MedSurg Exam 2
B, D, E
A RN assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action? A. BP 140/88 B. K 2.9 C. Warmth and redness D. Expanding groin hematoma E. Rhythm changes on the cardiac monitor F. O2 sat 93 on RA
C
A client asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." C. "It is hypertension with no specifie cause. d. "It refers to severe and life-threatening hypertension."
a
A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes.
c
A client had an acute MI. What assessment finding indicates to teh nurse that a significant complication has occured? a. BP 20 mmHg below baseline b. SpO2 94% RA c. poor peripheral pulses and cool skin d. urine output of 1.2 mL/kg/hr for 4 hrs
B
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take vour medicine or you will get kidney failure."
B
A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their trends. b. Ensure that the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowler position.
B
A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.
B
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes that the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b.Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.
b
A client has presented to the ED with an acute MI. What action by the RN is best for optimal client outcomes? a. obtain an ECG within 20 min b. give the client a nonenteric coated aspirin c. notify the Rapid Response team immediately d. prep to admin thrombolytics within 30 min
c
A client in the cardiac stepdown unit reports severe, crushing CP accompanied by N/V. What action takes priority by the nurse? a. Admin aspirin b. call for ECG c. maintain airway patency d. notify provider
b, d, e
A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.
A
A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. "Do you have any concerns about sexuality?" b. "I'm glad to hear you are sleeping well now." c. "Sleep near your spouse in case of emergency." d. "Why would you move into the guest room?"
B
A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's Oz saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.
D
A client is in the pre-op holding area prior to an emergency CABG. The client is yelling at the family members and tells the Dr. to "just get this over with" when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area b. inform the client that this behavior is unacceptable c. stay out of the room to dec the client's stress levels d. tell the client that anxiety is common and that you can help
C
A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the client's pupillary responses. b. Request a neurologic consultation. c. Call the primary health care provider immediately. d. Take and document a full set of vital signs.
a
A client is to receive a dopamine infusion. What does the nurse do to prepare for this infusion? a. Gather central line supplies. b. Mark the client's pedal pulses c. Monitor the client's vital signs. d. Ensure an accurate weight is charted.
c
A client pressents to the ED with an acute MI at 15:00. The facility has a 24-hr cath lab abilities. To improve client outcomes, by what time would the client have a percutaneous coronary intervention performed? a. 15:30 b. 16:00 c. 16:30 d. 17:00
B
A client received tissue plasminogen activator (‹PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurst is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."
D
A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.
B
A client with CAD asks the nurse about taking fish oil supplements. What response by the nurse is best? a. fish oil is contraindicated with most drugs for CAD b. the best source is fish, but pills have benefits too c. there isn't any evidence to support fish oil use with CAD d. you can reverse CAD totally with diet and supplements
C
A nurse administers prescribed adenosine to a client. Which response would the nurse assess for as the expected therapeutic response? a. Decreased intraocylar pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis
A
A nurse admits a client who is experiencing an exacerbation of heart failure. What action would the nurse take first? a. Assess the client's respiratory status. b. Draw blood to assess the client's serum electrolytes. c. Administer intravenous furosemide. d. Ask the client about current medications.
C
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."
B
A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure? a. "I sleep with four pillows at night." b. "My shoes fit really tight lately." c. "I wake up coughing every night." d. "I have trouble catching my breath.'
D
A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? A. BP inc from 98/42 to 132/60 B. Resp rate dec from 25 to 14 C. SPO2 inc from 88 to 96 D. Pulse dec from 100 to 80 bpm
D
A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take? a. Initiate oxygen therapy. b. Hold the next dose. c. Instruct the client to drink water. d. Administer PRN acetaminophen.
C
A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I have been drinking more water than usual." b. "I am awakened by the need to urinate at night." с. "I must stop halfway up the stairs to catch my breath." d. "I have experienced blurred vision on several occasions."
A
A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min
B
A nurse assesses a client who has a history of heart failure. Which question would the nurse ask to assess the extent of the client's heart failure? a. Do you have trouble breathing or chest pain?"* b. Are you still able to walk upstairs without fatigue?"* c. Do you awake with breathlessness during the night?" d. "Do you have new-onset heaviness in your legs?'
B
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia would the nurse assess? a. Preventricular contractions b. b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia
C
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg stic examination, Critical rescue
a, b, c, f
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings would alert the nurse to the possibility of heart transplant rejection? (Select all that apply.) a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia d. Increased ejection fraction e. Hypertension f. Fatigue
A
A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client's chart as the only action
D
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a.Client's level of anxiety b.Ability to turn self in bed c.Cardiac rhythm and heart rate d.Allergies to iodine-based agents
B
A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity
B
A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would alert the nurse to the possibility that the client's stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted svstolic murmur d. Upper extremity weakness
B
A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect to find? a. Heart rate that speeds up and slows down. b. Friction rub at the left lower sternal border. c. Presence of a regular gallop rhythm. d. Coarse crackles in bilateral lung bases.
A
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Midsternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
D
A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How would the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
A
A nurse assesses a pt who has aortic regurgitation. In which location in the pic would be best to hear a cardiac murmur related to aortic regurgitation? A B C D
C
A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.
A
A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at greatest risk for the development of left ended heart failure? a. A 36-year-old woman with aortic stenosis b. A 42-year-old man with pulmonary hypertension c. A 59-year-old woman who smokes cigarettes daily d. A 70-year-old man who had a cerebral vascular accident
A, b, d
A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.) a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery c. A 59-year-old woman recovering from a hysterectomy d. An 80-year-old man with a bacterial infection of the respiratory tract e. An 88-year-old woman with a stage III sacral ulcer
C
A nurse assesses clients on a med-surg floor. Which client woudl the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates.
C
A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm
A
A nurse assists a client showing VTach on the monitor. What action does the nurse take first? What action would the nurse take first? a. Assess airway, breathing, and circulation. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. d. Begin cardiopulmonary resuscitation (CPR).
B
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What action would the nurse take prior to the cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure that a tongue blade is available. d. Position the client on the left side.
B
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse? a. "The prosthetic valve places you at greater risk for a heart attack." b. "Blood clots form more easily in artificial replacement valves. c. "The vein taken from your leg reduces circulation in the leg." d. "The surgery left a lot of small clots in your heart and lungs.
B
A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. a. Make certain that your bath water is warm. b. Avoid straining while having a bowel movement." c. Limit your intake of caffeinated drinks to one a day." d. Avoid strenuous exercise such as running.
D
A nurse cares for a client who has advanced cardiac disease and states, "I'm having trouble breathing while sleeping at night." What is the nurse's best response? A. I will consult your HCP to prescribe a sleep study B. You become hypoxic while sleeping; O2 therapy via NC will help C. A continuous CPAP will help you breathe at night D. Use pillows to elevate your head and chest while sleeping
B
A nurse cares for a client who has an 80% blockage of the Right coronary artery and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? A. Compare the results with previous BP readings B. Inc the IV fluid rate because these readings are low C. Immediately notify HCP of the elevated BP D. Document the findings in the client's chart as the only action
B
A nurse cares for a client who is prescribed MRI of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a.Schedule an electrocardiogram just before the MRI. b.Notify the primary health care provider before scheduling the MRI. c.Request lab for cardiac enzymes from the primary health care provider. d.Instruct the client to increase fluid intake the day before the MRI.
a, c, e
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction c. Cardiac tamponade e. Dysthythmias
B
A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. What action would the nurse take next? a. Administer intravenous diltiazem. b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.
C
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What intervention would the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 L per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask assistive personnel (AP) to help bathe the client.
A, C, E
A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output
D
A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How would the nurse respond? a. Would you like to speak with a priest or chaplain?" b. I will arrange for a psychiatrist to speak with you." c. Do you want to come off the transplant list?" d. Would you like information about advance directives?"
A
A nurse cares for a client with infective endocarditis. Which infection control precautions would the nurse use? a. Standard Precautions b. Bleeding Precautions c. Reverse isolation d. Contact isolation
A
A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How would the nurse respond? a. "Weight is the best indication that you are gaining or losing fluid." b. "Daily weights will help us make sure that you're eating properly." c. c. "The hospital requires that all clients be weighed daily. d. "You need to lose weight to decrease the incidence of heart failure."
C
A nurse cares for a pt who is recovering from a MI. The pt states "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? A. Chili is high in fat and cal; it would be best to stop eating it B. the HCP has prescribed and antacid every morning C. What do you understand about what happend to you D. When did you start experiencing this indigestion
A
A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die What is the best response by the nurse? A. I can stay if you would you like to talk more about this. B. You are lucky to have such a devoted daughter." C. It is normal to feel as though you are a burden." D. Would you like to meet with the chaplain?"
A, c, d
A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive heart failure. Which instructions would the nurse provide to the AP when delegating care for this client? (Select all that apply.) A. Reposition the client every 2 hours." B. Teach the client to perform deep-breathing exercises." C. Accurately record intake and output." d. Use the same scale to weigh the client each morning." e. Place the client on oxygen if the client becomes short of breath."
A, b, e, f
A nurse evaluates laboratory results for a client with heart failure. Which results would the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L (130 mmol/L) c. Serum potassium: 4.0 mEg/L (4.0 mmol/L) d. Serum creatinine: 1.0 mg/dL. (88.4 mcmol/L) e. Proteinuria f. Microalbuminuria
B
A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication would the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol b. Warfarin c. Atropine d. Lidocaine
A, b, e
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations would the nurse assess? (Sefect all that apply.) a. Pulmonary crackles b. Confusion c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night f. Jugular venous distention
A
A nurse is assessing a client with peripheral artery disease (PAD). The client states that walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. "Could you walk further than that a few months ago?" b."Do you walk mostly uphill, downhill, or on flat surfaces?" c. "Have you ever considered swimming instead of walking?" d. "How much pain medication do you take each day?
B
A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily. b. b. A 50-year-old who is post coronary artery bypass graft surgery. c. A 78-year-old who had a carotid endarterectomy. d. An 80-year-old with chronic obstructive pulmonary disease.
D
A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits C. Classifying capillary filling of 4 seconds as normal d. Palpating both carotid arteries at the same time
a, c, e
A nurse is caring for a client who had CABG 2 days ago. What actions does the nurse delegate to AP? a. assist the client to the chair for meals and commode b. encourage the client to use the spirometer Q4 hrs c. ensure that the client wears TED hose or sequential compression devices d. have the client rate their pain 0-10 and report to nurse e. take and record a fulls set of vitals per hospital protocol
A
A nurse is caring for a client who had a myocardial infarction. The nurse is confused because the client states that nothing is wrong and yet listens attentively while the nurse provides education on lifestyle changes and healthy menu choices. What response by the charge nurse is best? a. Continue to educate the client on possible healthy changes." b. Emphasize complications that can occur with noncompliance." c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.
a
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action would the RN perform first for comfort? a. allow family members to stay at the bedside b. ask the family if the client would like a fan in the room c. keep the TV tuned to the client's favorite channel d. speak loudly to the client in case of hearing problems
A, c, e
A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM). What interprofessional care does the nurse anticipate providing? (Select all that apply.) a. Administering beta blockers b. Administering high-dose furosemide c. Preparing for a cardiac catheterization d. Loading the client on digitalis c. e. Instructing the client to avoid strenuous exercise f. Teaching the client how to use the CardioMEMS™
D
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologie comfort measure would the nurse implement? a. Apply an ice pack to the client's chest. b. Provide a neck rub, especially on the left side. c. Allow the client to lie in bed with the lights down. d. Sit the client up with a pillow to lean forward on.
A, B, C
A nurse is caring for a pt with a hx of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? SATA A. Assess for iodine allergies B. Admin IV fluids C. Assess BUN and Cr results D. Insert a foley E. Admin prophylactic abx F. Insert a central venous catheter
B
A nurse is caring for four clients. Which client would the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety c. Client who is post coronary artery bypass, with chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L)
B
A nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg. d. Client who needs pain medication prior to a dressing change of a surgical wound.
B
A nurse is in charge of thecoronary intensive care unit. Which client would the nurse see first? a. client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. client who is 1-day post CABG, whith BP 88/64 mmHG c. client who is 1-day post percutaneous coronary intervention, going home this morning d. Client who is 2-day post CABG, who became dizzy this morning while walking
A
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics
B
A nurse is providing discharge teaching to a client recovering from a heart transplant. Which statement would the nurse include? A. Use a soft-bristled toothbrush and avoid flossing." b. "Avoid large crowds and people who are sick" c. "Change positions slowly to avoid hypotension." d. Check your heart rate before taking the medication.'
a, c, d, e
A nurse is studying hemodynamic monitoring. Which measurements are correctly matched with the physiologic cause? (Select all that apply.) a. Right atrial pressure 12 mm Hg: right ventricular failure b. Right atrial pressure 4 mm Hg: hypovolemia c. Pulmonary artery pressure 20/10 mm Hg: normal finding d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation e.Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction
A, B, D
A nurse is teaching a client who has premature ectopic beats. Which education would the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium f. f. Types of aerobic exercise
A
A nurse is teaching a client with heart failure who has been prescribed enalapril. Which statement would the nurse include in this client's teaching? a. "Avoid using salt substitutes." b. "Take your medication with food." c. "Avoid using aspirin-containing products." d. "Check your pulse daily.
A
A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."
A
A nurse is working with a client who takes clopidogrel. The client's recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.
b, c, d, e
A nurse learns about modifiable risk factors for CAD. Which factors does this include? SATA a. age b. HTN c. obesity d. smoking e. stress f. gender
B
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."
C
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 L per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes bradycardia. What does the nurse do first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.
c
A nurse prepares a client for CABG. The client states, "I am afraid I might die." What is the nurse's best response? a. This is a routine surgery and the risk of death is very low b. would you like to speak with a chaplain prior to surgery? c. tell me more about your concerns about the surgery d. what support systems do you have to assist you
b, d, e
A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a.Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. c. e. Explain to the client that dobutamine will simulate exercise for this examination.
D
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client? a. Make sure that the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 J. d. Ensure that everyone is clear of contact with the client and bed
b, c, d, f
A nurse prepares to discharge a client who has heart failure. Based on national quality measures, what actions would the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about energy conservation techniques. b. Ensure that the client is prescribed a beta blocker. c. Document a discussion about advanced directives. d. Confirm that a postdischarge nurse visit has been scheduled. e. Consult a social worker for additional resources. f. Care transition record transmitted to next level of care within 7 days of discharge.
A, b, d
A nurse prepares to discharge a client who has heart failure. Which questions would the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.) a. Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" c. Will you be able to afford your oxygen therapy?" d. What spiritual beliefs may impact your recovery?" e. Are you able to accurately weigh yourself at home?"
A
A nurse prepares to discharge a client with a cardiac dysrhythmia who is prescribed home health care services. Which priority information would be communicated to the home health nurse upon discharge? a. Medication orders for home b. Immunization history c. Religious beliefs d. d. Nutrition preferences
C
A nurse preps a client for cardiac catheterization. The client states, "I'm afraid I might die". What's the nurse's best response? A. This is a routine test and the risk for death is very low B. Would you like to speak with a chaplain prior to test C. Tell me more about your concerns of the test D. What support systems do you have to assist you
A, c, e
A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL. (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 memol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)
a, b, d, e
A nurse studying acute coronary syndromes learns that the pain of a MI differs from stable angina in what ways? a. accompanied by SOB b. feelings of fear or anxiety c. lasts less than 15 min d. no relief from taking nitroglycerin e. pain occurs without known cause f. can be precipitated by exertion or stress
A
A nurse supervises an assistive personnel (AP) applying electrocardiographie monitoring. Which statement would the nurse provide to the AP related to this procedure? a. "'Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them. c. "Place the electrodes on the posterior chest. d. "Turn off oxygen prior to monitoring the client.
A
A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement would the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." C. "Use your oxygen when you experience PACs." d. "Take amiodarone daily to prevent PACs."
D
A nurse teaches a client who has a history of heart failure. Which statement would the nurse include in this client's discharge teaching? A. Avoid drinking more than 3 quarts (3 L) of liquids each day B. "Eat six sinall meals daily instead of three larger meals." C. "When you feel short of breath, take an additional diuretic." D. "Weigh yourself daily while wearing the same amount of clothing."
D
A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse include in this client's teaching? a. "Avoid taking aspirin or aspirin-containing products." b. "Increase your intake of foods that are high in potassium." c. "Hold this medication if your pulse rate is below 80 beats/min. d. "Do not take this medication within 1 hour of taking an antacid."
A, B, E
A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client's teacling? (Select all that apply.) a. Until your incision is healed, do not submerge your pacemaker. Only take showers." b. Report any pulse rates lower than your pacemaker settings." C. "If you feel weak, apply pressure over your generator."* d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI).' e. "'Do not lift your left arm above the level of your shoulder for 8 weeks.
B
A nurse teaches a client with diabetes mellitus and a BMI of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in the client's teaching? A. The best way to lose weight is a high-protein, low-carb diet B. You should balance weight loss with consuming necessary nutrients C. A nutritionist will provide you with info of your new diet D. If you exercise more often, you won't need to change your diet
B
A nurse teaches a client with heart failure about energy conservation. Which statement would the nurse include in this client's teaching? a. Walk until you become short of breath, and then walk back home." b. Begin walking 200 feet a day three times a week." c. Do not lift heavy weights for 6 months." d. Eat plenty of protein to build your strength
C
A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
B
After administering the first dose of captopril to a client with heart failure, the nurse implements interventions to decrease complications. Which intervention is most important for the nurse to implement? a. Provide food to decrease nausea and aid in absorption. b. Instruct the client to ask for assistance when rising from bed. c. Collaborate with assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia
B
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? a. "I would wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields. C. "I would participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication.
B
After teaching a client who is being discharged home after mitral valve replacement surgery. the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a. "TIl be able to carry heavy loads after 6 months of rest." b. "I will have my teeth cleaned by my dentist in 2 weeks." c. "I must avoid eating foods high in vitamin K, like spinach." d. "T must use an electric razor instead of a straight razor to shave."
C
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How would the nurse respond? a. "Rapid position changed can create shear and friction forces, which can tear out your internal vascular sutures. b. Your new vascular connections are more sensitive to position changes, leading to increased intravascular pressure and dizziness. C. Your new heart is not connected to the nervous system and is unable to respond to d. decreases in blood pressure caused by position changes." While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up.
a, d, e
After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. "I'll read the nutritional labels on food items for salt content." b. "T will drink at least 3 L of water each day." c. "Using salt in moderation will reduce the workload of my heart." d. I will eat oatmeal for breakfast instead of ham and eggs." e. Substituting fresh vegetables for canned ones will lower my salt intake." f. Salt substitutes are a good way to cut down on sodium in my diet."
B, C, E
An ED nurse assesses a female client. Which findings would alert teh nurse to request a prescription for an ECG? SATA A. HTN B. fatigue despite adequate rest C. Indigestion D. Abd Pain E. SOB
D
An ED nurse triages pt who present with chest discomfort. Which pt would the nurse plan to assess first? A. Pt who describes a dull ache B. Pt who reports moderate pain that is worse on inspiration C. Client who reports cramping substernal pain D. Pt who describes intense squeezing pressure across the chest
A
An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month."
a
An older adult is on cardiac monitoring after an MI. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. assess for any hemodynamic effects of teh rhythm b. prep to admin antidysrhythmic meds c. notify HCP or call the rapid response team d. turn the alarms off on the cardiac monitor
D
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "T'm glad I get energy assistance so my house isn't so cold." c. "My daughter makes sure I have plenty of lotion for my feet." d."My hands shake when I try to do things requiring coordination
b, c, f
Prior to discharge, a client who had an acute myocardial infarction and coronary artery bypass graft asks the nurse about sexual activity. What information does the nurse provide? (Select all that apply.) a. "You will need to wait at least 6 weeks before intercourse.' b. "Your usual sexual activity is not likely to damage your heart." c. "Start having sex when you are most rested, like in the morning." d. "When you can climb four flights of stairs, you can tolerate sex." e. "Don't eat for three hours before engaging in sexual activity." f. "Use a comfortable position that doesn't stress your incision."
C
The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" What is the nurse's best response? a. "Substance abuse puts clients at risk for many health issues. b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse.
B
The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows VFib. After calling for assistance and a defibrillator, what action would the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.
b
The nurse is caring for a client with a chest tube after a CABG. The drainage stops suddenly. What action by the nurse is most important? a. inc the setting on the suction b. notify HCP immediately c. reposition the chest tube d. take the tubing apart to asseses for clots
A
The nurse is caring for four hypertensive clients. Which drug--laboratory value combination would the nurse report immediately to the health care provider? a. Furosemide/potassium: 2.1 mEq/L b. Hydrochlorothiazide/potassium: 4.2 mEq/L c. Spironolactone/potassium: 5.1 mEq/L d. Torsemide/sodium: 142 mEq/L
B
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, combread, peas d. Spaghetti with meat sauce, garlic bread
D
The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. assess VS b. don a mask and gown c. gather supplies d. perform hand hygiene
c
The primary health care provider requests the nurse start an infusion of milrinone on a client. How does the nurse explain the action of this drug to the client and spouse? a. "It constricts vessels, improving blood flow." b. "It dilates vessels, which lessens the work of the heart." c. "It increases the force of the heart's contractions." d. "It slows the heart rate down for better filling."
A
While assessing a client on a cardiac unit, a nurse identifies the presence of an S; gallop. What action would the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the primary health care provider immediately. d. Transfer the client to the intensive care unit.
