MEDSURG exam 3 Chapters 33-35
A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis
C
A nurse prepares a client with acute renal insufficiency for a cardiac catheterization. The provider prescribes 0.9% normal saline to infuse at 125 mL/hr for renal protection. The nurse obtains gravity tubing with a drip rate of 15 drops/mL. At what rate (drops/min) should the nurse infuse the fluids? (Record your answer using a whole number, and rounding to the nearest drop.) _____ drops/min
31 drops/min
An emergency room nurse obtains the health history of a client. Which statement by the client should 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
. A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should 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
A
. A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences
A
. A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP 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 admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first? a. Assess the clients respiratory status. b. Draw blood to assess the clients serum electrolytes. c. Administer intravenous furosemide (Lasix). d. Ask the client about current medications
A
A nurse assesses a client who is recovering from a myocardial infarction. The clients pulmonary artery pressure reading is 25/12 mm Hg. Which action should the nurse take first? a. Compare the results with previous pulmonary artery pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the health care provider of the elevated pressures. d. Document the finding in the clients chart as the only action.
A
A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave
A
A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided 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
A nurse cares for a client with infective endocarditis. Which infection control precautions should 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 should 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 youre eating properly. c. The hospital requires that all inpatients be weighed daily. d. You need to lose weight to decrease the incidence of heart failure.
A
A nurse cares for an older adult client with heart failure. The client states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond? a. 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
A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients 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 teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this clients 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 (Cordarone) daily to prevent PACs.
A
While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next? a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.
A
A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D
A -The aortic valve is auscultated in the second intercostal space just to the right of the sternum.
A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).
A -Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should 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
A,B,C
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. Which actions should the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.
A,B,C
. A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this clients 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
A,B,D
A nurse assesses clients on a cardiac unit. Which clients should 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
A,B,D
A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.) a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.
A,B,D
A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients 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,B,D
. A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Pulmonary crackles b. Confusion, restlessness c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night
A,B,E
A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this clients teaching? (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
A,B,E
A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.) a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L c. Serum potassium: 4.0 mEq/L d. Serum creatinine: 1.0 mg/dL e. Proteinuria f. Microalbuminuria
A,B,E,F
A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP 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,C,D
. A nurse reviews a clients laboratory results. Which findings should alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL b. High-density lipoprotein cholesterol: 50 mg/dL c. Triglycerides: 200 mg/dL d. Serum albumin: 4 g/dL e. Low-density lipoprotein cholesterol: 160 mg/dL
A,C,E
A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure should the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade
A,C,E
. After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. Ill read the nutritional labels on food items for salt content. b. I will drink at least 3 liters 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.
A,D,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 should 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
A,D,E
A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention should the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide (Lasix) b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access
B
. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a. Preventricular contractions b. Atrial fibrillation c. Symptomatic bradycardia d. Sinus tachycardia
B
. A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigued. d. Dyspnea with activity
B
. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this clients medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)
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
B
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure? a. Do you have trouble breathing or chest pain? b. Are you 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 with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed? a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
B
A nurse assesses a client with pericarditis. Which assessment finding should 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
B
A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.
B
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard?(Click the media button to hear the audio clip.) a. Administer a diuretic. b. Document the finding. c. Decrease the IV flow rate. d. Evaluate the clients medications.
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? How should the nurse respond? 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 should the nurse suggest to avoid further slowing of the heart rate? 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.
B
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The clients health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the health care provider before scheduling the MRI. c. Call the physician and request a laboratory draw for cardiac enzymes. d. Instruct the client to increase fluid intake the day before the MRI.
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 clients electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.
B
A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?a. A 45-year-old who takes an aspirin daily 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.
B
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should 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.
B
A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching? 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.
B
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching? a. The best way to lose weight is a high-protein, low-carbohydrate diet. b. You should balance weight loss with consuming necessary nutrients. c. A nutritionist will provide you with information about your new diet. d. If you exercise more frequently, you wont need to change your diet.
B
A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching? a. Walk until you become short of breath, and then walk back home. b. Gather everything you need for a chore before you begin. c. Pull rather than push or carry items heavier than 5 pounds. d. Take a walk after dinner every day to build up your strength.
B
After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client? 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 unlicensed assistive personnel to bathe the client. d. Monitor potassium levels and check for symptoms of hypokalemia.
B
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800Temperature: 98 F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2 F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented .Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.
B
After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. I should wear a snug-fitting shirt over the ICD. b. I will avoid sources of strong electromagnetic fields. c. I should 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 clients understanding. Which client statement indicates a need for additional teaching? a. Ill 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. I must use an electric razor instead of a straight razor to shave.
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 the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the clients family about code status.
B -The clients rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The clients code status should already be known by the nurse prior to this event.
A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.) a. Weight gain b. Night sweats c. Cardiac murmur d. Abdominal bloating e. Oslers nodes
B,C,E
An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath
B,C,E
A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor
B,D,E
A nurse prepares a client for a pharmacologic stress echocardiogram. Which actions should the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the clients prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.
B,D,E
. 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. Which action should the nurse take? 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.
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. c. I must stop halfway up the stairs to catch my breath. d. I have experienced blurred vision on several occasions.
C
A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg.
C
A nurse assesses an older adult client who has multiple chronic diseases. The clients heart rate is 48 beats/min. Which action should the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the clients medications. d. Administer 1 mg of atropine.
C
A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Disorientation and confusion d. Numbness and tingling of the arm.
C
A nurse assesses clients on a medical-surgical unit. Which client should 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 Asian-American man with colorectal cancer c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy
C
A nurse cares for a client who is recovering from a myocardial infarction. The client states, I will need to stop eating so much chili to keep that indigestion pain from returning. How should the nurse respond? a. Chili is high in fat and calories; it would be a good idea to stop eating it. b. The provider has prescribed an antacid for you to take every morning. c. What do you understand about what happened to you? d. When did you start experiencing this indigestion?
C
A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this clients concerns? a. Administer oxygen therapy at 2 liters 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 unlicensed assistive personnel to help bathe the client.
C
A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond? 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?
C
A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability
C
After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond? a. Rapid position changes 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 decreases in blood pressure caused by position changes. d. While your heart is recovering, blood flow is diverted away from the brain, increasing the risk for stroke when you stand up.
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? How should the nurse respond? 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.
C
A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients 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.
D
A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The clients blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the clients rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take 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 -This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the clients current medications first.
. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Clients level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents
D
. A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond? a. I will consult the provider to prescribe a sleep study to determine the problem. b. You become hypoxic while sleeping; oxygen therapy via nasal cannula will help. c. A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night. d. Use pillows to elevate your head and chest while you are sleeping.
D
A nurse assesses a client after administering a prescribed beta blocker. Which assessment should the nurse expect to find? a. Blood pressure increased from 98/42 mm Hg to 132/60 mm Hg b. Respiratory rate decreased from 25 breaths/min to 14 breaths/min c. Oxygen saturation increased from 88% to 96% d. Pulse decreased from 100 beats/min to 80 beats/min
D
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take? a. Initiate oxygen therapy. b. Hold the next dose of Imdur. c. Instruct the client to drink water. d. Administer PRN acetaminophen
D
A nurse assesses a clients electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should 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 clients chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.
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 dont want to become a vegetable. How should 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?
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 nonpharmacologic comfort measure should the nurse implement? a. Apply an ice pack to the clients 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.
D
A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure 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 joules. d. Ensure that everyone is clear of contact with the client and the bed.
D
A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching? a. Avoid drinking more than 3 quarts of liquids each day. b. Eat six small 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
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? a. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers b. A 49-year-old male who reports moderate pain that is worse on inspiration c. A 53-year-old female who reports substernal pain that radiates to her abdomen d. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest.
D
. A nurse assesses a clients electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this clients ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)
D -Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.
