quiz 4 week 6 NU 230

A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?a. Anorexiab. Painc. Nausead. Hair loss

B

5. 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

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."

A

12. 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.

A

19. A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?a. Location Ab. Location Bc. Location Cd. Location D

A

Which early reaction is most common in clients with chest discomfort associated with unstable angina or myocardial infarction (MI)?A. DepressionB. AngerC. FearD. Denial

D

1. 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/minb. Cool, clammy skinc. Oxygen saturation of 90%d. Respiratory rate of 8 breaths/min

A

A nurse discusses inpatient hospice with a client and the clients family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond?a. The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.b. Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.c. A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given.d. Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility.

A

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezesc. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretionsd. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool

A

A nurse is caring for a client who is terminally ill. The clients spouse states, I am concerned because he does not want to eat. How should the nurse respond?a. Let him know that food is available if he wants it, but do not insist that he eat.b. A feeding tube can be placed in the nose to provide important nutrients.c. Force him to eat even if he does not feel hungry, or he will die sooner.d. He is getting all the nutrients he needs through his intravenous catheter.

A

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the wound care nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

A

How soon does the nurse expect anginal pain to begin subsiding after administering sublingual nitroglycerin to a client with chronic stable angina?A. 1-2 minutesB. 5-6 minutesC. 10-12 minutesD. 15-20 minutes

A

How would the critical care nurse assess for postoperative bleeding in a client who just had CABG surgery?A. Measure mediastinal and pleural chest tube drainage at least once an hour and report drainage amount over 150 mL/hr to the surgeon.B. Measure mediastinal and pleural chest tube drainage at least once a shift and report drainage amount over 50 mL/hr to the surgeon.C. Assess the sternal dressing for bleeding every 4 hours, then reinforce with sterile gauze as needed and report the approximate amount of bleeding to the surgeon.amount of serous drainage as well as pain to the surgeon.

A

The nurse is assessing a client on admission to the hospital. The client's leg appears as shown below: What action by the nurse is best? a. Assess the client's ankle-brachial index. b. Elevate the client's leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium

A

What priority question would the nurse ask before administering SL nitroglycerin to a middle-aged male client with chest pain?A. "Have you taken a medication for erectile dysfunction within the past 24 to 48 hours?"B. "Do you have a family history of heart disease, especially parents and grandparents?"C. "Have you experienced any other symptoms with your chest pain?"D. "What were you doing when the chest pain started?"

A

Which finding would the nurse expect when a client experiences a non-ST-segment elevation MI (NSTEMI)?A. ST depression and T-wave inversion on a 12-lead ECGB. Cardiac dysrhythmiasC. Immediate elevation of troponin levelsD. ST elevation in two contiguous leads on a 12-lead ECG

A

Which manifestation would the nurse expect with a client labeled class I on the Killip scale for heart failure?A. Clear lung sounds and absence of S3B. Crackles in the lower half of the lung fields and possible S3C. Crackles more than halfway up the lung fields and frothy sputumD. Systolic blood pressure less than 90 mm Hg and oliguria

A

Which statement by a client indicates to the nurse correct understanding of resuming sexual activity in the presence of angina?A. "When I can climb two flights of stairs, it is safe to resume sexual activity."B. "It is best to resume sexual activity in the evening before I go to sleep."C. "If I am unable to walk at least a mile, it is unsafe for me to resume sexual activity."D. "I will discuss alternative methods with my partner as I will no longer be able to resume my previous level of sexual activity."

A

1. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would 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 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 breathb. Abdominal bloatingc. New-onset bradycardiad. Increased ejection fractione. Hypertension

A, B, C

For which manifestations would the nurse monitor when providing care for a client prescribed beta-blocker therapy? Select all that apply.A. DepressionB. BradycardiaC. Decreased level of consciousnessD. Increased urine outputE. Crackles or wheezes in the lungsF. Chest discomfort

A, B, C, E, F

Which findings would the nurse expect when assessing a client with chronic stable angina? Select all that apply.A. Chest discomfort that occurs in a pattern that is familiar to the clientB. Chest discomfort that occurs with moderate to prolonged exertionC. Frequency, duration, and intensity of symptoms remain the same over several monthsD. Results in moderate limitation of activityE. Usually treated with rest and nitroglycerin (NTG)F. Pain lasts less than 15 minutes

A, B, C, E, F

Which statements about coronary artery disease and women are accurate? Select all that apply.A. Postmenopausal women in their 70s have the same incidence of myocardial infarction (MI) as men.B. Women have smaller coronary arteries and frequently have plaque that breaks off and travels into the small vessels to form an embolus.C. The older a woman is the more likely she is to have coronary artery disease.D. More men than women die within a year after a MI.E. Women whose parents had CAD are more susceptible to the disease.F. Many women experience atypical angina as indigestion, pain between shoulders, aching jaw, and a choking sensation.

A, B, C, E, F

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 surgeryc. A 59-year-old woman recovering from a hysterectomyd. An 80-year-old man with a bacterial infection of the respiratory tracte. 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 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, B, D

Which alternative therapies may be helpful in reducing a client's anxiety about progressive activity postoperatively and during rehabilitation? Select all that apply.A. Guided imageryB. Progressive muscle relaxationC. AcupunctureD. Music therapyE. Pet therapyF. Herbal remedies

A, B, D, E

Which signs and symptoms indicate to the nurse that a client with a myocardial infarction and heart failure is going into cardiogenic shock? Select all that apply.A. Cold, clammy skin with poor peripheral pulsesB. Pulmonary congestion and tachypneaC. Bradycardia and hypertensionD. Urine output less than 0.5 to 1 mL/kg/hrE. Agitation, restlessness, or confusionF. Systolic BP less than 100 mm Hg

A, B, D, E

Which statements about the use of thrombolytic agents for a client with an acute myocardial infarction are accurate? Select all that apply.A. Clients who cannot receive timely percutaneous coronary intervention (PCI) with indications of ST elevation myocardial infarction (STEMI) should be considered for fibrinolytic therapy.B. A client who has received a thrombolytic agent must be carefully monitored before, during, and after the drug is given.C. Thrombolytic therapy is indicated for chest pain of less than 15 minutes duration that is relieved by nitroglycerin.D. The client must be assessed for absolute and relative contraindications before a thrombolytic agent is administered.E. Monitor for bleeding which is a major risk when a client receives thrombolytic therapy.F. Indications that the clot has been dissolved and the artery reperfused include sudden onset of ventricular dysrhythmias.

A, B, D, E, F

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 cracklesb. Confusion, restlessnessc. Pulmonary hypertensiond. Dependent edemae. Cough that worsens at night

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/Lc. Serum potassium: 4.0 mEq/Ld. Serum creatinine: 1.0 mg/dLe. Proteinuria f. Microalbuminuria

A, B, E, F

Which are characteristics the nurse would expect to find in a client with unstable angina (USA)? Select all that apply.A. Chest pain occurs at rest or with exertionB. Pain causes severe limitation of activitiesC. Includes chronic stable angina, vasospastic angina, and new-onset anginaD. Presents with ECG changes and elevation of troponin levelsE. Ischemia does not cause myocardial damage or cell deathF. The pain or pressure is poorly relieved by nitroglycerin

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

Which observations would the nurse expect when a client develops mediastinitis after CABG surgery? Select all that apply.A. Anginal-type chest painB. Fever continuing beyond the first 4 days after surgeryC. Bogginess of the sternumD. Redness and drainage from the suture siteE. Induration or swelling at the suture siteF. Decreased white blood cell count

A, C, D, E

Which absolute contraindications would the nurse assess for when a client is being considered for thrombolytic therapy? Select all that apply.A. Any prior intracranial hemorrhageB. History of chronic, severe, poorly controlled hypertensionC. Suspected aortic dissectionD. Known malignant intracranial neoplasm (primary or metastatic)E. Severe uncontrolled hypertension on presentation (SBP >180 mm Hg)F. Active bleeding or bleeding diathesis (excluding menses)

A, C, D, F

Which clients are potential candidates for coronary artery bypass graft (CABG) surgery? Select all that apply.A. Client with angina and greater than 50% occlusion of the left main coronary artery that cannot be stentedB. Client with unstable angina with moderate one-vessel disease appropriate for stentingC. Client with valvular diseaseD. Client with coronary vessels unsuitable for percutaneous coronary intervention (PCI)E. Client with acute myocardial infarction (MI) that is responding to medical therapyF. Client with ischemia or impending MI after angiography or PCI

A, C, D, F

Which essential preoperative teaching would the nurse provide to a client scheduled for CABG surgery using the traditional procedure? Select all that apply.A. There will be a sternal incision.B. Coughing will be avoided to keep stress off of the sternal incision.C. There will as many as three chest tubes in place after the surgery.D. An indwelling urinary catheter will be in place to drain urine.E. You will be on bedrest for up to 48 hours after the surgery.F. An endotracheal tube will prevent talking immediately after surgery.

A, C, D, F

4. 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 mcmol/L)e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

A, C, E

6. 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 e. Cardiac tamponade f. Dysrhythmias

A, C, E

Which essential points would the nurse include when teaching a client with coronary artery disease how to manage activity at home? Select all that apply.A. Begin by walking the same distance at home as in the hospital (usually 400 feet) three times each day.B. Check your pulse before and after you exercise.C. Always carry a bottle of nitroglycerin with you.D. Stop your activity if your pulse increases by 10 beats/min.E. Exercise outdoors when the weather is pleasant.F. Avoid straining (lifting, push-ups, pull-ups, and straining at bowel movements).

A, C, E, F

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. "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

Which are post-administration nursing responsibilities when caring for a client who received thrombolytic therapy? Select all that apply.A. Observe all IV sites for bleeding and patency.B. Document the client's emotional reaction to the thrombolytic therapy.C. Monitor white blood cell (WBC) count and differential.D. Test stool, urine, and emesis for occult blood.E. Monitor clotting study values.F. Observe for signs of internal bleeding (e.g., blood pressure).

A, D, E, F

Which indicators of metabolic syndrome would the nurse expect in a client with heart failure? Select all that apply.A. Blood pressure of 130/86 mm Hg while taking a beta blockerB. Large waist of 35 inches (88 cm) or greater for menC. HDL-C greater than 40 mg/dL for menD. Increased fasting glucose of 100 mg/dL or higherE. Increased level of triglycerides of 150 mg/dL or higherF. Decreased LDL-C of less than 50 mg/dL for women

A, D, E, F

We have an expert-written solution to this problem! nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider has informed the client about possibly needing to amputate the client's leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)a. Ask the client to describe his or her current emotions.b. Assess the client for support systems and family.c. Offer to stay with the client if he or she desires.d. Relate how smoking contributed to this situation.e. Tell the client that many people have amputations.f. Arrange for an amputee to come visit the client.

ABC

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

ABD

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.)a. Teach family members about physical signs of impending death.b. Encourage the management of adverse symptoms.c. Assist family members by offering an explanation for their loss.d. Encourage reminiscence by both client and family members.e. Avoid spirituality because the clients and the nurses beliefs may not be congruent.

ABD

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client's plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

ABD

The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are most concerning? (Select all that apply.a. Elevated low-density lipoprotein (LDL-C b. Decreased levels of high-density lipoprotein cholesterol (HDL-C)c. Asian ethnicity d. History of smoking e. Blood pressure: 142/92 mm Hg on one occasion

ABD

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this clients pain management plan? (Select all that apply.)a. Play music that the client enjoys.b. Massage tissue that is tender from radiation therapy.c. Rub lavender lotion on the clients feet.d. Ambulate the client in the hall twice a day.e. Administer intravenous morphine.

AC

A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.)a. Can communicate his treatment preferencesb. Is able to read and write at an eighth-grade levelc. Is oriented enough to understand information providedd. Can evaluate and deliberate informatione. Has completed an advance directive

ACD

A client is being discharged on warfarin therapy. What discharge instruction is the nurse required to provide? (Select all that apply.)a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication f. Wearing a Medic Alert bracelet

ACDE

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosisb. Down syndromec. Frequent heartburnd. History of hypertensione. History of smokingf. Hyperlipidemia

ADEF

Which postprocedure medications would the nurse teach about, before discharge, to a client who had a percutaneous coronary intervention (PCI)? Select all that apply.A. FurosemideB. ClopidogrelC. MetoprololD. Isosorbide dinitrateE. DocusateF. Aspirin

B, C, D, F

2. An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)a. Hypertensionb. Fatigue despite adequate restc. Indigestiond. Abdominal paine. Shortness of breath

B, C, E

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)a. Weight gainb. Night sweatsc. Cardiac murmurd. Abdominal bloatinge. Osler's nodes

B, C, E

A client presents to the emergency department with a thoracic aortic aneurysm. Which findings are most consistent with this condition? (Select all that apply.)a. Abdominal tendernessb. Difficulty swallowingc. Changes in bowel habitsd. Shortness of breathe. Hoarseness

BE

11. A nurse cares for a client who is prescribed magnetic resonance imaging (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.

B

13. 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 would the nurse be prepared to implement while this client waits for surgery?a. Administration of IV furosemideb. Initiation of an external pacemakerc. Assistance with endotracheal intubationd. Placement of central venous access

B

14. 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 would the nurse include in this client's 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 won't need to change your diet."

B

6. 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."

B

A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death?a. Level of consciousnessb. Respiratory ratec. Bowel soundsd. Pain level on a 0-to-10 scale

B

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first?a. Call for emergency assistance so that resuscitation procedures can begin.b. Ask family members if they would like to spend time alone with the client.c. Ensure that a death certificate has been completed by the physician.d. Request family members to prepare the clients body for the funeral home.

B

A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this clients plan of care?a. Is your advance directive up to date and notarized?b. Do you want to be at home at the end of your life?c. Would you like a physical therapist to assist you with range-of-motion activities?d. Have your children discussed resuscitation with your health care provider?

B

A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this clients teaching?a. Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.b. Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.c. Hospice care will not help with your symptoms of depression. I will refer you to the facilitys counseling services instead.d. You seem to be experiencing some difficulty with this stage of the grieving process. Lets talk about your feelings.

B

After administering SL nitroglycerin to a client whose baseline blood pressure is 130/80 mm Hg, for which finding would the nurse immediately notify the health care provider?A. Client reports a headache.B. Systolic pressure is 90 mm Hg.C. Anginal pain is somewhat relieved.D. Heart rate is 92 beats/min.

B

An alert and oriented client comes to the walk-in clinic with left-sided chest pain, mild shortness of breath, and diaphoresis. What is the nurse's first priority action?A. Obtain a complete cardiac history for the client.B. Place the client in semi-Fowler position with supplemental oxygen.C. Instruct the client to go immediately to the nearest full-service hospital.D. Immediately alert the health care provider and establish IV access.

B

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying clients anxiety and restlessness. Which statement made by the family member indicates understanding of the nurses teaching?a. Maybe we should just hire an around-the-clock sitter to stay with Grandmother.b. I have some of her favorite hymns on a CD that I could bring for music therapy.c. I dont think that shell need pain medication along with her herbal treatments.d. I will burn therapeutic incense in the room so we can stop the anxiety pills.

B

The nurse would teach a client to seek treatment for symptoms of myocardial infarction (MI) immediately rather than delay, because physical changes occur in how many hours after an MI?A. 3 hoursB. 6 hoursC. 12 hoursD. 24 hours

B

What is the best action for the home health nurse to take when visiting a new client with CAD who is experiencing new-onset chest pain and shortness of breath?A. Instruct the client to rest quietly and take slow, deep breaths.B. Have the client chew a 325-mg aspirin tablet and call 911.C. Apply supplemental home oxygen until the symptoms subside.D. Administer a sublingual nitroglycerin tablet and have the family take the client to the emergency room.

B

Which procedure has shown promise for managing clients with cardiogenic shock?A. Percutaneous ventricular assistive deviceB. Immediate reperfusionC. Intra-aortic balloon pumpD. Minimally invasive bypass surgery

B

Which procedure would the nurse expect to be recommended for a client with discrete, proximal, noncalcified blockage in one coronary artery?A. Minimally invasive direct coronary artery bypass (MIDCAB)B. Percutaneous coronary intervention (PCI)C. Immediate thrombolytic reperfusion therapyD. Exercise tolerance test (stress test) on a treadmill

B

Which statement by the client who had CABG surgery indicates to the nurse that his or her pain is related to the sternotomy and is not anginal in origin?A. "The pain goes down my arm and sometimes into my jaw."B. "My pain increases when I cough or take a deep breath."C. "The nitroglycerin helped to relieve my pain."D. "I feel nausea and shortness of breath with the pain."

B

Which task would the nurse delegate to the assistive personnel (AP) when caring for a client in phase 1 of cardiac rehabilitation?A. Assist the client to ambulate 400 feet four times a day.B. Assist the client with ambulation to the bathroom.C. Assess the client's vital signs and fatigue level with each increase in activity.D. Teach the client to notify the health care provider for episodes of chest pain.

B

Which type of dysrhythmia would the nurse expect to monitor for when a client experiences an inferior wall myocardial infarction (IWMI)?A. Premature ventricular complexes (PVCs)B. Bradycardia with second-degree heart blockC. Supraventricular tachycardiaD. Atrial fibrillation

B

A client with chronic stable angina now has chest pressure, cool and clammy skin, blood pressure 150/90 mm Hg, heart rate 100 beats/min, and respiratory rate 32 breaths/min. What are the priorities of collaborative care for this client? Select all that apply.A. Maintain NPO status.B. Relieve chest pain.C. Improve coronary artery perfusion.D. Draw troponin blood samples.E. Improve myocardial oxygenation.F. Relieve nausea.

B, C, D, E

Which interventions would the nurse perform to protect a client from a sternal wound infection after CABG surgery? Select all that apply.A. Shave the client's body from neck to knees.B. Instruct the client to shower with 4% chlorhexidine gluconate.C. Prepare the surgical site by clipping hair then applying chlorhexidine with isopropyl alcohol (0.5% or 2 %).D. Collect and send urine and sputum samples to the laboratory for culture and sensitivity.E. Administer IV antibiotics 1 hour prior to the surgical procedure.F. Wear gloves, a gown, and a mask while preparing the client for surgery.

B, C, E

About which associated symptoms would the nurse ask a client with a history of intermittent episodes of chest pain? Select all that apply.A. DiarrheaB. NauseaC. Shortness of breathD. Joint painE. DizzinessF. Diaphoresis

B, C, E, F

What diagnostic tests would the nurse obtain to determine whether a client admitted with acute-onset chest pain and dyspnea had experienced a myocardial infarction (MI)? Select all that apply.A. C-reactive proteinB. 12-lead ECGC. Chest x-rayD. Serial troponins T and IE. Lipid profileF. Exercise stress test

B, D

3. 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 Hgb. Serum potassium of 2.9 mEq/L (2.9 mmol/L)c. Warmth and redness at the sited. Expanding groin hematomae. Rhythm changes on the cardiac monitorf. Oxygen saturation 93% on room air

B, D, E

5. 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.e. Explain to the client that dobutamine will simulate exercise for this examination.

B, D, E

Which advantages would the nurse teach a client about with regard to robotic heart surgery? Select all that apply.A. Shorter surgical time than traditional CABG surgeryB. Shorter hospital stay of just 2 to 3 daysC. Decreased pain due to smaller incisionsD. Shorter time on the heart-lung bypass machineE. Chest tubes are never neededF. Ability to reach otherwise inaccessible blockage sites

B,C,F

Which essential points would the nurse include when teaching a client with angina about nitroglycerin tablets? Select all that apply.A. If one tablet does not relieve the chest pain after 5 minutes, put two pills under your tongue.B. Keep your nitroglycerin pills with you at all times.C. The prescription should last about 7 to 8 months before a refill is needed.D. You can tell the tablets are active when you feel a tingling after placing one under your tongue.E. Keep the tablets in a glass, light-resistant container.F. If no immediate pain relief occurs, just wait because the drug will eventually take effect.

B,D,E

What nonpharmacologic comfort measures would the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options f. Encouraging participation in high impact aerobic activity

BCD

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)a. Administer pain medication.b. Assess distal pulses every 10 minutes.c. Have the client sign a surgical consent.d. Notify the Rapid Response Team.e. Take vital signs every 10 minutes.

BDE

16. 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." What is the nurse's best response?a. "Chili is high in fat and calories; it would be a good idea to stop eating it."b. "The primary health care provider has prescribed an antacid every morning."c. "What do you understand about what happened to you?"d. "When did you start experiencing this indigestion?"*

C

3. A nurse assesses clients on a medical-surgical unit. Which client would 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

4. 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.

C

7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect?a. Excruciating pain on inspirationb. Left lateral chest wall painc. Fatigue and shortness of breathd. Numbness and tingling of the arm

C

8. 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."

C

9. 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 intakeb. Bruising at the insertion sitec. Slurred speech and confusiond. Discomfort in the left leg

C

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?a. Roman Catholic Autopsies are not allowed except under special circumstances.b. Christian Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth.c. Judaism A person who is extremely ill and dying should not be left alone.d. Islam An ill or dying person should receive the Sacrament of the Sick.

C

A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response?a. "This is a routine test and the risk of death is very low."b. "Would you like to speak with a chaplain prior to test?"c. "Tell me more about your concerns about the test. d. "What support systems do you have to assist you?"

C

After teaching a client about advance directives, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?a. An advance directive will keep my children from selling my home when Im old.b. An advance directive will be completed as soon as Im incapacitated and cant think for myself.c. An advance directive will specify what I want done when I can no longer make decisions about health care.d. An advance directive will allow me to keep my money out of the reach of my family.

C

An intensive care nurse discusses withdrawal of care with a clients family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond?a. I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia.b. You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support.c. I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death.d. There is no need to worry. Most religious organizations support the clients decision to stop medical treatment.

C

Because many sudden cardiac arrest victims die before reaching the hospital, which priority teaching point would the nurse be sure to include in a community presentation about heart disease?A. The importance of controlling alcohol consumption and smoking cessationB. Modifying risk factors and blood pressure medication complianceC. How to operate an automatic external defibrillator (AED) in the workplaceD. Recognizing unstable angina and when to call for help

C

For which complication does the nurse monitor when a client with chronic stable angina (CSA) is prescribed a calcium channel blocker?A. TachycardiaB. Wheezes and cracklesC. HypotensionD. Forgetfulness

C

What is the nurse's next action 5 minutes after administering a sublingual (SL) nitroglycerin tablet to a client with chest pain?A. Apply oxygen at 2 to 4 L by nasal cannula.B. Administer morphine sulfate IV push.C. Recheck pain intensity and vital signs.D. Notify the health care provider and give a chewable aspirin.

C

What priority action will the nurse take when providing care for a client with chest pain being treated with IV nitroglycerin?A. Restrict the client to bedrest with use of a bedpan.B. Elevate the head of the bed to 90 degrees.C. Monitor blood pressure continuously.D. Increase the dose rapidly to achieve pain relief.

C

Which diagnostic test is performed after a client's acute stage of an unstable angina episode to determine if there are cardiac changes that are consistent with ischemia?A. ElectrocardiogramB. EchocardiographyC. Exercise tolerance testD. Chest CT scan

C

Which drug therapy would the nurse expect to be prescribed for a client with acute coronary syndrome (ACS) to decrease the risk of recurrent myocardial infarction, stroke, and mortality?A. Anti-inflammatory drugB. Central vasodilatorC. High-intensity statin therapyD. Anticoagulant therapy

C

Which finding most strongly indicates left heart failure in a client when the nurse auscultates heart sounds?A. MurmurB. Split S1 and S2C. S3 gallopD. Pericardial friction rub

C

Which finding prompts the nurse to immediately contact the surgeon for a client who had a minimally invasive direct coronary artery bypass (MIDCAB)?A. Client has difficulty with coughing and deep breathing.B. Client has acute incisional pain.C. Client has ECG changes including Q waves and ST-segment and T-wave changes in leads V2 to V6.D. Client has chest tube drainage of 80 mL/hr.

C

Which nursing assessment is specific to a client who had CABG surgery with the radial artery used as the graft?A. Check the fingertips, hand, and arm for sensation and mobility once a shift.B. Take blood pressure every hour on the unaffected arm or use a leg cuff on the legs.C. Assess hand color, temperature, ulnar pulse, and capillary refill every hour initially.D. Assess for and document expected edema, bleeding, and swelling at the donor site.

C

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)a. "A good abrasive pumice stone will keep my feet soft."b. "I'll always wear shoes if I can buy cheap flip-flops."c. "I will keep my feet dry, especially between the toes."d. "Lotion is important to keep my feet smooth and soft."e. "Washing my feet in room-temperature water is best."f. "I will inspect my feet daily."

CDE

10. 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 anxietyb. Ability to turn self in bedc. Cardiac rhythm and heart rated. Allergies to iodine-based agents

D

15. A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response?a. "I will consult your primary health care provider to prescribe a sleep study."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

18. An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first?a. Client who describes pain as a dull ache.b. Client who reports moderate pain that is worse on inspiration.c. Client who reports cramping substernal pain.d. Client who describes intense squeezing pressure across the chest.

D

2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find?a. Blood pressure increased from 98/42 to 132/60 mm Hg.b. Respiratory rate decreased from 25 to 14 breaths/min.c. Oxygen saturation increased from 88% to 96%.d. Pulse decreased from 100 to 80 beats/min.

D

A client tells the nurse that, even though it has been 4 months since her sisters death, she frequently finds herself crying uncontrollably. How should the nurse respond?a. Most people move on within a few months. You should see a grief counselor.b. Whenever you start to cry, distract yourself from thoughts of your sister.c. You should try not to cry. Im sure your sister is in a better place now.d. Your feelings are completely normal and may continue for a long time.

D

A nurse is caring for a dying client. The clients spouse states, I think he is choking to death. How should the nurse respond?a. Do not worry. The choking sound is normal during the dying process.b. I will administer more morphine to keep your husband comfortable.c. I can ask the respiratory therapist to suction secretions out through his nose.d. I will have another nurse assist me to turn your husband on his side.

D

Following CABG surgery, a client's body temperature is below 96.8oF (36oC). What measures would the nurse take to rewarm the client?A. Infuse warm IV fluids.B. Do not rewarm because cold cardioplegia is protective.C. Place the client in a warm fluid bath.D. Use lights and thermal blankets to slowly warm the client.

D

When would the nurse be sure to hold a beta blocker drug and notify the health care provider?A. When a client states he or she woke up with a headacheB. When a client's respiratory rate is 26 breaths/min on room airC. When a client is scheduled for a chest x-rayD. When a client's heart rate is less than 50 beats/min and SBP is less than 100 mm Hg

D

Which assessment would the nurse perform to help prevent harm from graft collapse after CABG surgery?A. Assess for motion and sensation in the donor extremity.B. Observe for generalized hypothermia.C. Auscultate lungs for crackles or wheezes.D. Monitor blood pressure for hypotension.

D

Which client does the nurse expect to have the highest risk for death related to damage to the left ventricle?A. Client with an inferior wall MI (IWMI)B. Client with a lateral wall MI (LWMI)C. Client with a posterior wall MI (PWMI)D. Client with an anterior wall MI (AWMI)

D

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring that the consent is signed c. Marking pulses with a pen d. Raising the side rails on the bed e. Recording baseline vital signs

DE

A nurse teaches a clients family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply.)a. Warm and flushed extremitiesb. Long periods of insomniac. Increased respiratory rated. Decreased appetite e. Congestion and gurgling

DE

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should 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. "Avoid using salt substitutes."

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?"

a. "Could you walk further than that a few months ago?"

A client is taking warfarin and asks the nurse if taking St. John's wort is acceptable. What response by the nurse is best? a. "No, it may interfere with the warfarin." b. "There isn't any information about that." c. "Why would you want to take that?" d. "Yes, it is a good supplement for you."

a. "No, it may interfere with the warfarin."

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. "No, women should only have one beer a day as a general rule."

A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

a. Appropriate hand hygiene before giving care

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 you're 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. "Weight is the best indication that you are gaining or losing fluid."

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." 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. "Would you like to talk more about this?"

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 stenosisb. A 42-year-old man with pulmonary hypertensionc. A 59-year-old woman who smokes cigarettes dailyd. A 70-year-old man who had a cerebral vascular accident

a. A 36-year-old woman with aortic stenosis

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

a. African-American churches

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.

a. Ask if the client eats grapefruit.

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. Assess for symptoms of left-sided heart failure.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of lisinopril.

a. Assess the client's lung sounds and oxygenation.

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should 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 (Lasix).d. Ask the client about current medications.

a. Assess the client's respiratory status.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin. The client is adamant about refusing the drug because "it's dangerous." What action by the nurse is best? a. Assess the reason behind the client's fear. b. Remind the client about laboratory monitoring. c. Tell the client that drugs are safer today than before. d. Warn the client about consequences of noncompliance

a. Assess the reason behind the client's fear.

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 post procedure lifestyle changes.

a. Client is able to decrease blood pressure medications.

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

a. Furosemide/potassium: 2.1 mEq/L

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?a. Standard Precautionsb. Bleeding precautionsc. Reverse isolationd. Contact isolation

a. Standard Precautions

A nurse assesses a client who has a history of heart failure. Which question should 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 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. "Are you able to walk upstairs without fatigue?"

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's 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. "Avoid large crowds and people who are sick."

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. "Blood clots form more easily in artificial replacement valves."

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's 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. "Gather everything you need for a chore before you begin."

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. "I'll 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. "I will have my teeth cleaned by my dentist in 2 weeks."

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. "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 your medicine or you will get kidney failure."

b. "Most people with hypertension do not have symptoms."

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. "My shoes fit really tight lately."

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the assistive personnel (AP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the client's leg. d. Provide an ice pack.

b. Apply a warm moist pack

A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse is most important? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client's chart. d. Notify the surgeon immediately.

b. Assess distal pulses and skin color.

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. Assist in finding one change the client can control.

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?a. Preventricular contractionsb. Atrial fibrillationc. Symptomatic bradycardiad. Sinus tachycardia

b. Atrial fibrillation

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, cornbread, peas d. Spaghetti with meat sauce, garlic bread

b. Baked chicken breast, broccoli, tomatoes

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. Client who had a first dose of captopril and needs to use the bathroom.

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed?a. Oxygen saturation of 92%b. Dyspnea on exertionc. Muted systolic murmurd. Upper extremity weakness

b. Dyspnea on exertion

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?a. Heart rate that speeds up and slows downb. Friction rub at the left lower sternal borderc. Presence of a regular gallop rhythmd. Coarse crackles in bilateral lung bases

b. Friction rub at the left lower sternal border

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. Instruct the client to ask for assistance when rising from bed.

A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse is most important? a. Assess the client's neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

b. Notify the Rapid Response Team.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates that an important outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

b. Oxygen saturation of 98%

. A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an "Ask the nurse" booth at the pet store

b. Participate in blood pressure screenings at the mall.

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. "I must stop halfway up the stairs to catch my breath."

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 specific cause." d. "It refers to severe and life-threatening hypertension."

c. "It is hypertension with no specific cause."

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. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."

A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

c. Measure for new compression stockings.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should 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."

d. "Do not take this medication within 1 hour of taking an antacid."

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. "I'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."

d. "My hands shake when I try to do things requiring coordination."

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's 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. "Weigh yourself daily while wearing the same amount of clothing."

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 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. "Would you like information about advance directives?"

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. Administer PRN acetaminophen.

A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse requires the nurse's mentor to intervene? a. Assesses the client for back pain. b. Auscultates over abdominal bruit. c. Measures the abdominal girth. d. Palpates the abdomen in four quadrants.

d. Palpates the abdomen in four quadrants.

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

d. Palpating both carotid arteries at the same time

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 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.

d. Sit the client up with a pillow to lean forward on.