Med surg. test 1
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The client has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client?
"Be sure to practice meticulous foot care.
A nurse is caring for a client who has hypertension and diabetes mellitus. The client's blood pressure this morning was 150/92 mm Hg. When the client asks the nurse what his or her blood pressure should be, what is the nurse's most appropriate response?
"Clients with diabetes should have a lower blood pressure goal. You should strive for 130/80 mm Hg."
A client with a strong family history of coronary artery disease asks the nurse how to reduce the risk of developing the disorder. Which is the best response by the nurse?
"Exercise, keep your blood sugar in check, and manage your stress."
Which electrolyte is a major cation in body fluid?
Potassium
A client scheduled for a catheter ablation procedure confides to the nurse that he is worried about having some of his heart cells destroyed. The best response by the nurse is which of the following?
"Only the specific cells causing your dysrhythmia are destroyed; your heart will function better without these cells."
A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide?
"Practice meticulous foot care."
After performing an ECG on an adult client, the nurse reports that the PR interval reflects normal sinus rhythm. What is the PR interval for a normal sinus rhythm?
0.12 and 0.2 seconds.
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering?
0.45% NaCl
The nurse is explaining the DASH diet to a client diagnosed with hypertension. The client inquires about how many servings of fruit per day can be consumed on the diet. What is the nurse's best response?
4 or 5 servings per day
Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment?
5
The nurse is assigned to care for several clients admitted to a telemetry unit. Which clients should the nurse assess first?
A client whose implantable cardioverter defibrillator (ICD) fired twice on the prior shift, requiring amiodarone IV
A nurse is caring for a client with a cardiac disorder who is prescribed diuretics. What important factor should the nurse include in this client's teaching plan?
A discussion of the signs and symptoms of electrolyte and water loss.
An older adult client has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan?
A high-protein diet that is rich in vitamins
Which nursing diagnosis is most significant in planning the care for a client with Raynaud's disease?
Acute Pain
Which diagnostic test is used to quantify venous reflux and calf muscle pump ejection?
Air plethysmography
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply
An elevated hematocrit level Electrolyte imbalance
A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on these symptoms, the nurse is aware to monitor for which type of aneurysm?
Anastomotic
The nurse is caring for a client being treated with isotonic IV fluid for hypernatremia. What complication of hypernatremia should the nurse continuously monitor for?
Cerebral edema
An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed the client hydrochlorothiazide and enalapril. What will the nurse be sure to include in educating this client?
Change positions (lying or sitting to standing) slowly.
Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:
Cigarette smoking.
A client has severe coronary artery disease (CAD) and hypertension. Which medication order should the nurse consult with the health care provider about that is contraindicated for a client with severe CAD?
Clonidine
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition?
Confusion
A nurse is providing education about hypertension to a community group. What are possible consequences of untreated hypertension? Select all that apply.
Coronary artery disease Myocardial infarction Stroke
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.
Distended neck veins Crackles in the lung fields Shortness of breath
The home health nurse is caring for a client who has a diagnosis of hypertension. What assessment question most directly addresses the possibility of worsening hypertension?
Do you ever see spots in front of your eyes?
The nurse analyzes the electrocardiogram (ECG) strip of a stable patient admitted to the telemetry unit. The client's ECG strip demonstrates PR intervals that measure 0.24 seconds. What is the nurse's most appropriate action?
Document the findings and continue to monitor the patient
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.
Drink at least eight glasses of fluid each day. Drink water as an inexpensive way to meet fluid needs. Respond to thirst
A diabetic client visits a walk-in clinic and asks the nurse to take a blood pressure (BP) reading. The measurements are 150/90 mm Hg. Which of the following would the nurse expect as the treatment to normalize the client's BP?
Drug therapy
The nurse is assessing a client with mitral regurgitation. The nurse expects to note what finding in this client?
Dyspnea, fatigue, and weakness
A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have?
Essential (primary)
The nurse is caring for a client at risk for thrombosis. What is an appropriate nursing action when evaluating this client?
Examine the legs for color, capillary refill time, and tissue integrity.
Which factor increases blood urea nitrogen (BUN)?
Gastrointestinal bleeding
In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.
Heart failure Pulmonary edema Renal impairment
Which is a modifiable risk factor for coronary artery disease (CAD)?
Hyperlipidemia
A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regime?
Improve venous return
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?
In 3 to 5 days
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
In dehydration, only extracellular is depleted.
While assessing a client's peripheral IV site, the nurse observes edema around the insertion site. How should the nurse document this complication related to IV therapy?
Infiltration
The nurse is discussing aging and the incidence of hypertension with an older adult. What lifestyle change will lower blood pressure for the older adult?
Keep weight stable.
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?
Lactated Ringer's solution
Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?
Large and superficial
A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully?
Low serum potassium level
The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?
Lowering the limb so that it is dependent
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:
Lowering the limb so that it is dependent.
A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia?
Magnesium and potassium
A female patient is being seen in the ER complaining of fatigue and shoulder blade discomfort. She is also short of breath. Based on these symptoms, what will the nurse suspect?
Myocardial infarction (MI)
The nurse is caring for a client who was admitted with fluid volume excess (FVE). Which nursing assessments should the nurse include in the ongoing monitoring of the client? Select all that apply.
Nutritional status and diet Blood pressure, heart rate, and rhythm Intake and output, urine volume, and color Skin assessment for edema and turgor
Which of the following would be appropriate nursing interventions for a client with hypokalemia? Select all that apply.
Offer a diet with fruit juices and citrus fruits. Monitor intake and output every shift.
A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.)
Oliguria Tachycardia Tachypnea
A patient with abnormal sodium losses is receiving a regular diet. How can the nurse supplement the patient's diet to provide 1,600 mg of sodium daily?
One beef cube and 8 oz of tomato juice
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?
Prothrombin time (PT)
The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter?
Sawtooth
What does the nurse recognize as one of the best indicators of the patient's renal function?
Serum creatinine
Which is a potassium-sparing diuretic used in the treatment of heart failure (HF)?
Spironolactone
The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the client's heart?
T wave
The nurse assesses a client with a heart rate of 120 beats per minute. What are the known causes of sinus tachycardia?
hypovolemia
The nurse is educating the patient about administering nitroglycerin prior to discharge from the hospital. What information should the nurse include in the instructions?
Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system.
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?
Taking daily walks
What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?
Teach the client how to apply an elastic sleeve
A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?
The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."
A client has been diagnosed with atrial fibrillation and has been prescribed warfarin therapy. What should the nurse prioritize when providing health education to the client?
The need to have regular blood levels drawn
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?
The severity of discomfort isn't related to the size of varicosities.
The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client?
Veins are tied off and left in the leg.
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventive measure for varicose veins?
Walk for several minutes every hour to promote circulation.
A client tells the nurse "my heart is skipping beats again; I'm having palpitations." After completing a physical assessment, the nurse concludes the client is experiencing occasional premature atrial complexes (PACs). The nurse should instruct the client to
avoid caffeinated beverages.
A client experiences a faster-than-normal heart rate when drinking more than two cups of coffee in the morning. What does the nurse identify on the electrocardiogram as an indicator of sinus tachycardia?
heart rate of 118 bpm
A client is diagnosed with a dysrhythmia at a rate slower than 60 beats/minute. What type of dysrhythmia does the client have?
sinus bradycardia
The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?
stroke
A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best?
"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."
When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction?
Avoid wearing canvas shoes.
A client is taking amiloride and lisinopril for the treatment of hypertension. What laboratory studies should the nurse monitor while the client is taking these two medications together?
Potassium level
The nurse documents that a client is having a normal sinus rhythm. What characteristics of this rhythm has the nurse assessed?
The sinoatrial (SA) node initiates the impulse.
The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply.
Weight loss Regular exercise Smoking cessation
The nursing student asks the nurse how to tell the difference between ventricular tachycardia and ventricular fibrillation on an electrocardiogram strip. What is the best response?
"Ventricular fibrillation is irregular with undulating waves and no QRS complex. Ventricular tachycardia is usually regular and fast, with wide QRS complexes."
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining?
1 L
The nurse is assessing a patient two days postoperatively who is suspected of having deep vein obstruction. The patient is complaining of pain in the left lower extremity and there is a 2-cm difference in the right and left leg circumference. What intervention can the nurse provide to promote arterial flow to the lower extremities?
Apply a heating pad to the patient's abdomen.
A nurse provides evening care for a client wearing a continuous telemetry monitor. While the nurse is giving the client a back rub, the client 's monitor alarm sounds and the nurse notes a flat line on the bedside monitor system. What is the nurse's first response?
Assess the client and monitor leads.
The nurse cares for a client with a dysrhythmia and understands that the P wave on an electrocardiogram (ECG) represents which phase of the cardiac cycle?
Atrial depolarization
A patient with mitral valve stenosis and coronary artery disease (CAD) is in the telemetry unit with pneumonia. The nurse assesses a 6-second rhythm strip and determines that the ventricular rhythm is highly irregular at a rate of 150 bpm, with no discernible P waves. What does the nurse determine this rhythm to be?
Atrial fibrillation
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder?
Atrial flutter
A nurse is creating an education plan for a client with venous insufficiency. What measure should the nurse include in the plan?
Avoid tight-fitting socks.
The nurse is providing education about angina pectoris to a hospitalized client who is about to be discharged. What instruction does the nurse include about managing this condition? Select all that apply.
Balance rest with activity. Stop smoking. Carry nitroglycerin at all times.