Quiz #2 - Ch. 33, 35 36

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client should alert the nurse to the presence of edema?

My shoes fit tighter by the end of the day.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the clients leg. d. Provide an ice pack.

* Apply a warm moist pack.

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

* Apply compression stockings. * Assist with ambulation * Offer fluids frequently.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

* Assess the clients lung sounds and oxygenation.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best? a. Assess the reason behind the clients fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

* Assess the reason behind the clients fear.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

* Baked chicken breast, broccoli, tomatoes

A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

* Client who had a first dose of captopril (Capoten) and needs to use the bathroom

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

* Consult with the Wound Ostomy Care Nurse.

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. Could you walk further than that a few months ago? b. Do you walk mostly uphill, downhill, or on flat surfaces? c. Have you ever considered swimming instead of walking? d. How much pain medication do you take each day?

* Could you walk further than that a few months ago?

An emergency room nurse assesses a female client. Which assessment findings should alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)

* Fatigue despite adequate rest * Indigestion * Shortness of breath

A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?

* Heart rate of 120 beats/min

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.) a. Ill read the nutritional labels on food items for salt content. b. I will drink at least 3 liters of water each day. c. Using salt in moderation will reduce the workload of my heart. d. I will eat oatmeal for breakfast instead of ham and eggs. e. Substituting fresh vegetables for canned ones will lower my salt intake.

* Ill read the nutritional labels on food items for salt content. * I will eat oatmeal for breakfast instead of ham and eggs. * Substituting fresh vegetables for canned ones will lower my salt intake.

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

* Oxygen saturation of 98%

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

* Palpating both carotid arteries at the same time

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. b. Teach the client to perform deep-breathing exercises. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning. e. Place the client on oxygen if the client becomes short of breath.

* Reposition the client every 2 hours. * Accurately record intake and output. * Use the same scale to weigh the client each morning.

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below should the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation?

* location A

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 c. Pulmonary hypertension d. Dependent edema e. Cough that worsens at night

*Pulmonary crackles *Confusion, restlessness *Cough that worsens at night

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. c. Encourage the client to take a baby aspirin each day. d. Confirm that an echocardiogram has been completed. e. Consult a social worker for additional resources.

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

A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease?

A 45-year-old American Indian woman with diabetes mellitus

An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first?

A 58-year-old male who describes his pain as intense stabbing that spreads across his chest

A nurse cares for a client who has advanced cardiac disease and states, I am having trouble sleeping at night. How should the nurse respond?

Use pillows to elevate your head and chest while you are sleeping.

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

Assess the clients respiratory status.

Which Statement would the nurse include in this patient's teaching who has right-sided heart failure

Avoid using salt substitutes

A nurse assesses an older adult client who is experiencing a myocardial infarction. Which clinical manifestation should the nurse expect?

Disorientation and confusion

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

Dyspnea on exertion

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching? a. Walk until you become short of breath, and then walk back home. b. Gather everything you need for a chore before you begin. c. Pull rather than push or carry items heavier than 5 pounds. d. Take a walk after dinner every day to build up your strength.

Gather everything you need for a chore before you begin.

An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure?

I get short of breath when I climb stairs.

A nurse prepares a patient for coronary cardiac catheterization surgery the patient states, "I'm afraid i might die", What is the nurses best response.

Tell me more about your concerns about the test

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

Weigh yourself daily while wearing the same amount of clothing.

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?

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 dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond? a. Would you like to talk more about this? b. You are lucky to have such a devoted daughter. c. It is normal to feel as though you are a burden. d. Would you like to meet with the chaplain?

Would you like to talk more about this?

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this clients teaching?

You should balance weight loss with consuming necessary nutrients.