ATI - Circulation and Perfusion 1

· A nurse is preparing to administer Digoxin to a 6-month old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

90bpm

· A nurse is teaching a client who is Post Op following the insertion of a permanent pacemaker. Which of the following instructions should the nurse include? Select all that apply.

o Count your pulse for 1 min. each morning o Don't wear tight clothing over insertion area

· A nurse is caring for a client who has difficulty swallowing medications and is prescribed enteric-coated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide?

o Crushing the medication might cause you to have a stomachache or indigestion

· A nurse finds that a client didn't receive a scheduled dose of Lasix. Which of the following should the nurse include in the incident/variance report? Select all that apply

o Date of incident o Time client was to receive the medication o The client's vital signs

· A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload.

o Dyspnea o Jugular vein distention o Confusion

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

o Heparin does not dissolve clots. It stops new clots from forming

· A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder?

o Hypercholesterolemia o Hypertension o Obesity o Smoking

· A nurse is teaching a client who takes Warfarin daily. Which of the following statements by the client indicates a need for further teaching?

o I have started taking ginger root to treat my joint stiffness

· A nurse is preparing to infuse a 250ml unit of packed RBC's over 2hrs. The drop factor of the manual IV tubing is 15gtts/ml. Drops per minute?

31gtts/min

· A nurse is caring for a client who has HF and a prescription for Digoxin 125mcg PO daily. Available is Digoxin PO 0.25mg/tablet. How many tablets should the nurse administer per dose?

0.5 tablet

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

Assess apical pulse for a full minute

· Nurse is assessing an older client who is receiving Digoxin. The nurse should recognize that which of the following findings is a manifestation of Digoxin toxicity?

Anorexia

· Nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a HR?

Apex of heart

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

Beans

· Nurse is providing discharge teaching to a client who has a new prescription for Verapamil for angina. Which of the following instructions should the nurse include?

Inc. your daily intake of dietary fiber

· A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

MRI of chest

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

Measure from heel to popliteal space

· A nurse is caring for a client who is prescribed Warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of Warfarin?

PT

· A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide?

Take medication with orange juice to enhance absorption

· A nurse is caring for a client who is on Warfarin therapy for A Fib. The client's INR is 5.2. Which of the following medications should the nurse prepare to administer?

Vitamin K

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

o Check vital signs

· A nurse is providing teaching to a client about smoking cessation. Which of the following client statements indicates a need for further education?

o "I will test my ability to quit smoking by going to the bar where I used to smoke."

· A client with a hx or MI is prescribed Aspirin 325mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication?

o Antiplatelet aggregate

· A nurse is teaching a client who has a new prescription for transdermal nitroglycerin to treat angina pectoris. Which of the following instruction should the nurse include in the teaching?

o Apply patch in the morning

· A nurse is providing teaching to a client who has stable angina and a new prescription for transdermal nitroglycerin. Which of the following instructions should the nurse include? Select all that apply.

o Apply the patch to a hairless area and rotate sites o Apply a new patch each morning o Remove patch for 10-12hrs daily

· A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client's plan of care? Select all that apply.

o Check peripheral pulses in the affected extremity o Keep client's hip and leg extended o Have client remain in bed up to 6hrs post op

· A nurse is caring for four clients. After administering morning medications, she realizes that the nifedipine prescribed for one client was inadvertently administered to another client. Which of the following actions should the nurse take first?

o Check the PT's vital signs

· A nurse is reinforcing teaching with a client regarding reduction of risk factors for coronary artery disease. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.

o I must stop smoking o I need to monitor my weight o I am limiting my intake of fast foods

· A nurse is instruction a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

o I will take my medications at the first sign of an attack

· A nurse is assessing a client who had fluid overload. Which of the following findings should the nurse expect? Select all that apply.

o Inc. HR o Inc. BP o Inc. RR

· A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

o Increasing my intake of foods containing trans fatty acids can lower my risk.

· A nurse is assisting with obtaining an ECG for a client who has A Fib. Which of the following actions should the nurse take? Select all that apply.

o Inspect electrode pads o Instruct the client not to talk during the test

· Nurse in an emergency dept is assessing a client who is having a suspected acute MI. Which of the following manifestations should the nurse expect to find for a client experiencing an acute MI?

o Nausea o Tachycardia o Diaphoresis

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

o Obtain a venous duplex ultrasound

· A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG trip should the nurse recognize as normal sinus rhythm?

o P wave falls before the QRS complex

· A nurse is caring for a male client who has peripheral vascular disease, takes dietary supplements and has a new prescription for Warfarin. The nurse should instruct the client to stop which of the following supplements prior to starting the Warfarin?

o Saw Palmetto o Glucosamine o Gingko Biloba

· A nurse is teaching a client who has a new prescription for Colesevelam to lower his low-density lipoprotein level. Which of the following instructions should the nurse include?

o Take medication 4hrs after other medications

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

o Take one tablet at the first indication of chest pain

· A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and diaphoretic. Which of the following lab tests are used to diagnose a MI? Select all that apply

o Troponin I o Troponin T o CPK o Myoglobin

· A nurse is planning to teach a client about a low potassium diet. Which of the following foods should the nurse instruct the client to avoid?

o Yogurt o Orange Juice