Med-Surge ( Cardio)

An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action?

Remove the clothing.

When developing a plan of care for a client who had a cardiac catheterization via a femoral insertion site, the nurse should include:

Maintaining the supine position for a minimum of four hours

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? (Select all that apply.)

Malaise Swollen lymph glands

A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which parameters should the nurse consider to determine the safe resumption of sexual activity? (Select all that apply.)

At least between 4 and 6 weeks after the myocardial infarction The point at which two flights of stairs can be climbed without dyspnea

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk factor for the development of a pulmonary embolus?

Atrial fibrillation

A client who has bone pain of insidious onset is suspected of having multiple myeloma. The nurse expects that a diagnostic finding specific for multiple myeloma is:

Bence Jones protein in the urine

A client who has been taking digoxin (Lanoxin) for 20 years is hospitalized. The client exhibits signs of dehydration and laboratory results identify the presence of hypokalemia. The nurse should monitor the client for which clinical finding indicating digoxin toxicity?

Blurred vision

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider most desirable? (Select all that apply.)

Boiled spinach Sweet potatoes

A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client?

The possible need for prophylactic antibiotic therapy before dental work

A nurse is responding to the needs of victims at a collapsed building. What principle guides the nurse's priorities during this disaster?

Those requiring minimal care are treated first so they can help others.

What clinical indicator is the nurse most likely to identify when completing a history and physical assessment of a client with complete heart block?

syncope

While receiving a blood transfusion, a client develops flank pain, chills, fever, and hematuria. What type of transfusion reaction does the nurse conclude that the client probably is experiencing?

Hemolytic

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common?

Increased cardiac workload

Thrombus formation is a danger for postoperative clients. Which independent interventions should the nurse perform to prevent this complication? (Select all that apply.)

Instruct the client to avoid crossing the legs Instruct the client to dorsiflex the feet routinely

A client who recently was diagnosed as having myelocytic leukemia discusses the diagnosis by referring to statistics, facts, and figures. The nurse determines that the client is using the defense mechanism known as:

Intellectualization

When discussing the therapeutic regimen of vitamin B12 for pernicious anemia with a client, the nurse explains that:

Intramuscular injections once a month will maintain control

Valsartan (Diovan), an angiotensin II receptor antagonist, is prescribed for a client. For which possible side effects should the nurse monitor the client? (Select all that apply.)

Irregular pulse rate Orthostatic hypotension

The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to:

Keep a diary of activities

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? (Select all that apply.)

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse

A nurse teaches a client about warfarin (Coumadin). Which information is essential for the nurse to include in the education plan?

Periodic blood testing is necessary.

A client is admitted to the emergency department with a blood pressure of 240/150 mm Hg. The client complains of a severe headache, blurred vision, and swelling of the ankles. In response to the clinical manifestations, the nurse should:

Assess the client's pulse and respirations

A woman comes to the emergency department reporting signs and symptoms determined by the health care provider to be caused by a myocardial infarction. The nurse obtains a health history. Which reported symptoms does the nurse determine are specifically related to a myocardial infarction in women? (Select all that apply.)

Severe fatigue Sense of unease

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication?

Kidney failure

What should the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?

Heart muscle ischemia

Which instructions should the nurse include in the teaching plan for a client with hyperlipidemia who is being discharged with a prescription for cholestyramine (Questran)?

"Increase your intake of fiber and fluid.

A nurse is evaluating the results of treatment with erythropoietin (Epogen). Which client response is considered significant?

Elevation in hematocrit level

A client with a dysrhythmia is admitted to telemetry for observation. In the morning, the client asks for a cup of coffee. What is the nurse's best response?

"Coffee has caffeine, which can affect your heart. It should be avoided."

Potassium supplements are prescribed for a client receiving diuretic therapy. What client statement indicates that the teaching about potassium supplements is understood?

"I will report any abdominal distress."

A client develops a non-healing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. The nurse's best response is:

"Pain occurs in the legs while walking because there is a lack of oxygen to the muscles."

A client is scheduled to have a coronary artery bypass graft (CABG). The client's spouse asks what the benefit of the surgery is. How should the nurse respond?

"This surgery significantly decreases symptoms in most clients."

A client experiences elevated triglycerides and cholesterol. The client appears discouraged and says, "Well, I guess I'd better cut out all the fat and cholesterol in my diet." Which is the nurse's most appropriate response?

"You need some fat to supply the necessary fatty acids, so it's mainly just a need to cut down on the amount of fat you consume."

The nurse is completing an assessment on a couple seeking genetic counseling for sickle cell anemia. Both prospective parents carry sickle cell traits. The nurse recognizes that the couple has what chance of having a child who develops the disease?

25%

While obtaining a health history, a nurse expects a client admitted to the hospital with chronic heart failure to report:

A need to use three pillows at night to sleep

A nurse is completing the admission assessment of a client with peripheral arterial disease. What assessments are consistent with this diagnosis? (Select all that apply.)

Absence of hair on the toes Reports of pain associated with exercising

The cardiac monitor reveals a series of premature ventricular complexes (PVCs). The nurse anticipates that the client will be receiving a prescription for:

Amiodarone (Cordarone)

A nurse is teaching a client who had a myocardial infarction about the prescribed 1500-calorie, 2-gram-sodium, weight-reducing diet. Which low-sodium, low-calorie nutrients should the nurse recommend that the client include in the diet? (Select all that apply.)

Baked chicken Mashed potatoes

A client comes to the ambulatory surgery unit on the morning of an elective surgical procedure. The client reports shortness of breath, dizziness, and palpitations. The nurse observes profuse diaphoresis and is concerned that the client may be having either a panic attack or a myocardial infarction. Which assessments support the conclusion that the client may be experiencing a myocardial infarction? (Select all that apply.)

Anxiety Chest pain Irregular pulse

A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat?

Apricots

A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor and concludes that these complexes are a sign of:

Cardiac irritability

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? (Select all that apply.)

Celery sticks Luncheon meat

A client is diagnosed with Hodgkin disease. Which lymph nodes does the nurse expect to be affected first? Correct1 Cervical

Cervical

A nurse asks a client with ischemic heart disease to identify the foods that are most important to restrict. The nurse determines that the client understands the dietary instructions when the client identifies the following foods. (Select all that apply.)

Chicken broth Enriched whole milk Red meats, such as beef Liver and other glandular organ meats

When monitoring a client for hyponatremia, what clinical findings should the nurse consider significant? (Select all that apply.)

Confusion Poor tissue turgor

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiological effect of nicotine should the nurse explain to the group?

Constriction of the peripheral vessels increases the force of flow.

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? (Select all that apply.)

Coughing Orthopnea Diaphoresis

A client's serum potassium level is below the expected range. Which clinical indicators should the nurse determine are consistent with hypokalemia? (Select all that apply.)

Decreased heart rate Decreased bowel sounds

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? (Select all that apply.)

Dependent edema Distended abdomen Polyuria at night

A nurse is caring for a client with right-sided heart failure. Which are key features of right-sided heart failure? (Select all that apply.)

Dependent edema Distended abdomen Polyuria at night

When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? (Select all that apply.)

Dependent rubor Ulcers on the toes Delayed capillary refil

Amlodipine (Norvasc) is prescribed for a client with hypertension. Which response to the medication should the nurse instruct the client to report to the health care provider?

Difficulty breathing

What clinical indicators are the nurse most likely to identify when taking the admission history of a client with right ventricular failure? (Select all that apply.)

Edema Dyspnea

What clinical indicators are the nurse most likely to identify when taking the admission history of a client with right ventricular failure? (Select all that apply.)

Edema 4 Dyspnea

During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions.

Elevate the head of the bed to 45 degrees Apply oxygen via nasal cannula Reduce the flow rate of the transfusion Administer furosemide (Lasix) per provider prescription Document findings in the client record

A nurse is caring for a client with a history of hypertension and aphasia. A family member states that a complete occlusion of the branches of the middle cerebral artery resulted in the client's aphasia. What is a common cause of this type of occlusion?

Emboli associated with atrial fibrillation

When assessing for hemorrhage after a client has a total hip replacement, the most important nursing action is to:

Examine the bedding under the client

A nurse is caring for a client who has a prescription for a diuretic, 2-gram sodium diet, and an oral fluid restriction of 1200 mL daily. The most recent laboratory results are blood urea nitrogen (BUN) level 42 mg/dL and creatinine 1.1 mg/dL. Considering the assessment findings, what is the most appropriate intervention by the nurse?

Expecting an increase in the oral fluid intake

A nurse observes a window washer falling 25 feet to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first?

Feel for a pulse

A nurse is collecting data from a client with varicose veins who is to have sclerotherapy. What should the nurse expect the client to report?

Feeling of heaviness in both legs

A nurse reviews the laboratory test results of a client with emphysema who is recovering from a myocardial infarction. The nurse obtains the client's vital signs and performs a physical assessment. Which prescribed medication should the nurse consider the priority at this time?

Metoprolol (Lopresor)

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. What locations on the client's body should the nurse assess? (Select all that apply.)

Nail beds Lining of eyelids Palms of hands

A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. The nurse explains that:

Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs

An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? (Select all that apply.)

Obtain a rectal temperature. Assess the fingers for areas of frostbite. Determine client's level of consciousness. Ask for client identification.

Within the first 2½ hours after a radical neck dissection, 40 mL of medium red, bloody fluid is collected in the portable wound drainage system. What should the nurse do first?

Obtain the vital signs.

An older African-American client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? (Select all that apply.)

Occasional cocaine use African-American heritage

A nurse in the postanesthesia care unit identifies a progressive decrease in blood pressure in a client who had major abdominal surgery. What clinical finding supports the conclusion that the client is experiencing internal bleeding?

Oliguria

The nurse concludes that a client is experiencing hypovolemic shock. Which physical characteristic supports this conclusion?

Oliguria

A client develops internal bleeding after an abdominal surgery. Which signs and symptoms of hemorrhage should the nurse expect the client to exhibit? (Select all that apply.)

Pallor Tachycardia

A nurse is caring for a client with varicose veins. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.)

Presence of ankle edema Increased muscle fatigue Report of nocturnal leg cramps

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. For which risk factors should the nurse assess the client that most likely may have caused the hyponatremia? (Select all that apply.)

Profuse diaphoresis Rapid IV infusion of 5% dextrose in water

A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). What should be the primary focus of the plan during the acute phase of recovery?

Promoting physical and emotional rest

How should the nurse make the bed of a client who is in the acute phase after a myocardial infarction?

Replace the top linen and only the necessary bottom linen.

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? (Select all that apply

Reports of leg fatigue Tortuous veins in the legs Pain in lower extremities when standing

A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? (Select all that apply.)

Reports of leg fatigue Tortuous veins in the legs Pain in lower extremities when standing

A client with type 1 diabetes asks what causes the several brown spots on the skin. The nurse's best response is, "The brown spots:

Result from small blood vessel damage; the blood contains iron, which leaves a brown spot."

A client with esophageal varices is admitted with hematemesis, and two units of packed red blood cells are prescribed. The client complains of flank pain halfway through the first unit of blood. The nurse's first action is to:

Stop the transfusion

When a client has a myocardial infarction, one of the major manifestations is a decrease in conductive energy provided to the heart. What is most important for the nurse to assess that has a direct relationship to the action potential of the heart?

Strength of contractions

A person is brought to the emergency department after prolonged exposure to cold weather. What clinical manifestations of hypothermia does the nurse expect? (Select all that apply.)

Stupor Paresthesia in affected body parts

A client is discharged with a prescription for sustained-release nitroglycerin. What should the nurse teach the client about sustained-release nitroglycerin?

Swallow the capsule whole

A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? (Select all that apply.)

Tender area in the posterior lower leg Warmth along the course of the involved vessel

A nurse observes the following dysrhythmia on a client's cardiac monitor. What rhythm does the nurse identify?

Ventricular fibrillation

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next?

Verify the pulse by using a Doppler

The nurse is making rounds on a patient who has developed severe bone marrow depression after receiving chemotherapy for cancer. Which of these actions by the nurse is appropriate? (Select all that apply.)

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately.

A client with a tentative diagnosis of pernicious anemia is scheduled for a Schilling test. Which body process associated with vitamin B12 is assessed with the Shilling test?

Absorption

A client with chronic heart failure is taking a diuretic twice a day. The health care provider prescribes a diet that includes the intake of dietary potassium. What foods that have a higher amount of potassium should the nurse instruct the client to consume? (Select all that apply.)

Bananas Baked potatoes with skins

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? (Select all that apply.)

Change positions slowly. Report peripheral edema. Avoid drinking grapefruit juice

A client with arterial insufficiency of both lower extremities is visited by the home health care nurse. An essential nursing intervention is to teach the client to:

Check pulses in the legs regularly

A nurse is assessing a middle-aged female client for the presence of risk factors associated with coronary heart disease. Which risk factor carries a greater risk for women than for men?

Diabetes mellitus

An older adult tells the nurse, "I read about a vitamin that may be related to aging because of its effect on the structure of cell walls. I wonder whether it is wise to take it." The nurse concludes the client probably is referring to:

E

An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid and the serum electrolyte value demonstrates hyponatremia. The nurse concludes that the element that most likely contributed to the hyponatremia is:

Fluid intake

A client is taking furosemide (Lasix) and digoxin (Lanoxin) for heart failure. Why does the nurse advise the client to drink a glass of orange juice every day?

Maintaining potassium levels

A client is diagnosed with acute lymphoid leukemia and is receiving chemotherapy. The nurse should monitor what thrombocytopenic side effects of chemotherapy? (Select all that apply.)

Melena Purpura Hematuria

During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?

Pulsating abdominal mass

A client has a low hemoglobin level, which is attributed to nutritional deficiency, and the nurse provides dietary teaching. Which food choices by the client indicate that the nurse's instructions are effective? (Select all that apply.)

Raisins Spinach

A client's blood pressure increases dramatically 6 hours after a femoral-popliteal bypass graft. Which concern motivates the nurse to inform the health care provider?

Rapidly increasing blood pressure may rupture the graft.

A client is admitted with thrombocytopenia. What specific nursing actions are appropriate to include in the plan of care for this client? (Select all that apply.)

Avoid intramuscular injections Examine the skin for ecchymotic areas

A client with varicose veins asks a nurse what is involved when ligation and stripping are performed rather than sclerotherapy. What should the nurse consider when planning a response in language the client will understand?

The dilated saphenous veins are removed.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction occurs.

A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication?

Aspirin (ASA)

A primary health care provider prescribes atenolol (Tenormin) 20 mg by mouth four times a day for a client who has had double coronary artery bypass surgery. What information is most important for the nurse to include in the discharge teaching plan for this client?

Avoid abruptly discontinuing the medication

A nurse is caring for a client who had pelvic surgery. The nurse should monitor for which clinical manifestations of thrombophlebitis? (Select all that apply.)

Tender area on the leg Warm area over the calf

A client with heart failure is digitalized and placed on a maintenance dose of digoxin (Lanoxin) 0.25 mg by mouth daily. What responses does the nurse expect the client to exhibit when a therapeutic effect of digoxin is achieved?

Diuresis and decreased pulse rate

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? (Select all that apply.)

Dry mouth Palpitations Constipation Orthostatic hypotension

When assessing a client with the diagnosis of left ventricular failure, the nurse expects to identify:

Dyspnea on exertion

Which factors should the nurse identify that can precipitate hyponatremia? (Select all that apply.)

Gastrointestinal (GI) suction Diuretic therapy Continuous bladder irrigation

A client with a history of hypertension develops dyspnea on exertion. What does the nurse conclude is the most likely cause of the client's dyspnea? Incorrect1 Cor pulmonale

Left heart failure

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? (Select all that apply.)

Unusual fatigue Dependent edema Nocturnal dyspnea

Laboratory results of a client's blood after chemotherapy indicate bone marrow depression. What should the nurse encourage the client to do? (Select all that apply.)

Use a soft toothbrush. Read the ingredients in over-the-counter drugs before taking them.

A client is brought to the emergency department with moderate substernal chest pain radiating to the inner aspect of the left arm, unrelieved by rest and nitroglycerin. The pain is associated with slight nausea and anxiety. What is the priority nursing intervention for this client?

Provide pain medication

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings should alert the nurse to the possible development of the life threatening response of thrombocytopenia? (Select all that apply.)

Hematuria Ecchymosis

A client takes isosorbide dinitrate (Isordil) daily. The client states, "I would like to start taking sildenafil (Viagra) for erectile dysfunction. I was told I can't take sildenafil and isosorbide dinitrate at the same time." The nurse explains that taking both of these medications concurrently may result in severe:

Hypotension

A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states what?

I will elevate my foot.

A client has coronary artery bypass graft (CABG) surgery for the second time via a sternal incision. What should the nurse teach the client to expect when returning home?

Increased edema in the leg that provided the donor graft

A client with impaired peripheral pulses and signs of chronic hypoxia in a lower extremity is scheduled for a femoral angiogram. What would be appropriate for the nurse to include in the postprocedure plan of care?

Perform a neurovascular assessment every two hours

Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate?

Protamine sulfate to parenteral heparin

A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis?

Put on elastic stockings before arising

A nurse is caring for a client with an infection caused by group A beta-hemolytic streptococci. The nurse should assess this client for responses associated with which illness?

Rheumatic fever

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse expect to be listed on the client's plan of care?

Small, frequent intake of juices, broth, or milk.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock?

Thirst, cool skin, and orthostatic hypotension

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client two days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of:

Tissue necrosis