Exam 1 M/S

A nurse is reinforcing teaching with a young adult female client who has been prescribed lisinopril. Which of the following instructions should the nurse plan to include? (Select all that apply.)

"Report the development of a persistent dry cough." "Monitor your blood pressure on a regular basis." "Notify your doctor immediately if you become pregnant."

A nurse is talking with a client who says she knows someone who takes metoprolol for blood pressure and asks if the medication would be appropriate for her as well. Which of the following data from the client's medical record should the nurse identify as a contraindication to metoprolol?

A history of sinus bradycardia *Metoprolol can cause bradycardia, dysrhythmias, and AV block. The nurse should recognize the medication is contraindicated for clients who have sinus bradycardia, sick sinus syndrome, or 2nd or 3rd degree heart block.

A nurse is caring for a client who has hypertension and is to start taking atenolol. The nurse should instruct the client to monitor for which of the following findings as an adverse effect of this medication?

Bradycardia Atenolol is a beta-adrenergic blocking agent, which slows the heart rate and can lead to bradycardia. *The nurse should instruct the client to check heart rate before each dose and to notify the provider if the rate is below his usual rate.

A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

Cardiac dysrhythmias

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

Check pedal pulses every 15 min. *The observation of a client who has undergone a cardiac catheterization includes monitoring the client's pulses below the puncture site.

A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Decreased level of consciousness *The rise in carbon dioxide dilates the cerebral vessels causing a feeling of fullness in the head, leading to mental cloudiness and a decreased level of consciousness.

A nurse is collecting data from client who has mitral stenosis. Which of the following findings is a manifestation of this condition?

Dyspnea on exertion *Due to narrowing of the valve, pressure in the lungs leads to dyspnea on exertion.

A client who is 7 days postpartum calls the provider's office and reports pain, swelling, and redness of her left calf. Besides the client seeing the provider, which of the following interventions should the nurse suggest?

Elevate the leg. to encourage venous return and to relieve pain.

A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match?

Lactated Ringer's

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGS are: pH: 7.6 Paco2: 40 mm Hg HCO3: 32 mEq/L. Which of the following acid base conditions should the nurse identify the client is experiencing?

Metabolic alkalosis *The client's pH is above 7.45, the PaCO2 is within the expected reference range and the HCO3 is above 26 mEg/L.

A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?

Monitor daily weight *The client who has had an aortic valve replacement is weighed daily to monitor for the presence of retained fluids which might indicate a decrease in cardiac output, a complication of the surgery.

A nurse sadministering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

Monitor the client's BP every 5 minutes. *When using the urgent vs non-urgent approach for a client who is in a hypertensive crisis, the nurse determines that the priority action is to monitor the client's BP every 5 minutes before, during, and after administering antihypertensive medication.

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7mg/dL. Which of the following client findings should the nurse expect?

Muscle tetany * This calcium level is below the expected reference range.

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Pitting edema *The venous system is unable to efficiently return blood to the heart resulting in increased venous pressure and an accumulation of fluid in the interstitial tissues.

A nurse is reinforcing teaching with a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

Plan to have potassium blood levels checked when taking a thiazide diuretics.

A nurse is reinforcing teaching with a client who has a family history of hypertension. The nurse should inform the client that his blood pressure reading of 124/84 mm Hg places him in which of the following categories?

Prehypertension *A blood pressure reading of 124/84 mm Hg places this client in the prehypertension category. This includes a systolic pressure of 120 to130 mm Hg and a diastolic pressure of 80 to 89 mm Hg.

A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia?

Reports of fatigue *Fatigue and muscle weakness manifestations of hypokalemia.

A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PacO2 of 53, and an HCO3. of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?

Respiratory acidosis * In analyzing blood gases, the nurse should first determine if the result is acidosis (pH less than 7.35) or alkalosis (pH greater than 7.45). A pH of 7.24 is decreased. Therefore, this is acidosis. The next step is to look at the PaCO2 (expected reference range 35 to 45) and the HCO3. (expected reference range 22 to 26). A PaCO2 of 53 is elevated (greater than 45) and the HCO3. of 24 is within the expected reference range. Therefore, if the pH is decreased, the PacOz is elevated and the HCO3- is within the expected reference range, the client experiencing respiratory acidosis.

A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?

Respiratory alkalosis *Clients who have respiratory alkalosis have an increased depth and rate of respiration, confusion, lightheadedness, paresthesias, tremors, and blurred vision.

A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?

Weak pulse

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Weak, irregular pulse *Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

A nurse is reinforcing teaching about a heart healthy diet with a group of clients who have hypertension. Which of the following statements by the clients indicates a need for further teaching?

"I can have a cola drink twice a day." *A client who is on a heart-healthy diet should avoid sugar-sweetened beverages because they increase caloric intake therefore.

A nurse is reinforcing discharge teaching with a client about dietary sources of potassium. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat cantaloupe for my morning snack." *The client should choose fruits such as cantaloupe, bananas, apricots, and peaches as food sources high in potassium.

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurse should recognize that which of the following statements by the client indicates a need for further teaching?

"I will wear stockings with elastic tops."

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for this disorder? (Select all that apply.)

-Hypercholesterolemia -Hypertension -Obesity -Smoking

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.)

-Shallow respirations -Cardiac dysrhythmias -Hyperactive reflexes

A nurse is preparing to administer 0.9% sodium chloride (NaCI) 750 ml IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

= 94

A nurse is reviewing the morning laboratory results of electrolytes for four clients who are receiving digoxin. Which of the following clients should the nurse identify as being at risk for developing digoxin toxicity?

A client taking furosemide for chronic hypertension

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Check the client's vital signs. *When using the airway, breathing, circulation approach to client care, the nurse should place the priority on obtaining vital signs. Nausea is a manifestation of digoxin toxicity, along with other manifestations such as muscle weakness, confusion, abdominal cramping, and changes in vision.

A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse also expect to be below the expected reference range?

Chloride *Hyponatremia refers to a decrease in the sodium level. The loss of sodium, a positively-charged ion, results in the loss of chloride, a negatively-charged ion, because these electrolytes have an electrical attraction to each other.

A nurse is assisting with the care of a client who has infective endocarditis. Which of the following manifestations should the nurse identify as a complication of this disorder?

Dyspnea *Emboli is a serious complication due to emboli arising in the right heart chambers which will terminate in the lungs, causing dyspnea, and left-chamber emboli may travel anywhere in the arteries, reaching the spleen, kidneys, brain, lungs, or extremities.

A nurse is reinforcing teaching with a client who has hypertension and asks if there is a herbal supplement he can use to help lower blood pressure. The nurse should identify that the client can use which of the following herbal supplement to help lower blood pressure?

Garlic *Clients can use garlic to decrease triglyceride and LDL cholesterol levels and increase HDL cholesterol, lower BP, inhibit platelet aggregation, and decrease atherosclerotic plaque. It might also have antimicrobial and anticancer effects. These effects occur from the actions of sulfides in garlic oil, which can interfere with cholesterol synthesis in the liver, inhibiting thromboxane synthesis, and cause vasodilation.

A nurse is collecting data from a client who has alcohol use disorder and is experiencing metabolic acidosis. Which of the following manifestations should the nurse expect?

Hyperventilation *The system attempts to compensate or return the pH to normal by increasing the rate and depth of respirations.

Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper socks for the client. *help provide warmth and increase the client's level of comfort.

A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy. The nurse should explain that which of the following medications can put clients at risk for hyperkalemia?

Spironolactone *Spironolactone is a potassium-sparing diuretic that blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and retention of potassium. The nurse should instruct that spironolactone therapy can increase the risk of hyperkalemia and hyponatremia.

A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

The stockings prevent venous stasis. *Venous stasis can result in a deep vein thrombosis, which can be life threatening. Antiembolic stockings are used to enhance and stimulate the milking and massaging action of veins.

A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

Thready pulse * A client who has hypovolemia will experience decreased volume of circulating blood and less pressure within the vessels, resulting in weak, thready peripheral pulses and flat neck veins.

A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?

pH 7.31 *A client who has respiratory acidosis will have a pH level less than 7.35 and a PaCo2 greater than 45 mm Hg.