Cardiac N-CLEX Questions

A nurse is told that the laboratory result for the serum digoxin level is 2.4 ng/mL. The nurse plans to do which of the following? 1.Hold the medication. 2.Check the client's last respiratory rate. 3.Record the normal value on the client's flow sheet. 4.Administer the next dose of the medication as scheduled

1.Hold the medication. Rationale: The normal therapeutic range for digoxin is 0.5 to 2 ng/mL. A value of 2.4 ng/mL exceeds the therapeutic range and could be toxic to the client. The nursing action is to hold further doses of digoxin. Option 3 is incorrect, because the value is not normal. Option 4 would cause the client to become more toxic. The next dose should not be administered automatically. Checking the client's respiratory rate is not applicable at this time.

A client is on nicotinic acid (niacin) for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client would indicate an understanding of the instructions? 1."It is not necessary to avoid the use of alcohol." 2."The medication should be taken with meals to decrease flushing." 3."Clay-colored stools are a common side effect and should not be of concern." 4."Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing."

"Ibuprofen (Motrin) taken 30 minutes before the nicotinic acid should decrease the flushing." Rationale: Flushing is a side effect of this medication. Aspirin or a nonsteroidal anti-inflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals, this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the health care provider (HCP).

A nurse is planning to use an external cardiac defibrillator on a client. Which one of the following actions should the nurse perform to check the cardiac rhythm? 1. Holding the defibrillator paddles firmly against the chest 2.Applying the adhesive patch electrodes to the skin and moving away from the client 3.Connecting standard electrocardiographic electrodes to a transtelephonic monitoring device 4.Applying standard electrocardiographic monitoring leads to the client and observing the rhythm

Applying the adhesive patch electrodes to the skin and moving away from the client Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

A nurse is assigned to assist with caring for a client after cardiac catheterization. The nurse plans to maintain bedrest with: 1. High Fowler's position 2.Bathroom privileges only 3.Head elevation of 45 degrees 4.Head elevation of no more than 30 degrees

Head elevation of no more than 30 degrees Rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period. The client may turn from side to side. The head of the bed is not elevated to more than 30 degrees to keep the affected leg straight at the groin and prevent arterial occlusion. Bathroom privileges are not allowed during the immediate postcatheterization period. For the high Fowler's position, the head of the bed is elevated 90 degrees.

A nurse has given instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further instructions if the client states that: 1.Smoking cessation is very important. 2.Moving to a warmer climate should help. 3.Sources of caffeine should be eliminated from the diet. 4.Taking nifedipine (Procardia) as prescribed will decrease vessel spasm

Moving to a warmer climate should help Rationale: Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial, because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse understands that this sodium level would be noted in a client with which condition? 1.The client with watery diarrhea 2.The client with diabetes insipidus 3.The client with an inadequate daily water intake 4.The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

4.The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. The nurse interprets that the boot: 1.Has not yet dried 2.Is controlling leg edema 3.Is impairing venous return 4.Has been applied too tightly

Has been applied too tightly Rationale: An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations

A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase (Activase, tPA). Which action is a priority nursing intervention? 1.Monitor for renal failure. 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. 4.Have heparin sodium available.

Monitor for signs of bleeding. Rationale: Tissue plasminogen activator is a thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

A nurse is caring for a client with cirrhosis. The nurse notes that the client is dyspneic and crackles are heard on auscultation of the lungs. What additional signs would the nurse expect to note in this client if a fluid volume excess is present? 1.Rapid weight loss 2.Flat hand and neck veins 3.A weak and thready pulse 4.An increase in blood pressure

4.An increase in blood pressure Rationale: Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

A client had an aortic valve replacement 2 days ago. This morning, the client says to the nurse, "I don't feel any better than I did before surgery." The appropriate response by the nurse is: 1."You will feel better in a week or two." 2."It's only the second day post-op. Cheer up." 3."This is a normal frustration. It'll get better." 4."You are concerned that you don't feel any better after surgery?"

"You are concerned that you don't feel any better after surgery?" Rationale: Paraphrasing is restating the client's message in the nurse's own words. Paraphrasing may be in the form of a question. Option 4 uses the therapeutic communication technique of paraphrasing. The client is frustrated and is searching for understanding. Options 1, 2, and 3 are inappropriate communication techniques. Option 1 belittles the client's concerns. Options 2 and 3 offer false reassurance by the nurse.

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for: 1.Hypovolemia 2. Acute renal failure 3.Glomerulonephritis 4. Urinary tract infection

Acute renal failure Rationale: The client who undergoes cardiac surgery is at risk for accute renal failure from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal failure is signaled by a decreased urine output and increased BUN and creatinine levels. The client may need medications to increase renal perfusion and could need peritoneal dialysis or hemodialysis.

A client is scheduled for a cardiac catheterization using a radiopaque dye. The nurse checks which most critical item before the procedure? 1.Intake and output 2.Height and weight 3.Peripheral pulse rates 4.Allergy to iodine or shellfish

Allergy to iodine or shellfish Rationale: This procedure requires a signed informed consent, because it involves injection of a radiopaque dye into the blood vessel. The risk of allergic reaction and possible anaphylaxis is serious and must be assessed before the procedure. Although options 1, 2, and 3 may be a component of data collection, they are not the most critical items.

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. A nurse listens to breath sounds, expecting to hear bilateral: 1.Rhonchi 2.Crackles 3.Wheezes 4.Diminished breath sounds

Crackles Rationale: Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Wheezes, rhonchi, and diminished breath sounds are not associated with pulmonary edema.

A nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. The nurse understands that which of the following are concerns related to the administration of this medication? 1.Hypouricemia, hyperkalemia 2.Increased risk of osteoporosis 3.Hypokalemia, hyperglycemia, sulfa allergy 4.Hyperkalemia, hypoglycemia, penicillin allergy

Hypokalemia, hyperglycemia, sulfa allergy Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

A nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: 1.Moderately impaired, and the surgeon should be called 2.Normal, caused by increased blood flow through the leg 3.Slightly deteriorating, and should be monitored for another hour 4.Adequate from an arterial approach, but venous complications are arising

Normal, caused by increased blood flow through the leg Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity cause by increased blood flow. Options 1, 3, and 4 are incorrect.

A nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which of the following to enable the client to best tolerate the ambulation? 1.Provide the client with a walker. 2.Remove the telemetry equipment. 3.Encourage the client to cough and deep breathe. 4.Premedicate the client with an analgesic before ambulating

Premedicate the client with an analgesic before ambulating Rationale: The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery, because analgesia will promote rest, decrease myocardial oxygen consumption caused by pain, and allow better participation in activities such as coughing, deep breathing, and ambulation.

A nurse is monitoring a client following cardioversion. Which of the following observations would be of highest priority to the nurse? 1.Blood pressure 2.Status of airway 3.Oxygen flow rate 4.Level of consciousness

Status of airway Rationale: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. Airway is the priority

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse would check the client for signs and symptoms of concurrent: 1.Viral infection 2.Yeast infection 3.Streptococcal infection 4.Staphylococcal infection

Streptococcal infection Rationale: Rheumatic endocarditis, also called rheumatic carditis, is a major indicator of rheumatic fever, which is a complication of infection with group A β-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis. Options 1, 2, and 4 are incorrect

Isosorbide mononitrate (Imdur) is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. The nurse appropriately suggests that the client: 1.Cut the dose in half. 2.Discontinue the medication. 3.Take the medication with food. 4.Contact the health care provider (HCP).

Take the medication with food. Rationale: Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the HCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust the dosages.

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate the: 1.Vagus nerve to slow the heart rate 2.Vagus nerve to increase the heart rate 3.Diaphragmatic nerve to slow the heart rate 4.Diaphragmatic nerve to increase the heart rate

Vagus nerve to slow the heart rate Rationale: Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The other maneuvers are the Valsalva maneuver of inducing the gag reflex and asking the client to strain or bear down. Medication therapy is often needed as an adjunct to keep the rate down or maintain the normal rhythm

A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as: 1.Stable angina 2.Variant angina 3.Unstable angina 4.Nonanginal pain

Variant angina Rationale: Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often in the morning. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower and lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction. The data in the question is characteristic of a type of angina pain and therefore option 4 is incorrect.

A client returns to the nursing unit after an above-the-knee amputation of the right leg. The nurse positions the client: 1.Prone 2.With the residual limb flat on the bed 3.With the foot of the bed elevated 4.In reverse Trendelenburg's position

With the foot of the bed elevated Rationale: During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

An ambulatory clinic nurse is interviewing a client who is complaining of flu-like symptoms. The client suddenly develops chest pain. Which question would best help the nurse to discriminate pain caused by a noncardiac problem? 1."Can you describe the pain to me?" 2."Have you ever had this pain before?" 3."Does the pain get worse when you breathe in?" 4."Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

"Does the pain get worse when you breathe in?" Rationale: Chest pain is assessed using the standard pain assessment parameters, (characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help determine the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration.

A client who is receiving digoxin (Lanoxin) daily has a serum potassium level of 3.0 mEq/L and is complaining of anorexia. A health care provider prescribes a digoxin level to rule out digoxin toxicity. A nurse checks the results, knowing that which of the following is the therapeutic serum level (range) for digoxin? 1. 3 to 5 ng/mL 2. 0.5 to 2 ng/mL 3. 1.2 to 2.8 ng/mL 4. 3.5 to 5.5 ng/mL

0.5 to 2 ng/mL Rationale: Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Therefore, options 1, 3, and 4 are incorrect.

The adult client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). The nurse reviews the client's record and reports which of the following serum potassium levels before administering the dose of furosemide? 1.3.2 mEq/L 2.3.8 mEq/L 3.4.2 mEq/L 4.4.8 mEq/L

1.3.2 mEq/L Rationale: The normal adult serum potassium level is 3.5 to 5.1 mEq/L. Option 1 is the only value that falls below the therapeutic range. Administering furosemide (Lasix) to a client with a low potassium level and a cardiac history could precipitate ventricular dysrhythmias in the client.

A nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1.Cut down on the amount of fats consumed in the diet. 2.Use a heating pad on the legs to aid vasodilation. 3.Walk each day to increase circulation to the legs. 4.Be careful not to injure the legs or feet. 5.Eat a well-balanced diet every day.

1.Cut down on the amount of fats consumed in the diet. 3.Walk each day to increase circulation to the legs. 4.Be careful not to injure the legs or feet. 5.Eat a well-balanced diet every day. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

An adult client with a critically high potassium level has received sodium polystyrene sulfonate (Kayexalate). The nurse determines that the medication has brought the potassium level back into normal range when the serum potassium level is 1.3.3 mEq/L 2.4.9 mEq/L 3.5.8 mEq/L 4.6.2 mEq/L

2.4.9 mEq/L Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 2 is the only option that reflects a normal potassium value.

A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which of the following will be prescribed? 1.Adding a dose of heparin 2.Holding the next dose of warfarin sodium 3.Increasing the next dose of warfarin sodium 4.Administering the next dose of warfarin sodium

2.Holding the next dose of warfarin sodium Rationale: The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for the adult female. Because the value stated is extremely high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. If the level were too high, then the antidote (vitamin K) may be prescribed. Options 1, 3, and 4 would make the client more toxic and prone to bleeding.

A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates: 1.A normal level 2.A low value that indicates possible gastritis 3.A level that indicates a myocardial infarction 4.A level that indicates the presence of possible angina

3.A level that indicates a myocardial infarction Rationale: Troponins are regulatory proteins that are found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in the skeletal muscle and the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T level greater than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is less than 0.6 ng/mL, whereas a level greater than 1.5 ng/mL is consistent with a myocardial infarction. A troponin T level of 0.6 is not normal, so option 1 is incorrect. Troponin T does not test for angina or gastritis; thus options 2 and 4 are incorrect.

A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which finding would be noted in the client with this condition? 1.Gurgling respirations 2.Increased blood pressure 3.Decreased hematocrit level 4.Increased specific gravity of the urine

4.Increased specific gravity of the urine Rationale: Findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. The signs in options 1, 2, and 3 are seen in a client with fluid volume excess.

A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse note on the cardiac monitor as a result of this laboratory value? 1.ST elevation 2.Peaked P wave 3.Prominent U wave 4.Narrow, peaked T waves

4.Narrow, peaked T waves Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; narrow, peaked T waves; and a depressed ST segment

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed? 1.Strict bedrest for 24 hours 2.Bathroom privileges and self-care activities 3.Unrestricted activities because the client is monitored 4.Unsupervised hallway ambulation with distances less than 200 feet

Bathroom privileges and self-care activities Rationale: Upon transfer from the CCU, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).

A client is scheduled for a dipyridamole (Persantine) thallium scan. The nurse would check to make sure that the client has not had which of the following before the procedure? 1.Caffeine 2.Fatty meal 3.Excess sugar 4.Milk products

Caffeine Rationale: This test is an alternative to the exercise stress test. Dipyridamole (Persantine) dilates the coronary arteries as exercise would. Before the procedure, any form of caffeine should be withheld, as well as aminophylline or theophylline forms of medication. Aminophylline is the antagonist to dipyridamole.

A nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT) followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first? 1.Go to the nurse's station quickly and call a code. 2.Run to get a defibrillator from an adjacent nursing unit. 3.Call for help and initiate cardiopulmonary resuscitation (CPR). 4.Start oxygen by cannula at 10 L/minute and lower the head of the bed.

Call for help and initiate cardiopulmonary resuscitation (CPR). Rationale: When VF occurs, the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client. Options 1, 2, and 4 are incorrect.

An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, "I don't need that—my dad takes that for his heart. There's nothing wrong with my heart." Which of the following best describes the client's response? 1.Angry 2.Denial 3.Phobic 4.Obsessive-compulsive

Denial Rationale: Denial is the most common reaction when a client has a myocardial infarction or anginal pain. No angry behavior was identified in the question. Phobias and obsessive-compulsive disorders are mental health diagnoses.

A nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse would expect to note which specific characteristic of this condition? 1.Dyspnea 2.Hacking cough 3.Dependent edema 4.Crackles on lung auscultation

Dependent edema Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A nurse understands that which of the following is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider? 1.One breath should be given for every five compressions. 2.Two breaths should be given for every 15 compressions. 3.Initially, two quick breaths should be given as rapidly as possible. 4.Each rescue breath should be given over 1 second and should produce a visible chest rise.

Each rescue breath should be given over 1 second and should produce a visible chest rise. Rationale: During adult CPR, each rescue breath should be given over 1 second and should produce a visible chest rise. Excessive ventilation (too many breaths per minute or breaths that are too large or forceful) may be harmful and should not be performed. Health care providers should employ a 30-compression-to-2-ventilation ratio for the adult victim. Options 1, 2, and 3 are incorrect

A nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium (Coumadin). Which statement, if made by the client, reflects the need for further teaching? 1."I will take my pills every day at the same time." 2."I will be certain to avoid alcohol consumption." 3."I have already called my family to pick up a Medic-Alert bracelet." 4."I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated."

"I will take Ecotrin (enteric-coated aspirin) for my headaches because it is coated." Rationale: Ecotrin is an aspirin-containing product and should be avoided. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel emergency information.

A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education? 1."Constipation and bloating might be a problem." 2."I'll continue to watch my diet and reduce my fats." 3."Walking a mile each day will help the whole process." 4."I'll continue my nicotinic acid from the health food store."

"I'll continue my nicotinic acid from the health food store." Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

A nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1.Diarrhea 2.Traumatic burn 3.Cushing's syndrome 4.Overuse of laxatives

2.Traumatic burn Rationale: A serum potassium level that exceeds 5.1 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for a potassium deficit? 1.The client with Addison's disease 2.The client with metabolic acidosis 3.The client with intestinal obstruction 4.The client receiving nasogastric suction

4.The client receiving nasogastric suction Rationale: Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

A client is diagnosed with thrombophlebitis. The nurse tells the client that which of the following will likely be prescribed? 1.Bedrest, with bathroom privileges only 2.Bedrest, keeping the affected extremity flat 3.Bedrest, with elevation of the affected extremity 4.Bedrest, with the affected extremity in a dependent position

Bedrest, with elevation of the affected extremity Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated and bedrest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in options 1, 2, and 4 are incorrect

A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse would first: 1. Call a code blue. 2. Call the health care provider. 3.Check the client status and lead placement. 4.Press the recorder button on the ECG console.

Check the client status and lead placement. Rationale: Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Checking of the client and equipment is the first action by the nurse.

The nurse is caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1.Limiting movement and abduction of the left arm 2.Limiting movement and abduction of the right arm 3.Assisting the client to get out of bed and ambulate with a walker 4.Having the physical therapist do active range of motion to the right arm

Limiting movement and abduction of the right arm Rationale: In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgment. The nurse helps prevent this complication by limiting the client's activities.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is: 1.Pneumonia 2.Pulmonary edema 3.Pulmonary embolism 4.Myocardial infarction

Pulmonary embolism Rationale: Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next check the client for: 1.Smoking history 2.Recent exposure to allergens 3.History of recent insect bites 4.Familial tendency toward peripheral vascular disease

Smoking history Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

A nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is in the client's hospital room? 1.Surgical tourniquet 2.Dry sterile dressings 3.Incentive spirometer 4.Over-the-bed trapeze

Surgical tourniquet Rationale: Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

A nurse is monitoring a client who is taking propranolol (Inderal LA). Which data collection finding would indicate a potential serious complication associated with propranolol? 1.The development of complaints of insomnia 2.The development of audible expiratory wheezes 3.A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication 4.A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication

The development of audible expiratory wheezes Rationale: Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. β-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

A client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, a nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Select the appropriate actions that the nurse should take. Select all that apply. 1.Call a code blue. 2.Contact the registered nurse. 3.Contact the client's family. 4.Assess the client's pain level. 5.Check the client's blood pressure. 6.Administer a second nitroglycerin, 0.4 mg, sublingually.

2.Contact the registered nurse. 4.Assess the client's pain level. 5.Check the client's blood pressure. 6.Administer a second nitroglycerin, 0.4 mg, sublingually. Rationale: The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain, for a total dose of three tablets. The registered nurse should be notified of the client's condition, who will then notify the health care provider as appropriate. Because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would assess the client's pain level and check the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has probably occurred? 1.Phlebitis 2.Infection 3.Infiltration 4.Thrombosis

3.Infiltration Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other three options identify complications that are likely to be accompanied by warmth at the site rather than coolness.

A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client? 1.Calcium chloride 2.Calcium gluconate 3.Calcitonin (Miacalcin) 4.Large doses of vitamin D

Calcitonin (Miacalcin) Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

A client with chronic atrial fibrillation is being started on amiodarone (Cordarone) as maintenance therapy for dysrhythmia suppression. A nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? 1."I will stop taking the prescribed anticoagulant after starting this new medication." 2."I will need to use sunscreen and protective clothing when outside." 3."I will periodically have blood drawn to monitor my thyroid function." 4."I will need to have routine follow-up with my ophthalmologist."

"I will stop taking the prescribed anticoagulant after starting this new medication." Rationale: Amiodarone is used for the dysrhythmia atrial fibrillation. The medication will have no effect in preventing thrombus formation within the atria so anticoagulants need to be continued. The medication increases sun sensitivity so protective measures are essential. Thyroid function studies should be monitored as the medication can affect thyroid function. Because the medication can cause corneal microdeposits, follow-up with the ophthalmologist is important.

Heparin sodium is prescribed for the client. The nurse expects that the health care provider will prescribe which of the following to monitor for a therapeutic effect of the medication? 1.Hematocrit level 2.Hemoglobin level 3.Prothrombin time (PT) 4.Activated partial thromboplastin time (aPTT)

Activated partial thromboplastin time (aPTT) Rationale: The PT will assess for the therapeutic effect of warfarin sodium (Coumadin) and the aPTT will assess the therapeutic effect of heparin sodium. Heparin sodium doses are determined based on these laboratory results. The hemoglobin and hematocrit values assess red blood cell concentrations.