Exam 2 Review

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. the client reports relief from the chest pain but now he is experiencing a headache. which of the following statements should the nurse make?

"A headache is an expected adverse effect of the medication"

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

"These tests help determine the degree of damage to the heart tissues."

While auscultating a client's heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following?

A systolic murmur

A client who has a history of myocardial infarction (IM) is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication

Antiplatelet aggregate

A nurse is preparing to measure an infants vital signs. The nurse should use which of the following sites to assess a heart rate?

Apex of the heart.

A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states, "She speaks only a little English" Which of the following actions should the nurse take?

Arrange to complete the assessment with only the client and a translator present.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia?

Atropine Atropine is commonly classified as an anticholinergic or antiparasympathetic (parasympatholytic) drug. As an antimuscarinic agent, it antagonizes the muscarine-like actions of acetylcholine and other choline esters. Competitively blocks the effects of acetylcholine at muscarinic cholinergic receptors on smooth muscle, cardiac muscle, secretory gland cells, and in peripheral autonomic ganglia and the central nervous system. By blocking parasympathetic (vagal) action on the heart, atropine increases the rate of discharge by the sinus node. This enhances conduction through the atrioventricular (AV) junction, accelerating the heart rate, thereby improving cardiac output and bradycardia

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflects the client's understanding of these dietary instructions?

Beans *High in soluble fiber

A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations?

Breathing ranging from very deep to very shallow with periods of apnea

A Nurse enters a client's room and finds client pulseless, family requested DNR status from provider but provider hasn't written the prescription yet, what does the nurse do?

Call emergency response team

A nurse is performing Cardiopulmonary resuscitation (CPR) for an adult client who is unresponsive. The nurse should evaluate the client's circulation by palpating which of the following pulses?

Carotid

A nurse is assessing a client who is receiving TPN therapy via an infusion pump. Which of the following actions should the nurse take?

Change the IV tubing every 24 hr.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes respirations

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 in a provider's office is assessing an older client whose son reports that the client has been sick with respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

Confusion

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Different apical and radial pulses *Atrial fibrillation is an abnormal heart rhythm (arrhythmia) characterized by rapid and irregular beating of the atrial chambers of the heart

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake.

A nurse is providing discharge instructions to the parent of a 10 year old child following a cardiac catheterization. Which of the following instructions should the nurse include?

Give the child acetaminophen for discomfort

A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following question should the nurse ask?

Has your son had a sore throat recently? *Rheumatic fever can result from inadequately treated strep throat or scarlet fever. -Usually takes about 1 to 5 weeks after strep throat or scarlet fever for rheumatic fever to develop, which is caused by a response of the body's immune system to the earlier strep throat or scarlet fever infection, causing a generalized inflammatory response

A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?

Heparin does not dissolve clots; it stops new clots from forming.

A nurse on a medical-surgical unit is caring for four clients who are 24 to 36 hr postoperative. Which of the following surgical procedures places the client at risk for deep-vein thrombosis?

Hip arthroplasty

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitoring strip?

Pacemaker spikes before each QRS complex

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 teaching a client who takes warfarin daily. Which of the following statements by the client indicates a need for further teaching?

I have started taking ginger root to treat my joint stiffness. *Warfarin is used to slow blood clotting. Ginger can also slow blood clotting. Taking ginger along with warfarin might increase the chances of bruising and bleeding.

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 diagnosis should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion

A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. What should the nurse include in instructions?

Increase your daily intake of fiber *A common adverse effect of verapamil is constipation

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 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 preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?

It requires lying quietly on one side

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs

A nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space

A nurse in inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Median vein in the forearm

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 caring for a client who has full thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Monitor the pulmonary artery *Clients who have a large percentage of burned body surface area require critical care and accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the cardiovascular system by detecting changes in both right and left heart pressure, which can indicate possible development of pulmonary edema, as well as monitor overall fluid status.

nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client

A nurse is caring for a client who reports an area of redness, warmth, tenderness, and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?

Obtain a venous duplex ultrasound

A nurse is planning care for a client who has acute respiratory distress syndrome. Which of the following interventions should the nurse include in the plan?

Place in prone position

A nurse is caring for a client who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer on the event of an overdose?

Protamine Protamine sulfate is a specific reversal agent used to reverse the effect of heparin. Due to the overall negative charge of heparin, the positively charged protamine competes with the thrombin-binding site of heparin and effectively blocks its anticoagulation effect

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 caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Suppress Respiratory Effort

A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse include?

Swallow the capsule whole

A nurse is teaching a client who has angina pectoris about starting therapy with SL nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

Take one tablet at the first indication of chest pain

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider?

The client has a history of bronchial asthma

A nurse is completing a medical interview with a client who has elevated cholesterol levels and takes warfarin. The nurse should recognize that which of the following actions by the client can potentiate the effects of warfarin?

The client uses garlic to lower cholesterol levels.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min 5 days a week.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound s1. the nurse should document this finding as which of the following heart sounds?

The fourth heart sound (S4)

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches the therapeutic level.

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

What brought you to the hospital?

a nurse in a coronary care unit is admitting a client who has had CPR following a cardiac arrest. The client is receiving a lidocaine IV at 2 mg/min when the client asks the nurse why he is receiving that medication the nurse should explain that this has which of the following actions?

prevents dysrhythmias