Ex3 Med Surg II Chps 22, 81 LWW Flash Cards FA20
A nurse is caring for a client diagnosed with myocardial infarction (MI) who is prescribed a nitrate. What does the nurse identify as the purpose of giving a nitrate to this client?
•to dilate coronary arteries
A child with a ventricular septal repair is receiving dopamine postoperatively. The nurse educates the child's parents that this medication is most likely to be given for which action?
•to increase cardiac output
A 9-year-old child had cardiac surgery 2 days ago. The child tells the nurse: "I'm sore and I don't want to move today." Which action by the nurse is most appropriate?
•Medicate the child for discomfort and then begin activities related to ambulation.
A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. The monitor displays the waveform depicted in the image. Which intervention should the nurse do first?
•Observe the client's airway, breathing, and circulation.
A nurse is monitoring a client who has symptoms of anxiety and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse?
•Obtain the client's vital signs and oxygen saturation.
A nurse is the first to respond to a client who is unresponsive. Which action should the nurse perform immediately?
•Palpate for a pulse.
A client is recovering from an acute myocardial infarction (MI). During the first week of recovery, the nurse should stay alert for which abnormal heart sound?
•Pericardial friction rub
A 3-year-old child has a high red blood cell count and polycythemia. When assisting with the planning of care, which action will be of greatest impact in preventing complications?
•Promote adequate fluid intake.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that's specific to heparin. Which agent fits this description?
•Protamine sulfate
A nurse is developing a plan of palliative care for a client with end-stage cardiomyopathy. Which action is appropriate to include in the care plan?
•Provide nonpharmacological measures to reduce discomfort.
An average-weight client reports of generalized steady abdominal pain. The nurse should suspect an abdominal aortic aneurysm, if the abdominal pain is accompanied by which finding?
•Pulsating mass in the periumbilical area
The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.
•Restrict exercise.
A child returns to the unit after a cardiac catheterization. The nurse should reinforce education for the child and parents on which point regarding mobility?
•The child will be maintained on bed rest with the affected extremity immobilized.
Propranolol 80 mg PO BID has been ordered by the health care provider. The nurse reinforces teaching of this medication. Which indicates teaching has been successful?
•The client checks pulse for bradycardia.
Which criterion is required to establish a diagnosis of acute rheumatic fever?
•Use of Jones criteria and presence of a streptococcal infection
The nurse is caring for a client with heart failure who is receiving furosemide daily. What action should the nurse instruct the client to perform?
•Weigh self daily.
A client with chest pain doesn't respond to nitroglycerin. On admission to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?
•Within 3 to 6 hours
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as:
•a third heart sound (S3).
A client, who is newly prescribed metoprolol, has a headache and asks the nurse what medication to take. The nurse should reinforce the health care provider's instructions to take which of the following medications?
•acetaminophen
An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder?
•acute pulmonary edema
A nurse is caring for a client with left-sided heart failure. Which intervention takes priority in this client's care?
•administering diuretics
A client develops atrial fibrillation after an acute myocardial infarction. The physician prescribes digoxin, 0.125 mg I.M. daily. The nurse clarifies the order with the physician because I.M. administration of digoxin leads to:
•an increased serum creatine kinase (CK) level.
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client?
•anticoagulant
A nurse is about to administer digoxin to a client with heart failure. Which parameter should the nurse check before administering the medication?
•apical pulse
A client with a history of chronic obstructive pulmonary disease (COPD) arrives in the emergency department with an oxygen saturation of 84%. Which diagnostic study does the nurse prepare the client for to evaluate cellular metabolism?
•arterial blood gas (ABG) analysis
A nurse receives a report on a client who has been diagnosed with an abdominal aortic aneurysm (AAA). The nurse would expect the client to have which underlying disease?
•atherosclerosis
Echocardiography reveals vegetation on a client's heart valves. The nurse knows that this finding indicates:
•bacterial invasion.
The nurse cares for an older adult client with a history of left-sided heart failure. Which finding indicates to the nurse that the client is experiencing an exacerbation of heart failure?
•bibasilar fine crackles
Which factor is an important part of observing a child with a possible cardiac anomaly?
•blood pressure in four extremities
A client is experiencing cardiac tamponade after a chest trauma. Which type of shock will the nurse monitor for?
•cardiogenic
Which potential side effects should the nurse include when assisting in discharge teaching of a male client who was started on atenolol?
•causes and treatments for erectile dysfunction
A child with tetralogy of Fallot has clubbing of the fingers and toes. The nurse understands that this finding is related to which condition?
•chronic hypoxia
The nurse is monitoring laboratory studies for a client who had a myocardial infarction. Which test will the nurse monitor that is most indicative of cardiac damage?
•creatine kinase isoenzymes (CK-MB)
Which characteristic can the nurse document when gathering data from a child with tricuspid atresia?
•cyanosis
A client recovers from an episode of acute pulmonary edema and is prescribed enalapril. What does the nurse determine is the most important outcome of administration of this medication?
•decreased workload of the heart
A client is admitted to the emergency department with chest discomfort, diaphoresis, and nausea. Suspecting possible in front of myocardial infarction (MI), the nurse would anticipate that the health care provider will prescribe which diagnostic test to quickly determine myocardial damage?
•electrocardiogram
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
•fine crackles.
When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom?
•headache
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. Which condition should the nurse suspect?
•heart failure
The nurse is observing a normal cardiac rhythm strip obtained from an adult client. Which characteristic leads to this normal finding?
•heart rate of 88 beats/minute
A client is recovering from surgical repair of a dissecting aortic aneurysm. The nurse should evaluate the client for signs of bleeding or recurring dissection. These signs include:
•hypotension and tachycardia.
The nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
•low serum potassium level
An increase in the creatine kinase-MB isoenzyme (CK-MB) can be caused by:
•myocardial necrosis.
A nurse is assisting with the teaching of a class for a group of teenagers at a local high school. What should the nurse include as risk factors for developing hypertension? Select all that apply.
•obesity •smoking •heredity
A client has been hospitalized with a diagnosis of acute arterial occlusive disease. After surgery, the health care provider orders heparin IV therapy for the client. What test does the nurse need to monitor for this client while on heparin?
•partial thromboplastin time (PTT)
A client is experiencing chest pain at rest that is unresponsive to nitroglycerin. The health care provider diagnoses unstable angina and alerts the nurse that the client will require treatment with immediate surgical intervention. For which treatment does the nurse prepare the client?
•percutaneous transluminal coronary¬ angioplasty (PTCA)
The nurse is caring for a client with cardiac tamponade. Which treatment will the nurse prepare the client for?
•pericardiocentesis
The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:
•place the client in high Fowler's position.
An older adult client with heart failure and 2+ pitting edema is prescribed furosemide. Due to the effects of furosemide, which supplemental medication would the nurse expect to see ordered for this client?
•potassium
A client has recently been diagnosed with hypertension. The client has an elevated blood pressure with no symptoms, and the cause is uncertain. Which term best describes this condition?
•primary hypertension
The most important reason for the nurse to encourage a client with peripheral vascular disease to initiate a walking program is because it:
•promotes collateral circulation.
After experiencing a transient ischemic attack (TIA), a client is prescribed aspirin, 325 mg by mouth daily. The nurse should teach the client that this medication has been prescribed to:
•reduce platelet agglutination.
The clinic nurse is reinforcing teaching about symptoms of cardiovascular disease (CVD) with the client. What are common symptoms associated with cardiovascular disease?
•shortness of breath, chest discomfort/pain, palpitations
The nurse is caring for a stable client with digoxin toxicity. Which treatment does the nurse anticipate for this client?
•time and symptomatic treatment
A client with a deep vein thrombosis (DVT) is admitted to the hospital for treatment. Which medication will the nurse administer orally to prevent further thrombus formation?
•warfarin
The nurse is talking with the parent of a 3-year-old child who has congenital heart disease. The parent reports feeling concerns that the child does not seem to be maturing emotionally in a manner that is at the same rate as the two older children in the family. Which response by the nurse is most appropriate?
•"Children who have chronic health issues may experience developmental delays."
A client comes to the health care provider's office for a follow-up visit 4 weeks after suffering a myocardial infarction (MI). The nurse gathers data regarding the knowledge of the client regarding the prescribed cardiac rehabilitation program. What statement suggests that the client needs more instruction?
•"Client walks 4 miles (6.4 km) in 1 hour every day."
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing the client's plan of care, the nurse should include which expected outcome?
•"Client will verbalize the intention to stop smoking."
The nurse is caring for a child that is undergoing cardiac surgery. Parents ask a nurse what the activity level for their child should be post-surgery. Which response would be best?
•"Encourage a balance of rest and exercise."
A client with high blood pressure is receiving an antihypertensive drug. The nurse knows that antihypertensive drugs commonly cause fatigue and dizziness, especially on rising. When developing a client teaching plan to minimize orthostatic hypotension, the nurse should include which instruction?
•"Flex your calf muscles, avoid alcohol, and change positions slowly."
The nurse is caring for an adolescent diagnosed with Wolff-Parkinson-White syndrome. When asking the teen how he or she is feeling, which response would be most consistent with this condition?
•"I have had periods of time today in which my heart seemed to beat very fast."
The nurse is reinforcing teaching with a client how to take nitroglycerin to treat angina pectoris. Which statements indicate that the client understands the potential side effects of nitroglycerine? Select all that apply.
•"I may experience a pounding headache." •"I may feel dizzy." •"I may feel flushed."
A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates that the client understands?
•"I should only have approximately 2400 mg of sodium per day."
Propranolol has been prescribed for a teen who has been diagnosed with hypertension. When discussing the medication with the teen, which statement indicates the need for further instruction?
•"I should take this medication daily on an empty stomach."
Which statement by the client best indicates an understanding on how to prevent complications while taking warfarin?
•"I should use a soft toothbrush."
An exercise stress test has been ordered for a 12-year-old child. Which statement by the child indicates the need for further instruction?
•"It will be important for me to eat the breakfast my mom makes for me before I take the test."
A teenager with heart failure who has been prescribed digoxin asks the nurse, "What will this drug do for my heart?" What is the best response by the nurse?
•"It will decrease the workload of the heart."
Before discharge, which instruction should the nurse give to a client receiving flecainide to reduce the risk of heart failure?
•"Limit your fluid intake."
A client who reported chest pain received sublingual nitroglycerin. Which statement by the client indicates that this drug is producing its therapeutic effect?
•"My chest pain is decreasing."
When collecting data from a client who reports recent chest pain, the nurse obtains a thorough history. Which statement by the client most strongly suggests angina pectoris?
•"The pain occurred while I was mowing the lawn."
The nurse is reinforcing discharge instructions for a client with varicose veins. Which statement by the client indicates a need for further instruction?
•"Wearing tight clothes won't affect me."
A 40-year-old female client who is taking nifedipine for hypertension tells the nurse that she has noticed a "little swelling" in her ankles. What should be the nurse's first response?
•"When did you first notice this?"
The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate?
•"While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery."
Treatment for a child with sinus bradycardia includes atropine 0.02 mg/kg. If the child weighs 20 kg, how much is given per dose?
•0.4 mg
The nurse is administering digoxin to a client diagnosed with congestive heart failure (CHF). The health care provider has ordered digoxin 0.125 mg PO daily. Calculate how many tablets will the nurse administer from a unit dose of 0.25 mg/tablet?
•0.5
The nurse is administering digoxin to a client diagnosed with congestive heart failure (CHF). The health care provider has ordered digoxin 0.125 mg PO daily. Calculate how many tablets will the nurse administer from a unit dose of 0.25 mg/tablet
0.5
The nurse is reviewing the diagnostic test results for a client with reports of chest pain. Which diagnostic test result is most consistent with a diagnosis of angina?
•12-lead electrocardiogram (ECG) with depressed, inverted, or downward slope to the T waves in leads II, III, and aVF
A client with a history of hypertension had a total hip replacement. The health care provider prescribes hydrochlorothiazide 35 mg oral solution by mouth once per day. The label on the solution reads hydrochlorothiazide 50 mg/5 mL. To administer the correct dose, how many milliliters should the nurse pour? Record your answer using one decimal place.
•3.5
Erythromycin is given to a 6-year-old child before dental work to prevent endocarditis. The child weighs 44 lb (20 kg). The order is for 20 mg/kg by mouth 2 hours before the procedure. How many milligrams should be given to this child? Record your answer using a whole number.
•400
A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. He also reports nausea, diaphoresis, and shortness of breath. What should the nurse do?
•Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client?
•Anticoagulant
A client, 1 hour after undergoing a cardiac catheterization through a percutaneous femoral access site, calls the nurse to report that there's something wet under the buttocks. Upon entering the client's room, what step should the nurse take first?
•Apply gloves and assess the femoral access site
Which precaution should a nurse take when caring for a client with a myocardial infarction (MI) who has received a thrombolytic agent?
•Avoid puncture wounds.
A client sustained a stroke and has impaired verbal communication. What interventions can the nurse provide that will maintain the client's dignity? Select all that apply.
•Be honest when unable to decipher the client's speech. •Use a normal tone of voice when communicating. •Allow adequate time for the client to respond.
A client who comes to the hospital reporting severe substernal chest pain that is radiating down the left arm is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). Which nursing action is a priority on admission to coronary care?
•Begin electrocardiogram (ECG) monitoring.
A client is in hemorrhagic shock. What data best reflects the effectiveness of fluid replacement therapy?
•Blood pressure
An older adult client has experienced an episode of acute pulmonary edema. Fearful of a repeat episode, the client asks what precautions should be taken to prevent another episode. What instruction should the nurse give to this client?
•Call the health care provider if he gains more than 3 lb (1.4 kg) in 1 day.
A preschooler with a history of heart failure is prescribed digoxin. Which nursing intervention is most important to perform before administering this drug to a child?
•Check apical heart rate for 1 minute.
A client taking a new prescription for propranolol calls the clinic to report a weight gain of 3 lb (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?
•Due to fluid accumulation, have the client assessed for worsening heart failure by the health care provider.
A pregnant client is suspected of experiencing worsening mitral valve prolapse. Which diagnostic test should the nurse prepare the client for?
•Echocardiography
A client is diagnosed with pericarditis. The nurse anticipates that the client may exhibit which signs and symptoms?
•Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
A nurse educator in the cardiac care unit is assigned to orient a newly hired nurse. Included in the orientation is the medication administration system. What is the best way to determine if the nurse understands the medication system?
•Have the nurse demonstrate the procedure.
The nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?
•Heart failure
Which of the following complications is most common after an abdominal aortic aneurysm resection?
•Hemorrhage and shock
The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?
•Heparin sodium
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?
•Homans'
The physician prescribes digoxin for a client with heart failure. During digoxin therapy, which electrolyte imbalance may predispose the client to digoxin toxicity?
•Hypokalemia
A nurse is reinforcing education for a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, what should the nurse encourage the client to do?
•Increase activity level.
A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How should the nurse intervene?
•Instruct the client to flex the calf muscles and then sit up for several minutes before standing.
Which statement best explains why furosemide is administered to treat hypertension?
•It inhibits reabsorption of sodium and water in the loop of Henle.
The nurse is discussing bacterial/infective endocarditis with the parent of a teen who has been diagnosed with the disorder. Which statement about bacterial/infective endocarditis indicates an understanding of the condition?
•It is an infection of the valves and inner lining of the heart.
A client who suffered blunt chest trauma in a car accident reports chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position?
•Leaning forward while sitting
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
•Leg edema
A client is diagnosed with prehypertension. Which of the following would most likely be included in the client's treatment plan?
•Lifestyle modification instructions
A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take?
•Look at the chart for his last potassium level and contact the physician.
Before discharge, which instruction should the nurse give to a client receiving digoxin?
•"Call the physician if your heart rate goes above 120 beats/minute."
Which client statement given when obtaining data is consistent with the diagnosis of varicose veins?
•"My legs feel tired and have a dull ache, especially when I walk or stand for long periods."
The nurse is talking with the parent of a 5-year-old child. The parent reports having recently read an article about rheumatic fever and heart disease and questions how to prevent this from happening to the child. What is the best response by the nurse?
•"Prompt treatment of strep infections is a key to preventing this condition."
A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client is anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate preparing the client for? Select all that apply.
creatine kinase (CK) •troponin T and troponin I •myoglobin
A nurse is caring for several clients on a medical floor. Which client does the nurse identify to have the greatest chance of developing cardiogenic shock?
•a client with acute myocardial infarction (MI)
Which condition most commonly results in coronary artery disease (CAD)?
•atherosclerosis
The parents of a 3-year-old with a congenital heart disease report during a checkup that they are concerned about giving a flu vaccine to their child. Which statement is appropriate for inclusion in the nurse's response?
•"The flu vaccine is both safe and recommended to children who have chronic illness such as heart disease."
A client is hospitalized to rule out an acute myocardial infarction (MI). Laboratory studies indicate a normal lactate dehydrogenase level and an elevated troponin I level. The nurse enters the client's room and finds the client pacing the floor. Which statement by the nurse would be most appropriate in this situation?
•"You seem upset. Why don't you get into bed and, if you wish, we can talk for a while."
When obtaining data from a child with suspected Kawasaki disease, which symptom is common?
•"strawberry" tongue
A 2-year-old child is showing signs of shock. A 10-mL/kg bolus of normal saline solution is ordered. The child weighs 20 kg. How many milliliters should be administered? Record your answer using a whole number.
•200
A nurse is obtaining data from a client who is at risk for cardiac tamponade due to chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if the blood pressure is 108/82 mm Hg? Record your answer using a whole number.
•26
A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive. What action should the nurse take?
•Ask the client for a copy of the advance directive to place on his chart.
The licensed practical nurse discovers a client with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he reports dizziness. Which medication would the registered nurse use to treat the client's bradycardia?
•Atropine
A nurse has administered enalapril to a client. What intervention should the nurse perform to accurately determine the effectiveness of this drug?
•Check blood pressure 1 hour after administration.
For a client with cardiomyopathy, the highest priority nursing diagnosis is:
•Decreased cardiac output related to reduced myocardial contractility.
A nurse is preparing the family of a child with Kawasaki disease for discharge. Which instruction is most appropriate?
•Frequent echocardiography will be needed.
A nurse is caring for a hypertensive client who has been placed on a low-sodium diet. Which menu selection demonstrates the client's understanding of this diet?
•Fresh green beans and chicken salad
A client is admitted to the acute care facility for treatment of heart failure. The nurse expects the physician to prescribe which drug?
•Furosemide
A white male, age 43, is admitted to an acute care facility with a tentative diagnosis of infective endocarditis. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years ago and an aortic valve replacement 2 years ago. Which history finding is a major risk factor for infective endocarditis?
•History of aortic valve replacement
The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse include in the care plan for the next 8 hours? Select all that apply.
•Maintain pressure over the femoral access site. •Check the dressing and access site for bleeding. •Keep the extremity straight.
A nurse is monitoring a client receiving a continuous infusion of lidocaine for ventricular dysrhythmias. During breakfast, the client states, "I am so tired. My vision is so blurry I can't see my food." What is the nurse's best action?
•Notify the primary registered nurse of the client's symptoms.
The nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms would suggest circulatory impairment?
•Numbness, cool skin temperature, and pallor
A nurse is monitoring a client who has just returned from a cardiac catheterization. Which is an appropriate nursing intervention?
•Palpate the peripheral pulses.
A client is receiving captopril for heart failure. Which finding indicates that the medication isn't producing the desired treatment outcome and requires the nurse to notify the physician?
•Peripheral edema
A client comes to the emergency department diagnosed with a ruptured aortic aneurysm. What is the priority action for this client?
•Prepare the client for surgery.
The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant?
•Rheumatic fever
The nurse is evaluating a client who had a myocardial infarction (MI) 7 days ago. Which outcome indicates that the client is responding favorably to therapy?
•The client demonstrates the ability to tolerate increasing activity without chest pain.
A client with severe angina and electrocardiogram changes is seen in the emergency department. In terms of serum testing, the nurse can expect which laboratory test to be ordered?
•Troponin
The nurse is caring for a client diagnosed with left-sided cerebrovascular accident, with expressive aphasia and right-sided weakness. When administering care for this client, which intervention should the nurse delegate to unlicensed assistive personnel (UAP)?
•Turn and position the client every 2 hours.
A client comes to the emergency department reporting visual changes and a severe headache. The nurse measures the client's blood pressure at 210/120 mm Hg. However, the client denies having hypertension or any other disorder. After diagnosing malignant hypertension, a life-threatening disorder, the physician initiates emergency intervention. What is the most common cause of malignant hypertension?
•Untreated hypertension
Which client is most at risk for developing deep vein thrombosis (DVT)?
•a 62-year-old female recovering from a total hip replacement
A 2-year-old child is being monitored after cardiac surgery. Which findings signal a potential decrease in cardiac output? Select all that apply.
•blood pressure of 80/45 mm Hg •urinary output of 45 mL in the past 2 hours •weak peripheral pulses
A male with heart failure is experiencing tachycardia, decreased blood pressure, and decreased peripheral pulses. The nurse interprets these symptoms as indicating which condition?
•cardiogenic shock
A client who had an anterior wall myocardial infarction (MI) would have a greater risk for exhibiting crackles in the lungs related to which disorder?
•left-sided heart failure
The nurse is caring for a child with acute rheumatic fever. Which data does the nurse anticipate in this child?
•leukocytosis
A client is diagnosed with prehypertension. Which treatment option would most likely be included in the client's treatment plan?
•lifestyle modification instructions
A client is recovering from coronary artery bypass graft (CABG) surgery. Which nursing diagnosis takes highest priority at this time?
•output related to depressed myocardial function, deficient fluid volume, or impaired electrical conduction
The nurse advises a client recovering from a myocardial infarction to decrease fat and sodium intake. Which foods should the nurse instruct the client to avoid? Select all that apply.
•pepperoni pizza •bacon •cheese •soft drinks
A nurse is monitoring laboratory results for a client admitted with a possible myocardial infarction (MI). Which laboratory result would be used to rule out an MI?
•troponin level of less than 0.2 ng/mL (0.2 µg/L)
A client with a history of severe angina is being seen in the emergency department for chest pain. In terms of diagnostic laboratory testing, it's most important for the nurse to advocate ordering a:
•troponin level.
The nurse suspects that a 68-year-old client has digoxin toxicity. The nurse should assess for:
•vision changes.
A client with chronic heart failure is receiving digoxin, 0.25 mg by mouth daily, and furosemide, 20 mg by mouth twice daily. The nurse instructs the client to notify the physician if nausea, vomiting, diarrhea, or abdominal cramps occur because these signs and symptoms may signal digoxin toxicity. Digoxin toxicity also may cause:
•visual disturbances.
A client comes to the emergency department with symptoms of a myocardial infarction (MI). The health care provider prescribes reteplase. The nurse is aware that this medication will be most effective when given at which time?
•within 1 to 3 hours of onset of symptoms
