ATI MED SURG (p. 179-255)

A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review? A. "This means the pacemaker fires in an asynchronous pattern." B. "This means the pacemaker fires only when the heart rate is below a certain rate." C."The pacemaker can automatically adjust to a client's increased activity level." D."The pacemaker activity is triggered by heart muscle activity."

A

A nurse in a clinic is caring for a client who has been on long‐term NSAID therapy to treat myocarditis. Which of the following laboratory findings should the nurse report to the provider? A. Platelets 100,000/mm3 B. Serum glucose 110 mg/dL C. Serum creatinine 0.7 mg/dL D. Amino alanine transferase (ALT) 30 IU/L

A

A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 min. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 min.

A

A nurse is assessing a client who has splinter hemorrhages in her nail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? A. Infective endocarditis B. Pericarditis C. Myocarditis D. Rheumatic endocarditis

A

A nurse is caring for a client who asks why her provider prescribed a daily aspirin. Which of the following is an appropriate response by the nurse? A. "Aspirin reduces the formation of blood clots that could cause a heart attack." B. "Aspirin relieves the pain due to myocardial ischemia." C."Aspirin dissolves clots that are forming in your coronary arteries." D."Aspirin relieves headaches that are caused by other medications."

A

A nurse is caring for a client who has a prescription for an afterload‐reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive

A

A nurse is completing discharge teaching with a client who has a permanent pacemaker. Which of the following statements by the client indicates understanding of the teaching? A. "I will notify the airport screeners about my pacemaker." B. "I will expect to have occasional hiccups." C."I will have to disconnect my garage door opener." D."I will take my pulse every 2 to 3 days."

A

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime

A

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statements is an appropriate response by the nurse? A. "Pour the amount of fluid you drink into an empty 2‐liter bottle to keep track of how much you drink." B. "Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day." C. "This is the same as 2 quarts, or about the same as two pots of coffee." D. "Take sips of water or ice chips so you will not take in too much fluid."

A

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Avoid the consuming grapefruit while taking this medication. B. Monitor for the presence of black, tarry stools. C. Use an electric razor when shaving. D. Schedule a weekly PT test. E. Limit food sources containing vitamin K while taking this medication.

A, B

A nurse educator is reviewing the use of cardiopulmonary bypass during surgery for coronary artery bypass grafting with a group of nurses. Which of the following statements should the nurse include in the discussion? (Select all that apply.) A. "The client's demand for oxygen is lowered." B. "Motion of the heart ceases." C."Rewarming of the client takes place." D."The client's metabolic rate is increased." E. "Blood flow to the heart is stopped."

A, B, C

A nurse educator is reviewing expected findings in a client who has right‐sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (Select all that apply.) A. Dyspnea B. Client report of fatigue C. Bradycardia D. Pleural friction rub E. Peripheral edema

A, B, E

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow‐up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes

A, B, E

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestation are expected findings? (Select all that apply.) A. Tachypnea B. Persistent cough C. Increased urinary output D. Thick, yellow sputum E. Orthopnea

A, B, E

A nurse at a provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin I 0.02 ng/mL

A, C

A nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. Which of the following nursing actions should the nurse use to promote client safety? (Select all that apply.) A. Wear gloves when handling pacemaker leads. B. Ensure electronic equipment has three‐pronged grounding plugs. C. Minimize the client's shoulder movements. D. Hold the lead wires taut when turning the client. E. Keep extra pacemaker batteries at least 300 ft away from the client.

A, C

A nurse is caring for a client following the insertion of a temporary venous pacemaker via the femoral artery that is set as a VVI pacemaker rate of 70/min. Which of the following findings should the nurse report to the provider? (Select all that apply.) A. Cool and clammy foot with capillary refill of 5 seconds B. Observed pacing spike followed by a QRS complex C. Persistent hiccups D. Heart rate 84/min E. Blood pressure 104/62 mm Hg

A, C

A nurse is planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Use a 10 mL syringe to flush the PICC line. B. Apply gentle force if resistance is met during injection. C. Cleanse ports with alcohol for 15 seconds prior to use. D. Maintain a transparent dressing over the insertion site. E. Flush with 10 mL heparin before and after medication administration.

A, C, D

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (Select all that apply.) A. 1 slice cheddar cheese B. 1 medium beef hot dog C. 3 oz Atlantic salmon D. 3 oz roasted chicken breast E. 2 oz lean baked ham

A, C, D

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (Select all that apply.) A. Surgical repair of an atrial septal defect at age 2 B. Measles infection during childhood C. Hypertension for 5 years D. Weight gain of 10 lb in past year E. Diastolic murmur present

A, C, E

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

A, D, E

A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing? A. Administer large volumes of IV fluids. B. Assist with insertion of pulmonary artery catheter. C. Obtain Doppler pulses of the extremities. D. Gather supplies for insertion of a peripheral IV catheter.

B

A nurse is caring for a 72‐year‐old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? A. "This will improve blood flow in your mother's coronary arteries." B. "This will permit your mother to resume her activities of daily living." C. "This will prolong your mother's life." D. "This will reverse the effects to the damaged area."

B

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh‐high compression stockings. Which of the following actions should the nurse take? A. Massage both legs firmly with lotion prior to applying the stockings. B. Apply the stockings in the morning upon awakening and before getting out of bed. C. Roll the stockings down to the knees to relieve discomfort on the legs. D. Remove the stockings while out of bed for 1 hr, four times a day, to allow the legs to rest.

B

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight. B. Assist the client into high‐Fowler's position. C. Auscultate lungs sounds. D. Check oxygen saturation with pulse oximeter.

B

A nurse is caring for a client who is 4 hr postoperative following coronary artery bypass grafting (CABG) surgery. He is able to inspire 200 mL with the incentive spirometer, then refuses to cough because he is tired and it hurts too much. Which of the following actions should the nurse take? A. Allow the client to rest, and return in 1 hr. B. Administer IV bolus analgesic, and return in 15 min. C. Document the 200 mL as an appropriate inspired volume. D. Tell the client that he must try to cough if he does not want to get pneumonia.

B

A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk of acquiring rheumatic endocarditis? A. Older adult who has chronic obstructive pulmonary disease B. Child who has streptococcal pharyngitis C. Middle‐age adult who has lupus erythematosus D. Young adult who recently received a body tattoo

B

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? A. "I will be glad to get back to my exercise routine right away." B. "I will have my prothrombin time checked on a regular basis." C."I will talk to my dentist about no longer needing antibiotics before dental exams." D."I will continue to limit my intake of foods containing potassium."

B

A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increase potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? A. 1 medium apple B. 1 medium baked potato C. 1 slice toast with 1 tbsp peanut butter D. 1 large scrambled egg

B

A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? A. Maintain adequate fluid volume with IV infusions. B. Administer antibiotic therapy. C. Monitor hemodynamic status. D. Administer vasopressor medication.

B

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate to my provider." C."I should replace the salt shaker on my table with a salt substitute." D."I will decrease the dose of this medication when I no longer have headaches and facial redness."

B

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine

B

A nurse is caring for a client following peripheral bypass graft surgery of the left lower extremity. Which of the following findings pose an immediate concern? (Select all that apply.) A. Trace of bloody drainage on dressing B. Capillary refill of affected limb of 6 seconds C. Mottled appearance of the limb D. Throbbing pain of affected limb that is decreased following IV bolus analgesic E. Pulse of 2+ in the affected limb

B, C

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply.) A. Heart rate 60/min B. Seizure activity C. Respiratory rate 42/min D. Increased urine output E. Weak, thready pulse

B, C, E

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular vein distension D. Dry mucous membranes E. Hepatomegaly

B, C, E

A nurse is screening a male client for hypertension. The nurse should identify that which of the following actions by the client increase his risk for hypertension? (Select all that apply.) A. Drinking 8 oz nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz beer daily E. Getting a massage once a week

B, D

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast

C

A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? A. Methylprednisolone IV bolus B. Diphenhydramine subcutaneously C. Epinephrine IV D. Albuterol inhaler

C

A nurse is caring for a client following an angioplasty that was inserted through the femoral artery. While turning the client, the nurse discovers blood underneath the client's lower back. Which of the following findings should the nurse suspect? A. Retroperitoneal bleeding B. Cardiac tamponade C. Bleeding from the incisional site D. Heart failure

C

A nurse is caring for a client who has a deep‐vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C."It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D."Only one of these medications is being given to treat your deep‐vein thrombosis."

C

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states that she ran out of her diltiazem 3 days ago, and is unable to purchase more. Which of the following actions should the nurse take first? A. Administer acetaminophen for headache. B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication.

C

A nurse is completing the admission physical assessment of a client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect? A. S4 heart sound B. Petechiae C. Crackles in lung bases D. Splenomegaly

C

A nurse is presenting a community education program on recommended lifestyle changes to prevent angina and myocardial infarction. Which of the following changes should the nurse recommend be made first? A. Diet modification B. Relaxation exercises C. Smoking cessation D. Taking omega‐3 capsules

C

A nurse on a cardiac unit is reviewing the laboratory findings of a client who has a diagnosis of myocardial infarction (MI) and reports that his dyspnea began 2 weeks ago. Which of the following cardiac enzymes would confirm the MI occurred 14 days ago? A. CK‐MB B. Troponin I C. Troponin T D. Myoglobin

C

A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that A. the cardioverter is being charged to the appropriate setting. B. they should initiate CPR due to pulseless electrical activity. C. they cannot be in contact with equipment connected to the client. D. a time‐out is being called to verify correct protocols.

C

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? A. Arterial blood gases B. Serum albumin C. Liver enzymes D. Throat culture

D

A nurse is admitting a client who has complete heart block as demonstrated by ECG. The client's heart rate is 34/min and blood pressure is 83/48 mm Hg. The client is lethargic and unable to complete sentences. Which of the following actions should the nurse perform first? A. Transport the client to the cardiovascular laboratory. B. Prepare the client for insertion of a permanent pacemaker. C. Obtain a signed informed consent form for a pacemaker. D. Apply transcutaneous pacemaker pads.

D

A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Edema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling eczema of the lower legs with stasis dermatitis D. Pallor on elevation of the limbs, and rubor when the limbs are dependent

D

A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? A. Petechiae B. Murmur C. Rash D. Friction rub

D

A nurse is completing the admission assessment of a client who will undergo peripheral bypass graft surgery on the left leg. Which of the following findings should the nurse expect? A. Rubor of the affected leg when elevated B. 3+ dorsal pedal pulse in left foot C. Thin, peeling toenails of left foot D. Report of intermittent claudication in the affected leg

D

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C."The transducer should be level with the second intercostal space after the line is placed." D."A chest x‐ray is needed to verify placement after the procedure."

D

A nurse is teaching a client who has angina about a new prescription for metoprolol. Which of the following statements by the client indicates understanding of the teaching? A. "I should place the tablet under my tongue." B. "I should have my clotting time checked weekly." C. "I will report any ringing in my ears." D. "I will call my doctor if my pulse rate is less than 60."

D

A nurse is teaching a client who has been a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting. C. Apply a heating pad to both legs for comfort. D. Place both legs in dependent position while sleeping.

D

A nurse is teaching a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? A. "You should have nothing to eat or drink for 4 hours prior to the procedure." B. "You will be given general anesthesia during the procedure." C. "You should not have this procedure done if you are allergic to eggs." D. "You will need to keep your affected leg straight following the procedure."

D

fluid accumulation in the pericardial sac; manifestations include hypotension, jugular vein distention, muffled heart sounds, and paradoxical pulse (variance of 10 mmHg or more in systolic blood pressure between expiration and inspiration)

cardiac tamponade