (Select all that apply.) 1. Thirst 2. Confusion 3. Tachycardia 4. Pale coloring 5. Poor tissue turgor

2. Confusion 5. Poor tissue turgor

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 **Left-sided heart failure causes fluid accumulation in the capillary network of the lungs; fluid eventually enters alveolar spaces and causes crackling sounds at the end of inspiration.

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? (Select all that apply.) 1. Oliguria 2. Dry mouth 3. Palpitations 4. Constipation 5. Urinary retention 6 . Orthostatic hypotension

2. Dry mouth 3. Palpitations 4. Constipation 6 . Orthostatic hypotension

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

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? 1. Poached eggs 2. Spinach salad 3. Sweet potatoes 4. Cheese sandwich

2. Spinach salad **Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet tall and weighs 293 pounds puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? (Select all that apply.) 1 . Age 2 . Height 3 . Weight 4 . Smoking 5 . Family history

3 . Weight 4 . Smoking

A client with intermittent claudication has been instructed to stop smoking. The nurse explains that the reason that the client should quit smoking is because: 1. "The policy states that the hospital is a smoke-free environment." 2. "Nicotine causes arteries to go into spasm, which decreases circulation." 3. "Cigarette smoking is not suggested for clients like you that have vascular problems." 4. "The health care provider may allow you to begin smoking again after you are feeling better."

3. "Cigarette smoking is not suggested for clients like you that have vascular problems."

Which client should a nurse consider the greatest risk for developing hypernatremia? 1. 52-year-old who is receiving 0.45% NaCl intravenously 2. 76-year-old who developed syndrome of inappropriate antidiurectic hormone secretion (SIADH) as a result of head trauma 3. 63-year-old who has had watery diarrhea since traveling abroad 4. 48-year-old who is admitted with a diagnosis of Addison disease

3. 63-year-old who has had watery diarrhea since traveling abroad

A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat? 1. Apples 2. Grapes 3. Apricots 4. Cranberries

3. Apricots

A nurse is advising a client about the risks associated with failing to seek treatment for acute pharyngitis caused by beta-hemolytic streptococcus. For what health problem is the client at risk? 1. Asthma 2. Anemia 3. Endocarditis 4. Reye syndrome

3. Endocarditis

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 **Dysrhythmias, including second-degree heart block, are cardiovascular side effects of valsartan .

During a routine physical examination, an abdominal aortic aneurysm is diagnosed. The client immediately is admitted to the hospital, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when performing an assessment of this client? 1 .Severe radiating abdominal pain 2. Pattern of visible peristaltic waves 3. Palpable pulsating abdominal mass 4 . Cyanosis with other symptoms of shock

3. Palpable pulsating abdominal mass

The left foot of a client with a history of intermittent claudication becomes increasingly cyanotic and numb. Gangrene of the left foot is diagnosed, and because of the high level of arterial insufficiency, an above-the-knee amputation (AKA) is scheduled. The response that demonstrates emotional readiness for the surgery is when the client: 1. Explains the goals of the procedure 2. Displays few signs of anticipatory grief 3. Participates in learning perioperative care 4. Verbalizes acceptance of future dependency needs

3. Participates in learning perioperative care

Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate? 1. Aspirin to warfarin (Coumadin) 2. Amoxicillin (Amoxil) to systemic infection 3. Protamine sulfate to parenteral heparin 4. Enoxaparin (Lovenox) to dalteparin (Fragmin)

3. Protamine sulfate to parenteral heparin **Protamine sulfate is the antidote for heparin overdose and naloxone will reverse the effects of opioids such as morphine.

An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action? 1. Offer cool fluids. 2. Suction the airway. 3. Remove the clothing. 4. Prepare for intubation

3. Remove the clothing.

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply, which may be diminished further by: 1. Drinking alcohol 2. Lowering the limb 3. Smoking cigarettes 4. Consuming excessive fluid

3. Smoking cigarettes

A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for AIDS? 1. CD4 T cell count 2. Western blot test 3. Polymerase chain reaction test 4. Enzyme-linked immunosorbent assay (ELISA)

4. Enzyme-linked immunosorbent assay (ELISA) **The ELISA is the first screening test done to detect serum antibodies that bind to human immunodeficiency virus (HIV) antigens on test plates.

A client is admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? 1. Hypercalcemia may result from parathyroid damage. 2. Hypotension and bradycardia may result from thyroid storm. 3. Tetany may result from underdosage of thyroid hormone replacement. 4. Hoarseness and airway obstruction may result from laryngeal nerve damage.

4. Hoarseness and airway obstruction may result from laryngeal nerve damage.

A client admitted to the hospital for chest pain is diagnosed with angina. The nurse should teach the client that the most common characteristic of anginal pain is that it is: 1. Relieved by rest 2. Precipitated by light activity 3. Described as sharp or knifelike 4. Unaffected by the administration of vasodilators

1. Relieved by rest **Anginal pain commonly is relieved by immediate rest because rest decreases the cardiac workload.

A client develops iron deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased? 1. Ferritin level 2. Platelet count 3. White blood cell count 4. Total iron-binding capacity

1. Ferritin level **Ferritin, a form of stored iron, is reduced with iron deficiency anemia.

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

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

4. Intermittent claudication **Pain that develops during exercise is a classic symptom of peripheral arterial occlusive disease; arterial occlusion prevents adequate blood flow to the muscles of the legs, causing ischemia and pain.

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client two days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of: 1. Tissue necrosis 2. Venous thrombosis 3. Pulmonary infarction 4. Respiratory infection

1. Tissue necrosis **The body's inflammatory response to myocardial necrosis causes an elevation of temperature as well as leukocytosis within 24 to 48 hours after the event.

A nurse is teaching a health class to older adult women about heart disease. The nurse discusses the most common prodromal symptom reported by women with acute coronary heart disease that usually is not experienced by men. What response indicates that a woman understood the teaching? 1. Unusual fatigue 2. Shortness of breath 3. Crushing pain in the chest 4. Substernal pressure radiating to the neck

1. Unusual fatigue

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? (Select all that apply.) 1. Dependent rubor 2. Warm extremities 3. Ulcers on the toes 4. Thick, hardened skin 5 . Delayed capillary refill

1. Dependent rubor 3. Ulcers on the toes 5 . Delayed capillary refill **Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities. As a result, the extremities exhibit rubor while in the dependent position and pallor while elevated, ulcers on the feet and toes, cool skin, and capillary refill greater than three seconds

A client with heart failure is digitalized and placed on a maintenance dose of digoxin (Lanoxin) 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved? 1. Diuresis and decreased pulse rate 2. Increased blood pressure and weight loss 3. Regular pulse rhythm and stable fluid balance 4. Corrected heart murmur and decreased pulse pressure

1. Diuresis and decreased pulse rate

A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" From this statement the nurse determines that the client most likely is experiencing: 1. Fear 2. Depression 3. Dependency 4. Ambivalence

1. Fear

A client's diet is modified to eliminate foods that act as cardiac stimulants. The nurse should teach the client to avoid what foods? (Select all that apply.) 1. Iced tea 2. Red meat 3. Club soda 4. Hot cocoa 5 . Chocolate pudding

1. Iced tea 4. Hot cocoa 5 . Chocolate pudding

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? (Select all that apply.) 1. Lack of hair 2. Thickened toenails 3. Pain at the ulcer site 4. Diminished pedal pulse 5 . Brown skin discoloration

1. Lack of hair 2. Thickened toenails 3. Pain at the ulcer site 4. Diminished pedal pulse

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? (Select all that apply.) 1. Malaise 2. Confusion 3. Constipation 4. Swollen lymph glands 5. Oropharyngeal candidiasis

1. Malaise 4. Swollen lymph glands

A client is receiving total parenteral nutrition solution. Potassium has not been added to the solution. The nurse monitors the client for which signs of hypokalemia? (Select all that apply.) 1. Muscle weakness 2. Metabolic alkalosis 3. Cardiac dysrhythmias 4. Serum potassium of 5.5 mEq/L 5. Respiratory rate of 24 or higher

1. Muscle weakness 3. Cardiac dysrhythmias

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. What recommendation by the nurse will help the client maintain blood vessel patency? 1. Practice relaxation techniques 2. Lead a more sedentary lifestyle 3. Decrease the amount of exercise 4. Increase saturated fats in the diet

1. Practice relaxation techniques

A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? (Select all that apply.) 1. Severe fatigue 2. Sense of unease 3. Choking sensation 4. Chest pain relieved by rest 5. Pain radiating down the left arm

1. Severe fatigue 2. Sense of unease

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? (Select all that apply.) 1. Stupor 2. Erythema 3. Increased anxiety 4. Rapid respirations 5. Paresthesia in affected body parts

1. Stupor 5. Paresthesia in affected body parts

A homosexual client is diagnosed with human immunodeficiency virus (HIV). The primary nurse informed the nursing team that the client wept when told of the diagnosis. A health care team member responded by saying, "I don't feel sorry for people like that. My philosophy is that you made your bed and now you can sleep in it." What is the basis of the team member's comment? 1. Values and beliefs about sexual lifestyles. 2. Anger and mistrust of homosexuals in general. 3. Discomfort with people who are unable to control their emotions. 4. Hostility over having to care for someone with a sexually related infection.

1. Values and beliefs about sexual lifestyles.

A client is admitted with a diagnosis of a ruptured spleen. The client's blood pressure is 100/60. The nurse should assess the client for an early sign of decreased arterial pressure which is: 1. Weak radial pulses 2. Warm, flushed skin 3. Lethargy with confusion 4. Increased pulse pressure

1. Weak radial pulses **Hypovolemia occurs with decreased cardiac output and the resulting decreased arterial pressure is reflected in weak, thready peripheral pulses.

A nurse is providing dietary instruction to a client with cardiovascular disease. Which dietary selection by the client indicates the need for further instruction? 1. Whole milk with oatmeal 2. Garden salad with olive oil 3. Tuna fish with a small apple 4. Soluble fiber cereal with skim milk

1. Whole milk with oatmeal **Although oatmeal is a soluble fiber, whole milk is high in saturated fat and should be avoided.

A client with extensive bone and soft tissue injuries to the right leg is on bed rest. When positioning the client, the nurse should: 1. Keep the right leg resting straight on the bed, parallel to the left leg 2. Elevate the entire right leg with pillows, keeping the foot higher than the knee 3. Maintain both legs on the bed and use an abduction pillow to keep them separated 4. Attach a padded ankle sling to a Balkan frame to support the right foot and elevate the leg

2. Elevate the entire right leg with pillows, keeping the foot higher than the knee

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness? 1. Hepatitis A 2. Rheumatic fever 3. Spinal meningitis 4. Rheumatoid arthritis

2. Rheumatic fever

A client has an open reduction and internal fixation of a fractured hip. To prevent the most common complication after this type of surgery, the nurse expects the client's postoperative plan of care to include: 1. Routinely turning the client from side to side 2. Sequential compression stockings 3. Isometric exercises to the extremities 4. Passive range of motion (ROM) to the affected extremity

2. Sequential compression stockings

When two nurses are getting an older adult out of bed, the client reports feeling lightheaded. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? 1. Slide slowly to the floor to prevent a fall and injury. 2. Sit on the edge of the bed while they hold the client upright. 3. Bend forward because this will increase blood flow to the brain. 4. Lie down quickly so the legs can be raised above the heart level.

2. Sit on the edge of the bed while they hold the client upright.

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse expect to be listed on the client's plan of care? 1. A glass of water every hour until hydrated. 2. Small, frequent intake of juices, broth, or milk. 3. Short-term nasogastric (NG) replacement of fluids and nutrients. 4. A rapid intravenous (IV) infusion of an electrolyte and glucose solution.

2. Small, frequent intake of juices, broth, or milk.

During a blood transfusion a client develops chills and a headache. What is the priority nursing action? 1. Cover the client. 2. Stop the transfusion at once. 3. Decrease the rate of the blood infusion. 4. Notify the health care provider immediately

2. Stop the transfusion at once.

A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, the nurse on the medical-surgical unit should monitor the client for: 1. Lethargy 2. Tachycardia 3. Deep breathing 4. Abdominal pain

2. Tachycardia

A nurse provides instruction when the beta-blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? 1. Move slowly when changing positions. 2. Take the medication before going to bed. 3. Expect to feel drowsy when taking this drug. 4. Count the pulse before taking the medication.

2. Take the medication before going to bed. **Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping.

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand? 1. Plaque from within the veins is abraded. 2. The dilated saphenous veins are removed. 3. Superficial veins are anastomosed to deep veins. 4. An umbrella filter is placed in the large affected veins.

2. The dilated saphenous veins are removed.

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? 1. The signs and symptoms of pericarditis 2. The possible need for prophylactic antibiotic therapy before dental work 3. That cardiac surgery will have to be done eventually for the other valves 4. That pregnancy and childbirth are too stressful when one has this problem

2. The possible need for prophylactic antibiotic therapy before dental work **Antibiotic therapy before invasive procedures, such as dental work, is often prescribed to prevent endocarditis because these situations may introduce infectious agents systemically.

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (Select all that apply.) 1. Anorexia 2. Vomiting 3. Constipation 4 . Muscle weakness 5 . Irregular heart rate

2. Vomiting 4 . Muscle weakness 5 . Irregular heart rate

An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client? 1. "Adhere to the medical regimen." 2. "Remain normoglycemic for three weeks." 3. "Demonstrate correct use of the insulin pump." 4. "List three self-care activities that help control the diabetes."

3. "Demonstrate correct use of the insulin pump."

A client who is receiving methotrexate for acute lymphocytic leukemia (ALL) develops a temperature of 101° F. The nurse notifies the health care provider. Aspirin 650 mg every four hours as needed for temperature equal to or greater than 101° F is prescribed. What should the nurse do regarding this prescription? 1. Express concern about the dosage prescribed. 2. Request a prescription for an antacid. 3. Express concern about the type of antipyretic prescribed. 4. Ask if the frequency should be every six hours instead.

3. Express concern about the type of antipyretic prescribed.

An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? (Select all that apply.) 1. Increased high-density lipoprotein (HDL) 2. Taking an aspirin a day 3. Occasional cocaine use 4. Reduced hemoglobin level 5. African-American heritage

3. Occasional cocaine use 5. African-American heritage

A nurse is assessing a client with the diagnosis of primary hypertension. What clinical finding does the nurse identify as an indicator of primary hypertension? 1. Mild but persistent depression 2. Transient temporary memory loss 3. Occipital headache in the morning 4. Cardiac palpitation during periods of stress

3. Occipital headache in the morning

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1. Diuresis, irritability, and fever 2. Lethargy, cold skin, and hypertension 3. Thirst, cool skin, and orthostatic hypotension 4. Bounding pulse, restlessness, and slurred speech

3. Thirst, cool skin, and orthostatic hypotension

The nurse is making rounds on a patient who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? (Select all that apply.) 1. Monitor for signs of alopecia. 2. Encourage an increase in fluids. 3. Wash hands before entering the client's room. 4. Advise use of a soft toothbrush for oral hygiene. 5. Report an elevation in temperature immediately. 6. Encourage the client to eat raw, fresh fruits and vegetables.

3. Wash hands before entering the client's room. 4. Advise use of a soft toothbrush for oral hygiene. 5. Report an elevation in temperature immediately.

several days ago and has been receiving warfarin sodium (Coumadin) therapy. An international normalized ratio (INR) is performed each afternoon, and the evening warfarin sodium dose is prescribed by the health care provider on a daily basis. The nurse identifies that the afternoon INR is 4.6. The next action the nurse should take is to: 1. Contact the health care provider to request the day's dosage of warfarin sodium 2. Obtain a blood specimen to have a partial thromboplastin time performed 3. Assist with meal planning to increase the intake of foods high in vitamin K 4. Maintain the client on bed rest until the health care provider reviews the laboratory results

4. Maintain the client on bed rest until the health care provider reviews the laboratory resultsThe

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, the nurse should include: 1. Ambulating the client two hours after the procedure 2. Checking the vital signs every 15 minutes for eight hours 3. Keeping the client nothing by mouth for four hours after the procedure 4. Maintaining the supine position for a minimum of four hours

4. Maintaining the supine position for a minimum of four hours

The nurse helps a client create a list of appropriate food choices to maintain a 2-gram sodium diet that recently has been prescribed for the client. The nurse also assesses the client's cooking habits. The client tells the nurse that, at home, all food is cooked without salt. The nurse concludes that further teaching is needed when the client places what food items on the list of appropriate food choices? 1. Soft-cooked egg, salt-free toast, jelly, and skim milk 2. Baked chicken, boiled potatoes, broccoli, and coffee 3. Fillet of sole, baked potato, lettuce and tomato salad, fresh fruit cup, and milk 4. Mixed fruit salad bowl with cottage cheese, crackers, celery, sweet pickles and tea

4. Mixed fruit salad bowl with cottage cheese, crackers, celery, sweet pickles and tea

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care? 1. Elevate the foot of the bed 2. Perform urinary catheter care every 12 hours 3. Place in the high-Fowler position 4. Perform a neurovascular assessment every two hours

4. Perform a neurovascular assessment every two hours **Because of the trauma associated with the insertion of the catheter during the procedure, the involved extremity should be assessed for sensation, motor ability, and arterial perfusion; hemorrhage or an arterial embolus can occur.

A 75-year-old client has a baseline blood pressure of 140/90 mm Hg. The nurse obtains a sitting blood pressure in the client's left arm, and the reading is 160/100 mm Hg. What action should the nurse take next? 1. Advise the client to restrict fluid and sodium intake, then begin to develop a teaching plan for the client. 2. Contact the primary health care provider immediately to report the blood pressure reading. 3. Record the findings, recognizing that the result is expected for an older adult. 4. Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standing.

4. Take the blood pressure in the right arm, and then take the blood pressure in both arms while the client is standi

When performing a physical assessment, the nurse identifies bilateral varicose veins. What does the nurse expect the client to report about the legs? 1. Burning sensations in the legs. 2. Calf pain when the feet are dorsiflexed. 3. Increased sensitivity of the legs to cold. 4. Worsening ankle edema as the day progresses.

4. Worsening ankle edema as the day progresses.