Perfusion

Which clinical indicators is the nurse most likely to identify when taking the admission history of a client with right ventricular failure? Select all that apply. 1 Edema 2 Vertigo 3 Polyuria 4 Ascites 5 Palpitations

1 4

A client is considered to be in septic shock when what changes are assessed in the client's labwork? 1 Blood glucose is 70-100 mg/dL 2 An increased serum lactate level 3 An increased neutrophil level 4 A white blood count of 5000 cells/µL

2

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? 1 "I am unable to run a mile (1.6 kilometers) now." 2 "I wake up at night short of breath." 3 "My wife says I snore very loudly." 4 "My shoes seem larger lately."

2

A client with coronary artery disease is scheduled for a cardiac catheterization. What should the client be able to describe if the nurse's preoperative teaching is considered effective? 1 What will occur if there is an emergency 2 What will be experienced during the procedure 3 The risks associated with this invasive procedure 4 The importance of immediate postoperative exercises

2

A nurse is caring for a client who is scheduled to have an abdominal perineal resection for colorectal cancer. The client has type B negative blood. If a blood infusion is needed, which type is preferred for administration? 1 A positive 2 B negative 3 O negative 4 AB positive

2

After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? 1 A fever may lead to diaphoresis. 2 A fever increases the cardiac output. 3 An increased temperature indicates cerebral edema. 4 An increased temperature may be a sign of hemorrhage.

2

A client just had a total hip replacement and is experiencing restlessness and changes in mentation. Which complication does the nurse consider the client may be experiencing based on these responses? 1 Bladder spasms 2 Polycythemia vera 3 Hypovolemic shock 4 Pulmonary hypertension

3

A client with a history of heart failure and hypertension is admitted with reports of syncope. Which prescribed medication should the nurse prepare to administer based on the electrocardiogram (ECG) rhythm strip image? 1 Digoxin 2 Enalapril 3 Atropine 4 Metoprolol

3

A nurse in the prenatal clinic is caring for a client with heart disease who is in her second trimester. Which hemodynamic change of pregnancy is likely to affect the client at this time? 1 Decreased red blood cell count 2 Gradually increasing size of the uterus 3 Heart rate acceleration in the last half of pregnancy 4 Increase in cardiac output during the third trimester

3

A 5-month-old infant experiences severe diarrhea and is given intravenous (IV) fluids. What is the most important reason for the nurse to closely monitor the IV flow rate? 1 Limitation of output 2 Replacement of lost fluids 3 Avoidance of IV infiltration 4 Prevention of cardiac overload

4

A client develops hydrocephalus two weeks after cranial surgery for a ruptured cerebral aneurysm. The nurse concludes that the hydrocephalus probably is related to which physiologic response? 1 Vasospasm of adjacent cerebral arteries 2 Ischemic changes in the Broca speech center 3 Increased production of cerebrospinal fluid (CSF) 4 Blocked absorption of fluid from the arachnoid space

4

The nurse provides medication discharge instructions to a client who received a prescription for digoxin following the client's myocardial infarction. Which statement by the client leads the nurse to conclude that the teaching was effective? 1 "I will avoid foods high in potassium." 2 "I must increase my intake of vitamin K." 3 "I should adjust the dosage according to my activities." 4 "It will be important to check my radial pulse rate daily."

4

A client has a discectomy and fusion for a herniated nucleus pulposus (HNP). When getting out of bed for the first time, the client reports feeling faint and lightheaded. Which instruction should the nurse provide to the client? 1 "Sit upright on edge of the bed." 2 "Slide to the floor to prevent a fall and injury." 3 "Bend forward to increase the blood flow to the brain." 4 "Lie down immediately so a blood pressure can be obtained."

1

A client is prescribed epoetin injections. To ensure the client's safety, which lab value should the nurse assess before administration? 1 Hemoglobin 2 Platelet count 3 Prothrombin time 4 Partial thromboplastin time

1

The client reports a "fluttering in my chest." The nurse analyzes the client's heart rhythm and notices that there are three P waves for each QRS complex. The waves have a sawtooth appearance. The atrial rate is 240 beats per minute, but the ventricular rate is only 80 beats per minute. The nurse notifies the primary healthcare provider for which rhythm? 1 Atrial flutter 2 Atrial fibrillation 3 Ventricular fibrillation 4 Atrial flutter with rapid ventricular response

1

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1 Bradycardia 2 Hypotension 3 Spastic paralysis 4 Bladder dysfunction 5 Increased pulse pressure

1 2 3

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse will look for potential causes. Which causes will the nurse look for in this client? Select all that apply. 1 Anxiety 2 Caffeine 3 Exercise 4 Anemia 5 Hypothermia

1 2 3 4

During a cardiovascular assessment, a nurse auscultates a client's heart and hears these sounds. How does the nurse document these sounds on the client's assessment report? 1 Cardiac murmurs 2 Third heart sound (S 3) 3 Second heart sound (S 2) 4 Pericardial friction rubs

2

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. Which response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements? 1 Increasing pulse rate 2 Slowing of the heart 3 Dilating the bronchioles 4 Reducing gastric acid secretions

2

Upon auscultating a client's heart, a nurse hears these sounds. What should the nurse document? 1 First heart sound (S 1) 2 Second heart sound (S 2) 3 Third heart sound (S 3) 4 Fourth heart sound (S 4)

2

A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? 1 Call the chaplain to convince the client to receive the blood transfusion. 2 Discuss the case with coworkers. 3 Notify the primary healthcare provider of the client's refusal of blood products. 4 Explain to the client that they will die without the blood transfusion.

3

A nurse is caring for a client with Cushing syndrome. Which cardiovascular complication should the nurse assess for in this client? 1 Chest pain 2 Tachycardia 3 Hypertension 4 Atrial fibrillation

3

A nurse is preparing medications. Which client's health problem motivates the nurse to question a prescription for a beta blocker? 1 Coronary artery disease 2 Essential hypertension 3 Acute heart failure 4 Sinus tachycardia

3

After undergoing a cardiac catheterization, the client complains of tingling sensations in the affected leg. What should the nurse do to determine the cause of the tingling? 1 Assess for bleeding at the puncture site. 2 Evaluate the affected leg for signs of inflammation. 3 Compare femoral, popliteal, and pedal pulses in both legs. 4 Obtain the temperature, pulse, respirations, and blood pressure.

3

An electrocardiogram (ECG) is prescribed for a client who reports chest pain. Which early finding does the nurse expect on the lead over the infarcted area? 1 Flattened T waves 2 Absence of P waves 3 Elevated ST segments 4 Disappearance of Q waves

3

What should the nursing care of an 8-month-old infant with tetralogy of Fallot include? 1 Restriction of fluid intake to conserve energy 2 Provision of iron-fortified formula to prevent anemia 3 Administration of coagulants to control bleeding tendencies 4 Prevention of increased respiratory effort to promote oxygenation

4

Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? Select all that apply. 1 Increase the client's intravenous (IV) flow rate. 2 Massage the client's extremities with lotion. 3 Place the client's legs in pneumatic stockings. 4 Instruct the client to avoid crossing the legs. 5 Instruct the client to dorsiflex the feet routinely.

4 5

A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse notifies the surgeon. What is the rationale for the nurse's action? 1 Graft is leaking. 2 Venous return is compromised. 3 Leg may be developing compartment syndrome. 4 Femoropopliteal arteries are becoming occluded.

1

A client is admitted to the hospital with pancytopenia as a result of chemotherapy. What should the nurse plan to teach this client in an effort to minimize the risk of complications as a result of pancytopenia? 1 Avoid traumatic injuries and exposure to infection. 2 Perform frequent mouth care with a firm toothbrush. 3 Increase oral fluid intake to a minimum of 3 L daily. 4 Report any unusual muscle cramps or tingling sensations in the extremities.

1

A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. Which is the priority nursing intervention for this client? 1 Provide pain medication. 2 Transfer to the coronary care unit. 3 Obtain a single electrocardiogram (ECG). 4 Have a blood specimen drawn for enzyme studies.

1

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). Which goal is priority during the acute phase of recovery? 1 Promote pain relief 2 Increase activity tolerance 3 Prevent cardiac dysrhythmias 4 Maintain potassium and sodium intake

1

A nurse is caring for a client in postoperative recovery who just had a central venous catheter inserted. The client begins to complain of chest pain. Upon further assessment, the nurse notes that the client has decreased breath sounds on the affected side. Which action should the nurse do first? 1 Administer oxygen as prescribed. 2 Notify the healthcare provider. 3 Assist with insertion of chest tube. 4 Continue to assess client's respiratory status.

1

The nurse prepares a list of recommended foods for a client with hypertension who is to begin a 2-gram sodium diet. Which foods should the nurse include in the list? Select all that apply. 1 Beef steaks 2 Mushrooms 3 Aged cheeses 4 Luncheon meats 5 Cooked broccoli

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A nurse is completing the admission assessment of a client with peripheral arterial disease. Which assessments will the nurse expect to observe? Select all that apply. 1 Absence of hair on the toes 2 Superficial ulcer with irregular edges 3 Pitting edema of the lower extremities 4 Reports of pain associated with exercising 5 Increased pigmentation of the medial malleolus area

1 4

The client is admitted with paroxysmal supraventricular tachycardia at a rate of 140 beats per minute. The client's blood pressure is 110/55 mm Hg, and the client is asymptomatic except for a "fluttering feeling" in the chest. Which treatments should the nurse be prepared to administer? Select all that apply. 1 Intravenous adenosine 2 Intravenous beta blockers 3 Intravenous amiodarone 4 Synchronized cardioversion 5 Intravenous calcium channel blockers

1,2,3,5

Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. Which condition does the nurse determine the client is most likely developing? 1 Renal failure 2 Hypervolemia 3 Cerebral hypoxia 4 Metabolic acidosis

3

A client admitted with the diagnosis of subarachnoid hemorrhage exhibits aphasia and hemiparesis. The nurse concludes that these neurologic deficits are caused primarily by which response? 1 Blood loss 2 Tissue death 3 Vascular spasms 4 Electrolyte imbalance

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