Exam 4

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)

a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L e. Proteinuria f. Microalbuminuria

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?

b. Atrial fibrillation

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.)

a. Decrease in cardiac output d. Increase in blood pressure e. Decrease in urine output

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed?

b. Dyspnea on exertion

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge?

a. Medication reconciliation

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse?

a. Mid-sternal chest pain

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate?

b. "Avoid straining while having a bowel movement."

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next?

b. Assess vital signs and level of conciousness

A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?

a. Assess the client's respiratory status.

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this client's safety prior to discharging home? (Select all that apply.)

a. "Are your bedroom and bathroom on the first floor?" b. "What social support do you have at home?" d. "What spiritual beliefs may impact your recovery?"

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this client's teaching?

a. "Avoid using salt substitutes."

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure?

a. "Clean the skin and clip hairs if needed."

After teaching a client with congestive heart failure (CHF), the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

a. "I'll read the nutritional labels on food items for salt content." d. "I will eat oatmeal for breakfast instead of ham and eggs." e. "Substituting fresh vegetables for canned ones will lower my salt intake."

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching?

a. "Minimize or abstain from caffeine."

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.)

a. "Reposition the client every 2 hours." c. "Accurately record intake and output." d. "Use the same scale to weigh the client each morning."

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.)

a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)

a. Pulmonary crackles b. Confusion, restlessness e. Cough that worsens at night

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.)

a. Smoking cessation b. Stress reduction and management d. Adverse effects of medications

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?

a. Standard Precautions

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.)

a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. d. Confirm that an echocardiogram has been completed.

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?

b. "Are you able to walk upstairs without fatigue?"

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this client's discharge teaching?

b. "Avoid large crowds and people who are sick."

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?

b. Friction rub at the left lower sternal border

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next?

b. Initiate cardiopulmonary resuscitation (CPR).

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client?

b. Instruct the client to ask for assistance when rising from bed.

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)

b. Night sweats c. Cardiac murmur e. Osler's node

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98° F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2° F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take?

b. Slow the amiodarone infusion rate.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion?

b. Turn off oxygen therapy.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition?

b. Warfarin (Coumadin)

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond?

c. "Clients who use cocaine are at risk for fatal dysrhythmias."

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

c. "I must stop halfway up the stairs to catch my breath."

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, "Why is this important?" How should the nurse respond?

c. "Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes."

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first?

c. Ask the client what medications he or she takes.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns?

c. Schedule periods of exercise and rest during the day.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response?

c. short period of asystole

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this client's teaching?

d. "Do not take this medication within 1 hour of taking an antacid."

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this client's discharge teaching?

d. "Weigh yourself daily while wearing the same amount of clothing."

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, "I know a transplant is my last chance, but I don't want to become a vegetable." How should the nurse respond?

d. "Would you like information about advance directives?"

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?

d. Administer PRN acetaminophen.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client?

d. Ensure that everyone is clear of contact with the client and the bed.

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip?

d. Sinus rhythm with premature ventricular contractions (PVCs)

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?

d. Sit the client up with a pillow to lean forward on.

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation?

d. Ventricular and atrial depolarization are initiated from different sides

A nurse cares for a client with right-sided heart failure. The client asks, "Why do I need to weigh myself every day?" How should the nurse respond?

a. "Weight is the best indication that you are gaining or losing fluid."

A nurse cares for an older adult client with heart failure. The client states, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." How should the nurse respond?

a. "Would you like to talk more about this?"

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?

a. A 36-year-old woman with aortic stenosis

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery d. An 80-year-old man with a bacterial infection of the respiratory tract

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first?

a. Assess airway, breathing, and level of consciousness.

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

a. Assess for symptoms of left-sided heart failure.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond?

b. "Blood clots form more easily in artificial replacement valves."

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this client's teaching?

b. "Gather everything you need for a chore before you begin."

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching?

b. "I will avoid sources of strong electromagnetic fields."

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?

b. "I will have my teeth cleaned by my dentist in 2 weeks."

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?

b. "My shoes fit really tight lately."

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation?

b. A 50-year-old who is post coronary artery bypass graft surgery

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?

b. Speech alterations