Cardiac practice

1. A client is started on lisinopril therapy. Which assessment finding requires immediate action? 1) Blood pressure 129/80 mm Hg 2) Heart rate 100/min 3) Serum creatinine 2.5 mg/dL (221 umol/L) 4) Serum potassium 3.5 mEq/L (3.5 mmol/L)

3) Serum creatinine 2.5 mg/dL (221 umol/L)

1. The home care nurse visits the house of an elderly client. Which assessment finding requires immediateintervention? 1) The client cannot remember what was done yesterday 2) The client has a painful red area on the buttocks 3) The client has new dependent edema of the feet 4) The client has strong, fouls smelling urine

3) The client has new dependent edema of the feet

1. A client with a history of diabetes mellitus, hypertension, and chronic tobacco use reports leg pain during walking and a wound on the right 5th toe. On assessment of the wound, the nurse notes a small, circular, and deep ulcer with little drainage at the tip of the 5th toe. Based on the history and assessment, which statement would be most appropriate to document? 1) "A suspected arterial ulcer is present on the right 5th toe" 2) "A suspected pressure ulcer is present on the right 5th toe" 3) "A suspected vascular ulcer is present on the right 5th toe" 4) "A suspected venous ulcer is present on the right 5th toe"

1) "A suspected arterial ulcer is present on the right 5th toe"

1. The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply. 1) "I will apply moisturizing lotion on my legs everyday" 2) "I will elevate my legs at night when I am sleeping" 3) "I will keep my legs below heart level when sitting" 4) "I will start walking outside with my neighbor" 5) "I will use a heating pad to promote circulation"

1) "I will apply moisturizing lotion on my legs everyday" 3) "I will keep my legs below heart level when sitting" 4) "I will start walking outside with my neighbor"

1. The nurse is planning discharge teaching for a client who just received a permanent pacemaker. Which topics should the nurse include? Select all that apply. 1) Avoid magnetic resonance imagining (MRI) scans 2) Do not place cell phones directly over pacemaker 3) Notify airline security when traveling 4) Perform should range-of-motion exercises 5) Refrain from using microwave ovens

1) Avoid magnetic resonance imagining (MRI) scans 2) Do not place cell phones directly over pacemaker 3) Notify airline security when traveling

1. A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply. 1) Blood pressure of 90/70 mm Hg 2) Bounding peripheral pulses 3) Decreased breath sounds on left side 4) Distant heart tones 5) Jugular venous distension

1) Blood pressure of 90/70 mm Hg 4) Distant heart tones 5) Jugular venous distension

1. A client with severe vomiting and diarrhea has a blood pressure of 90/70 mm Hg and pulse of 120/min. IV fluids of 2-liter normal saline were administered. Which parameters indicate that adequate rehydration has occurred? Select all that apply. 1) Capillary refill is less than 3 seconds 2) Pulse pressure is narrowed 3) Systolic blood pressure drops only when standing 4) Urine output is 360 mL in 4 hours 5) Urine specific gravity is 1.020

1) Capillary refill is less than 3 seconds 4) Urine output is 360 mL in 4 hours 5) Urine specific gravity is 1.020

1. The nurse identifies which risk factors as contributing to the development of peripheral artery disease? Select all that apply. 1) Cigarette smoking 2) Diabetes mellitus 3) Hyperlipidemia 4) Oral contraceptive use 5) Prolonged standing

1) Cigarette smoking 2) Diabetes mellitus 3) Hyperlipidemia

1. The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective? 1) Client is able to shower, dress, and fix hair without any chest pain 2) Client reports a reduction in stress level and anxiety 3) Client reports being able to sleep through the night 4) Client's blood pressure is 128/78 mm Hg and heart rate is 82/min

1) Client is able to shower, dress, and fix hair without any chest pain

1. The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1) Ecchymosis of the scrotum 2) Increased abdominal girth 3) Increased urinary output 4) Report of groin pain 5) Report of increased thirst and appetite loss

1) Ecchymosis of the scrotum 2) Increased abdominal girth 4) Report of groin pain

1. The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time? 1) Immunosuppressive therapy as a lifelong commitment 2) Importance of accurate daily weight monitoring 3) Importance of periodic endomyocardial biopsies 4) Maintenance of meticulous surgical incision care

1) Immunosuppressive therapy as a lifelong commitment

1. The nurse is caring for a client with newly diagnosed infective endocarditis (IE). Which assessment finding by the nurse is the highest priority to report to the health care provider (HCP)? 1) Pain and pallor in one foot 2) Pain in both knees 3) Splinter hemorrhages in the nail beds 4) Temperature of 102.2

1) Pain and pallor in one foot

1. A client is being discharged after receiving an implantable cardioverter defibrillator (ICD). Which statement by the client indicates that teaching has been effective? 1) "I am not worried about the device firing now because I know it won't hurt" 2) "I will let my daughter fix my hair until my health care provider (HCP) say I can do it" 3) "I will look into public transportation because I won't be able to drive" 4) "I will notify my travel agent that I have an ICD now"

2) "I will let my daughter fix my hair until my health care provider (HCP) say I can do it"

1. A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply. 1) Apical pulse 2) Capillary refill 3) Lung sounds 4) Pupillary response 5) Skin color and temperature

2) Capillary refill 5) Skin color and temperature

1. A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP? 1) Blood pressure (BP) of 140/86 mm Hg 2) Difficulty swallowing 3) Dry, hacking cough 4) Low back pain

2) Difficulty swallowing

1. The nurse assesses a client diagnosed with acute pericarditis. Which assessment would require immediate follow-up? 1) Client reports chest pain that is worse with deep inspiration 2) Distant heart tones and jugular venous distension 3) ECG showing ST-segment elevations in all leads 4) Pericardial friction rub auscultated at the left sternal border

2) Distant heart tones and jugular venous distension

1. The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply. 1) Crackles in lung bases 2) Increased abdominal girth 3) Jugular venous distension 4) Lower extremity edema 5) Orthopnea

2) Increased abdominal girth 3) Jugular venous distension 4) Lower extremity edema

1. The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? 1) How to transmit the readings over the phone 2) Keep a diary of activities and any symptoms experienced 3) Refrain from exercising while wearing the monitor 4) The monitor may be removed only when bathing

2) Keep a diary of activities and any symptoms experienced

1. The nurse assesses pitting edema of the extremities, dyspnea, bilateral crackles posteriorly, and a serum sodium level of 130 mEq/L (130 mmol/L) in a client with chronic heart failure. The nurse should question which prescription? 1) Furosemide 20 mg IV push twice daily 2) Maintenance IV line of 0.9% normal saline at 85 mL/h 3) Potassium chloride 20 mEq orally twice daily 4) Sodium-restricted diet

2) Maintenance IV line of 0.9% normal saline at 85 mL/h

1. The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding? 1) Arterial bruit 2) Murmur heard at the aortic area 3) Pericardial friction rub 4) S3 gallop heard at the mitral area

2) Murmur heard at the aortic area

1. The nurse is caring for a client who had a large anterior wall myocardial infarction (MI) 24 hours ago. Which finding is most important to report to the health care provider (HCP)? 1) Nausea and vomiting 2) New S3 heart sound 3) Occasional unifocal premature ventricular contractions (PVCs) 4) Temperature of 100.4 F (38 C)

2) New S3 heart sound

1. An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN? 1) Nurse carefully auscultates for heart murmurs at Erb's point 2) Nurse palpate bilateral carotid arteries simultaneously to assess for symmetry 3) Nurse places client in semi-Fowler's position to assess for jugular vein distention 4) Nurse positions client supine to assess the point of maximal impulse

2) Nurse palpate bilateral carotid arteries simultaneously to assess for symmetry

1. A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off? 1) Hematocrit of 30% (0.30) 2) Partial thromboplastin time of 10 seconds 3) Platelet count of 80,000/mm3 (80 x 10^9/L) 4) Prothrombin time of 11 seconds

2) Partial thromboplastin time of 10 seconds

1. The nurse is preparing to perform cardioversion in a client in supraventricular tachycardia shown below that has been unresponsive to drug therapy. The client has become hemodynamically unstable. Which step is mostimportant in performing cardioversion? 1) Charge the defibrillator 2) Push the synchronize button 3) Sedate the client 4) Select energy level

2) Push the synchronize button

1. The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation? 1) 30-year-old athlete with a heart rate of 50/min 2) 45-year-old client with a body mass index of 35 kg/m² and fingerstick glucose of 150 mg/dL (8.3 mmol/L) 3) 55-year-old client missing all the hair on the lower legs and failing the pinprick test 4) 80-year-old client with a blood pressure of 150/90 mm Hg

3) 55-year-old client missing all the hair on the lower legs and failing the pinprick test

1. A 70-year-old client is admitted to the hospital with a lower gastrointestinal bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphoretic and reports dizziness. Which action should the nurse perform first? 1) Check the vital signs 2) Draw blood for hemoglobin and hematocrit 3) Lower the head of the bed 4) Maintain an IV line with normal saline

3) Lower the head of the bed

1. The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? 1) Food poisoning 2) Influenza 3) Myocardial infarction 4) Stroke

3) Myocardial infarction

1. A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action? 1) Attach defibrillator pads to the client's chest 2) Check the lipid profile laboratory results 3) Obtain a 12-lead electrocardiogram (ECG) 4) Prepare to administer a heparin drip

3) Obtain a 12-lead electrocardiogram (ECG)

1. The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider? 1) Gram-negative infection and positive blood cultures in a client prescribed tobramycin 2) Serum B-type natriuretic peptide (BNP) 650 pg/mL (650ng/L) in a client prescribed furosemide 3) Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone 4) Serum sodium 132 mEq/L (132 mmol/L) in a client prescribed IV normal saline solution at 175

3) Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone

1. The nurse has just received report on the telemetry unit. Which client should be seen first? 1) The client 2 days post coronary artery bypass; the night shift nurse reports diminished lung sounds in the bases 2) The client 4 hours post permanent pacemaker insertion that is 100% paced 3) The client with a deep vein thrombosis (DVT) who has a dose of enoxaparin due 4) The client with coronary disease artery disease and atrial fibrillation who has a dose of warfarin due

3) The client with a deep vein thrombosis (DVT) who has a dose of enoxaparin due

1. The office nurse receives 4 telephone messages. Which client should the nurse call back first? 1) 28-year-old female client who fell on ice yesterday and has low back pain and spasm 2) 42-year-old male client who developed sharp, burning leg pain radiating from buttock to knee after lifting heavy weights 3) 65-year-old female client 10 days post spinal fusion who has increased persistent back pain and fever of 101.2 F (38.4 C) 4) 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back

4) 70-year-old male client with peripheral vascular disease who has acute-onset abdominal pain radiating to the low back

1. The nurse is assigned to the following clients. Which client does the nurse assess/identify as being at greatest risk for the development of a deep venous thrombosis (DVT)? 1) A 25-year-old client wit abdominal pain who smokes cigarettes and takes oral contraceptives 2) A 55-year-old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3) A 72-year-old client with a fever who is 2 days post coronary stent placement 4) An 80-year-old client who is 4 days postoperative from repair of a fractures hip

4) An 80-year-old client who is 4 days postoperative from repair of a fractures hip

1. After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning? 1) Client rates leg pain as "7" 2) Negative Homan sign 3) Prominent varicose veins bilaterally 4) Right calf is 4 cm large than left calf

4) Right calf is 4 cm large than left calf

1. The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client? 1) Decreasing sodium intake 2) Decreasing stress levels at work and home 3) Increasing activity level 4) Taking blood pressure medications as prescribed

4) Taking blood pressure medications as prescribed

1. A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI). Which laboratory test should the nurse monitor to determine if the client has had an MI? 1) D-dimer test 2) Low-density lipoprotein (LDL) 3) Myoglobin 4) Troponin

4) Troponin

1. The nurse admits a client with newly diagnosed unstable angina. Which information obtained during the admission health history is most important for the nurse to report to the health care provider (HCP) immediately? 1) Drinks 6 cans of beers on the weekend 2) Gets up 4 times during the night to void 3) Smokes 1 pack of cigarettes daily 4) Uses sildenafil occasionally

4) Uses sildenafil occasionally

1. A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider (HCP) about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? 1) If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP 2) Inform the client that medications such as sildenafil or tadalafil are available as prescription from the HCP 3) It will be 6 mouths before the heart is healthy enough for sexual activity 4) The client will be ready for sexual activity after completion of cardiac rehabilitation

1) If the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP

1. A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action? 1) Auscultate the client's breath sounds 2) Encourage the client to increase fluid intake 3) Report the findings to the health care provider (HCP) 4) Start an intravenous line for diuretic administration

1) Auscultate the client's breath sounds

1. A client is diagnosed with lower-extremity deep venous thrombosis (DVT) after a cross-country road trip. Which clinical manifestations most characteristic of a DVT does the nurse expect to assess? Select all that apply. 1) Blue, cyanotic toes 2) Calf pain 3) Dry, shiny, hairless skin 4) Edema 5) Warmth and erythema

2) Calf pain 4) Edema 5) Warmth and erythema

1. The nurse is admitting a client with heart failure-related fluid overload. Which action should the nurse complete first? 1) Administer oxygen 2) Assess the client's the client's breath sounds 3) Initiate cardiac monitoring 4) Insert a peripheral IV catheter

2) Assess the client's the client's breath sounds

1. A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatestconcern? 1) Diminished breath sounds in bilateral lung bases 2) Hypoactive bowel sounds in all 4 quadrants 3) Urinary output of 90 mL in the past 4 hours 4) Warm extremities with 1+ bilateral pedal pulses

3) Urinary output of 90 mL in the past 4 hours

1. An elderly client tells the nurse "I have experienced leg pain for several weeks when I walk to the mailbox each afternoon, but it goes away once I stop walking." What is the priority assessment the nurse should perform? 1) Assess for dry, scaly skin on the lower legs 2) Assess for presence or absence of hair growth on lower extremities 3) Check for presence and quality of posterior tibial and dorsalis pedis pulses 4) Obtain a dietary history

1) Check for presence and quality of posterior tibial and dorsalis pedis pulses

1. The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information ismost important to report to the health care provider (HCP)? 1) Chest tube output of 175 mL in past hour 2) International Normalized Ratio (INR) of 1.5 3) Temperature of 100.3 F (37.9 C) 4) Total urine output of 85 mL over past 3 hours

1) Chest tube output of 175 mL in past hour

1. What clinical symptoms might the nurse expect to find in a client with a central venous pressure (CVP) (measurement of right ventricular preload) of 24 mm Hg? Select all that apply. 1) Crackles in lungs 2) Dry mucous membranes 3) Hypotension 4) Jugular venous distension 5) Pedal edema

1) Crackles in lungs 4) Jugular venous distension 5) Pedal edema

1. A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply. 1) Crackles on auscultation 2) Dry mucous membranes 3) Increases jugular venous distention 4) Rhonchi on auscultation 5) Skin "tenting" 6) 3+ pitting edema of the lower extremities

1) Crackles on auscultation 3) Increases jugular venous distention 6) 3+ pitting edema of the lower extremities

1. A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a priority need for follow-up teaching? 1) "I always take my simvastatin in the evening" 2) "I prop my legs up in the recliner and use a heating pad when my feet are cold" 3) "I've been walking on my treadmill at home for 15 minutes each day" 4) "I've noticed that I don't have much hair on my lower legs anymore"

2) "I prop my legs up in the recliner and use a heating pad when my feet are cold"

1. A client comes to the emergency department in acute decompensated heart failure. The client is very anxious, with a respiratory rate of 30/min and pink, frothy sputum. After placing the client on oxygen via nasal cannula, which of these actions is the next priority? 1) Administer digoxin 0.25 mg 2) Administer furosemide 40 mg IV push 3) Initiate dopamine infusion at 5mcg/kg/min 4) Obtain blood sample for arterial blood gases

2) Administer furosemide 40 mg IV push

1. A client is diagnosed with Buerger's disease (thromboangiitis obliterans). The nurse anticipates teaching the client about which treatment option? 1) Avoidance of warm temperatures 2) Initiation of statin 3) Initiation of warfarin 4) Smoking cessation

4) Smoking cessation

1. The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply. 1) Avoid excessive caffeine 2) Immerse hands in cold water 3) Practice yoga or tai chi 4) Refrain from using tobacco products 5) Wear gloves when handling cold objects

1) Avoid excessive caffeine 3) Practice yoga or tai chi 4) Refrain from using tobacco products 5) Wear gloves when handling cold objects

1. The nurse is caring for a client who has been admitted to the hospital for an acute exacerbation of heart failure. Blood pressure is 104/62 mm Hg, pulse is 96/min, respirations are 22/min, and oxygen saturation is 91%. Which of these findings supports the diagnosis of acute heart failure exacerbation? 1) B-type natriuretic peptide (BNP) 1382 pg/mL (1382 pmol/L) 2) Flat jugular veins when seated at a 45-degree angle 3) Sodium 150 mEq/L (150 mmol/L) 4) Urine output greater than 100 mL/hr

1) B-type natriuretic peptide (BNP) 1382 pg/mL (1382 pmol/L)

1. A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first? 1) Auscultate breath sounds 2) Check for peripheral edema 3) Measure the client's vital signs 4) Review the client's weight log over the past several days

1) Auscultate breath sounds

1. The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take? 1) Ask if the client wants pain medication for the "numbness and tingling" 2) Ask the client if the "numbness and tingling" were present before surgery 3) Continue assessment by observing the surgical dressing 4) Notify the health care provider (HCP) immediately

2) Ask the client if the "numbness and tingling" were present before surgery

1. When admitting a client who had an anterior wall ST-elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform first? 1) Assess for jugular vein distension 2) Attach the cardiac monitor to the client 3) Auscultate heart and breath sounds 4) Obtain the client's vital signs

2) Attach the cardiac monitor to the client

1. A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be mostuseful to the nurse in determining if this is an exacerbation of heart failure? 1) Arterial blood gases (ABGs) 2) B-type natriuretic peptide (BNP) 3) Cardiac enzymes (CK-MB) 4) Chest x-ray

2) B-type natriuretic peptide (BNP)

1. A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply. 1) "I don't plan on eating any more frozen meals" 2) "I plan to take my diuretic pill in the morning" 3) "I will weigh myself at least every other day" 4) "I'm going to look into joining a cardiac rehabilitation program" 5) "Ibuprofen works best for me when I have pain"

3) "I will weigh myself at least every other day" 5) "Ibuprofen works best for me when I have pain"

1. The emergency department nurse is assigned to triage. Which of the following clients does the nurse triage first? 1) A client who smokes with 2 months of intermittent leg cramping pain that gets worse with walking and eases with rest 2) A client with leg swelling and calf pain who flew from Australia to New York 2 days ago 3) A diabetic client with a temperature of 100.7 F (38.2 C) 4) A healthy, afebrile client with edema and redness in the leg following a dog bite 1 hour ago

2) A client with leg swelling and calf pain who flew from Australia to New York 2 days ago

1. A client in the emergency department has an acute myocardial infarction (MI). The health care provider (HCP) has prescribed thrombolytic therapy. Which assessment data should the nurse report immediately to the HCP? 1) Client is currently menstruating 2) Client rates chest pain at a 8 out of 10 on pain scale 3) Client reports a history of cerebral aneurysm at age 20 4) Current blood pressure is 170/96 mm Hg, heart rate is 110/min

3) Client reports a history of cerebral aneurysm at age 20

1. A cardiac catheterization was performed on a client 2 hours ago. The catheter was inserted into the left femoral artery. What signs of potential complications should the nurse report immediately to the health care provider (HCP)? Select all that apply. 1) Bleeding at the catheterization site 2) Client lying down and quietly watching television 3) Client taking only sips of fluids 4) Left foot remarkably cooler than right foot 5) Urine output of100 mL since the procedure

1) Bleeding at the catheterization site 4) Left foot remarkably cooler than right foot

1. The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis (DVT) that is now resolved. Which instructions does the nurse include to prevent the reoccurrence of DVT? Select all that apply. 1) "Do not travel by car or airplane for at least 3-4 weeks" 2) "Drink plenty of fluids every day and limit caffeine and alcohol intake" 3) "Elevate legs on a footstool when sitting and dorsiflex the feet often" 4) "Resume walking or swimming exercise program as soon as possible after getting home" 5) "Sit in a cross-legged yoga position for 5-10 minutes as it is good for circulation"

2) "Drink plenty of fluids every day and limit caffeine and alcohol intake" 3) "Elevate legs on a footstool when sitting and dorsiflex the feet often" 4) "Resume walking or swimming exercise program as soon as possible after getting home"

1. The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? 1) Administer the next scheduled dose of warfarin 2) Anticipate infusing fresh, frozen plasma 3) Call the pharmacy to see if protamine is available 4) Request a prescription from the health care provider (HCP) for vitamin K

4) Request a prescription from the health care provider (HCP) for vitamin K

1. The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1) Glucose 200 mg/dL (11.1 mmol/L) 2) Hematocrit 38% (0.38) 3) Potassium 3.4 mEq/L (3.4 mmol/L) 4) Troponin 0.7 ng/mL (0.7 mcg/L)

4) Troponin 0.7 ng/mL (0.7 mcg/L)

1. A client develops sinus bradycardia with blood pressure of 90/40 mm Hg and a heart rate of 46/min. Which of the following actions should the nurse take? 1) Give scheduled dose of metoprolol 50 mg orally 2) Instruct client to cough forcefully 3) Place client in reverse Trendelenburg position 4) Prepare to administer atropine 0.5 mg intravenous (IV) push

4) Prepare to administer atropine 0.5 mg intravenous (IV) push

1. A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.36 kg) over the last 2 days. Which information is most important for the nurse to ask this client? 1) Diet recall for this current week 2) Fluid intake for the past 2 days 3) Medications and dosages taken over the past 2 days 4) Presence of shortness of breath, coughing, or edema

4) Presence of shortness of breath, coughing, or edema

1. A client diagnosed with a ST-segment elevation myocardial infarction (STEMI) is receiving an intravenous thrombolytic infusion. In evaluating the client's response to treatment, which assessment finding by the nurse is the best indicator that reperfusion has occurred? 1) Increase in troponin level 2) Nonsustained ventricular tachycardia 3) Reduction of chest pain 4) Return of ST segment to baseline

4) Return of ST segment to baseline

1. A 62-year-old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? 1) Assess and compare blood pressure in each arm 2) Assess character quality of peripheral pulses 3) Assess for presence or absence of hair on lower extremities 4) Assess for presence of bowel sounds

2) Assess character quality of peripheral pulses

1. The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up? 1) Abdomen is soft, nondistended, and tender to touch 2) Blood pressure is 96/66 mm Hg and apical pulse is 112/min 3) Client rates pain as 4 on a scale of 0-10 4) Green bile is draining from the nasogastric tube

2) Blood pressure is 96/66 mm Hg and apical pulse is 112/min

1. The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective? 1) "I'm glad that I can continue taking my Ginkgo biloba" 2) "I will increase my intake of leafy green vegetables" 3) "I will start applying vitamin E to my chest incision after showering" 4) "I will shave with an electric razor from now on"

4) "I will shave with an electric razor from now on"

1. The nurse is assessing a client with a possible diagnosis of peripheral artery disease. Which client statement is consistent with the diagnosis? 1) "At the end of the day, my shoes and socks are tight" 2) "I have a slow-healing sore right above my ankles" 3) "My legs ache when I stand for extended periods" 4) "When I sit down to rest and elevate my legs, the pain increases"

4) "When I sit down to rest and elevate my legs, the pain increases"

1. A 62 year old client was admitted to the telemetry unit after having an acute myocardial infarction 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is the priority? 1) Ask the client how long the leg has been tender and warm 2) Assess the electrocardiogram (ECG) for any ectopic beats 3) Check vital signs including pulse oximetry 4) Complete neurovascular assessment on lower extremities

4) Complete neurovascular assessment on lower extremities

1. The nurse is monitoring a client following a radiofrequency catheter ablation. The nurse notes that the P waves are not associated with the QRS complexes on the cardiac monitor. Which intervention is most appropriate at this time? 1) Call a code and begin chest compressions 2) Call the rapid response team and prepare for cardioversion 3) Document the findings in the chart and continue to monitor 4) Notify the cardiologist and prepare for temporary pacing

4) Notify the cardiologist and prepare for temporary pacing

1. Four clients enter the emergency department at the same time. Which should the triage nurse see first? 1) 25-year-old client with sudden-onset chest pain and heart rate of 110/min 2) 45-year-old client with type 2 diabetes who is traveling and has lost insulin glargine 3) 60-year-old client with pain, swelling, erythema, and warmth in the right leg 4) 70-year-old client with left lower abdominal pain and diarrhea for 2 days

1) 25-year-old client with sudden-onset chest pain and heart rate of 110/min

1. The emergency nurse is triaging clients. Which report is most concerning and would be given priority for definitive diagnosis and care? 1) Abrupt, tearing, moving (upper to lower) back pain 2) Severe lower back pain after lifting heavy boxes 3) Sharp calf ache with ambulation that improves with rest 4) Unilateral leg swelling with 2+ pitting edema after an airplane trip

1) Abrupt, tearing, moving (upper to lower) back pain

1. The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? Select all that apply. 1) Blood pressure 2) Blood urea nitrogen (BNP) 3) Liver enzymes 4) Potassium 5) White blood cell (WBC) count

1) Blood pressure 2) Blood urea nitrogen (BNP) 4) Potassium

1. The nurse is developing a teaching plan for a 65-year-old African American male client with a BMI of 30 kg/m2 and a strong family history of cardiovascular disease. Which risk factor for coronary artery disease (CAD) should the nurse focus on during teaching? 1) Client's BMI of 30kg/m² 2) Client's ethnicity 3) Client's gender 4) Client's strong family history of cardiovascular disease

1) Client's BMI of 30kg/m²

1. The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse? 1) The client has a temperature of 100 F (37.7 C) 2) The client is ambulating up and down the hallways 3) The client is breathing at a rate of 16/min 4) The client is massaging the leg at the site of inflammation

4) The client is massaging the leg at the site of inflammation

1. A nurse is making initial client rounds at the beginning of the shift. Which client should the nurse see first? 1) A 36-year-old client with endocarditis who has a temperature of 100.6 F (38.1 C), chills, malaise, and a heart murmur 2) 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension 3) 67-year-old client admitted for pneumonia with new-onset atrial fibrillation, who has blood pressure of 130/90 mm Hg and heart rate of 110/min 4) 70-year-old client with advanced heart failure who is receiving intravenous (IV) diuretics, has blood pressure of 80/60 mm Hg, and is watching TV

2) 40-year-old client with pericardial effusion who has blood pressure of 84/62 mm Hg and jugular venous distension

1. The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first? 1) Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban 2) Bradycardia in a client with a demand pacemaker set at 70/min 3) First-degree atrioventricular block in a client prescribed atenolol 4) Sinus tachycardia in a client with gastroenteritis and dehydration

2) Bradycardia in a client with a demand pacemaker set at 70/min

1. A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1) 30 seconds 2) 35 seconds 3) 60 seconds 4) 85 seconds

3) 60 seconds

1. Which client is in need of follow-up education by the nurse? 1) Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping 2) Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out 3) Client with venous leg ulcer who refuses to wear elastic compression stockings during the day 4) Postsurgical client who points and flexes feet when lying in bed

3) Client with venous leg ulcer who refuses to wear elastic compression stockings during the day

1. A nurse is making a home visit to a client with chronic venous insufficiency (CVI). The home health (HH) aide is there with the client. Which action by the HH aide would require intervention by the nurse? 1) Applying lotion to the client's dry, cracked skin on lower extremities 2) Assisting the client with placing medications in a daily pill reminder box 3) Cutting the client's fingernails and toenails 4) Putting compression stocking on the client

3) Cutting the client's fingernails and toenails

1. A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? 1) Bronchial breath sounds at lung periphery 2) Clear vesicular breath sounds at lung bases 3) Diffuse bilateral crackles at lung bases 4) Stridor in upper airways

3) Diffuse bilateral crackles at lung bases

1. The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first? 1) Administer as-needed (prn) albuterol by nebulizer 2) Administer prn intravenous (IV) furosemide 3) Elevate the head of the bed 4) Give prn sublingual morphine

3) Elevate the head of the bed

1. A client taking a diuretic for chronic heart failure experiences constipation. What is the nurse's best recommendation? 1) Drink 2 extra glasses of water with each meal 2) Exercise for longer periods 3) Include more fiber in the diet 4) Take warm baths to relax the abdomen

3) Include more fiber in the diet

1. A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? 1) Jugular venous distention 2) Mean arterial blood pressure 65 mm Hg 3) Urine output <0.5 mL/kg/hr 4) Warm, flushed skin

3) Urine output <0.5 mL/kg/hr

1. A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which of the following statements regarding digoxin toxicity indicates that further teaching is needed? 1) "I must visit my health care provider (HCP) to check my drug levels" 2) "I should report to my HCP if I develop nausea and vomiting" 3) "I should tell my HCP if I feel my heart skip a beat" 4) "I will need to increase my potassium intake"

4) "I will need to increase my potassium intake"

1. A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply. 1) Amphetamine use 2) Cigarette smoke 3) Cold exposure 4) Deep sleep 5) Sexual intercourse

1) Amphetamine use 2) Cigarette smoke 3) Cold exposure 5) Sexual intercourse