study guide 3

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider required clarification?

0.9% Normal saline IV at 50ml/hr continuous

A nurse is caring for a client following the insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure?

A. "I can't get rid of these hiccups."

A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following indicates effective treatment?

A. Absence of adventitious breath sounds.

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

A. Check the client's vital signs Rationale: It's possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. Withhold medication and call provider if client's heart rate is >60bpm

A nurse in an emergency department is assessing a client who has a bradydysrhythmia. Which of the following findings should the nurse monitor for?

A. Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status. Also monitor client for hypotension and diaphoresis. Friction rub is an expected finding

A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect?

A. Dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI) ?

A. Serum creatinine 1.8mg/dL Rationale: An indication that the client is at risk for developing AKI is a creatinine level that is 1.5 times greater than the expected range. In an older female client, the expected range for creatinine is 0.5-1.2 mg/dL

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately?

A. Slurred speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?

A. These tests help determine the degree of damage to the heart tissues.

A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider?

A. Weight gain of 0.9 kg (2lb) in 24 hr Rationale: When using the urgent vs. non urgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 1.2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching?

A. You might no longer be able to feel chest pain Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart

A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's history reveals they are 1 week postoperative following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated?

Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy

A nurse is caring for a client who reports a new onset of chest pressure severe epigastric distress. The physician prescribes monitoring of the creatine kinsase (CK) isoenzymes. When should the nurse anticipate the CK isoenzymes will begin to rise if the client has had a MI (Select all that apply)

B, C. 2 hr 3 hr. Rationale: Creatine kinase is an isoenzyme that is found in skeletal muscles, the heart, and the brain. The isoenzyme specific to heart is CK-MB, which can accurately detect tissue necrosis or injury within a few hours of onset. One of the earliest markers of an MI is myoglobin, which begins to rise within 2 hrs of injury. However, it is not specific to heart tissues and has limited diagnostic usefulness

A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease?

B. A client who has diabetes mellitus

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heartbeat with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? A. First-degree AV block B. Atrial fibrillation C. Sinus bradycardia D. Sinus tachycardia

B. Atrial fibrillation Rationale: A-fib causes a disorganized twitching of the atrial muscles. The rate is irregular with no visible P waves. The ventricular response is irregular which results in an irregular pulse and a pulse deficit First-degree AV block is a regular rhythm w/ a prolonged P-R interval. A pulse deficit doesn't occur. Sinus bradycardia is a slow heart rate w/ a regular rhythm. A pulse deficit doesn't occur. Sinus tachycardia is a rapid heart rate w/ a regular rhythm. A pulse deficit doesn't occur.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

B. Blood pressure 115/68 mmHg Rationale: The sympathetic nervous system is stimulated, resulting in the release or epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure within normal limits during the compensatory stage of shock.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medication should the nurse identify as most important for the client's recovery?

B. It facilitates the client's deep breathing Rationale: When using the ABC approach to client care, the nurse should identify facilitation of deep breathing as the most important desired effect of opioids aside from pain relief.

A nurse is caring for a client who is being treated for heart failure and has a prescription for furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication?

B. Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

B. Manifestations preceded by a severe headache Rationale: A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden severe headache is an expected initial manifestation.

A nurse is caring for a client who was admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first?

B. Review serum electrolyte values

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

B. The client should hold his cell phone on the side opposite the ICD Rationale: Close proximity could interfere with the ICD's function

A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to supraventicular tachycardia. The nurse should prepare to assist with which of the following interventions?

B. Vagal stimulation

A nurse is caring for a client who is 8hr postoperative following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report?

Blood pressure 160/80 mmHg Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should identify that an increase in which of the following values is diagnostic of a myocardial infarction (MI)?

Creatine kinase-MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury

A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory values?

C. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL

A nurse is caring for a client who is schedule for a coronary artery bypass graft (CABG) in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse?

C. I took my warfarin last night according to my usual schedule

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

C. Pacemaker spikes before each QRS complex Rationale: The pacemaker fires, showing a spike on the monitor strip, which stimulates the ventricle, and the QRS complex appears, indicating that depolarization has occurred.

A nurse is caring for a client who has a-fib and is receiving heparin. Which of the following findings is the nurse's priority?

C. The client experiences sudden weakness of one arm and leg Rationale: Sudden weakness or numbness of the face and one arm or leg can indicate the client is at greatest risk for stroke. In addition to these findings, the client may appear confused, have slurred speech, loss of balance, dizziness, or sudden severe headache

A nurse is caring for a client who has a history of angina and is schedules for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling?

D. "I smoked a cigarette this morning to calm my nerves about having this procedure."

A nurse is assessing a client who has a history of deep-vein thrombosis and is receiving warfarin. Which of the following findings should indicate to the nurse that the mediterm-2cation is effective?

D. INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and stroke.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

D. Packed RBC's

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds?

D. Stop the heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse is caring for a client who has endocarditis. Which of the following should the nurse recognize as a potential complication?

D. Valvular disease

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mmHg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions B. Tell the client to report vision changes C. Elevate the head of the client's bed D. Start a peripheral IV

Elevate the head of the client's bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

Hypotension Rationale: Verapamil is a calcium channel blocker & can be used to control supraventricular tachyarrhythmias. It also decrease BP and acts as a coronary vasodilator and anti-anginal agent. BP and pulse must be monitored before and during parenteral admin.

A nurse is planning a presentation for a group of clients who have hypertension. Which of the following lifestyle modifications should the nurse include? (Select all that apply)

Limit alcohol Regular exercise Tobacco cesattion

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? A. Serum cardiac enzyme levels B. MRI of the chest C. Physical therapy D. Low-sodium diet

MRI of the chest Rationale: A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction

A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat hypertension. The nurse should instruct the client to notify their provider if they experience which of the following adverse effects of this medication.

Persistent cough

A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching?

Place the patch on an area of skin away from skin folds and joints

A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior the the procedure?

Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.

A nurse is reviewing the laboratory values of a client who had a MI 3 hrs ago. The nurse should expect which of the following values to be elevated?

Troponin I Rationale: Troponin I and Troponin T are biochemical markers that are specific to myocardial cell injury. A client who has MI cell damage can have elevated troponin levels within 2-3hrs. Troponin I levels pearl in 10-24 hrs and stay elevated 10-14 days

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a MI (select all that apply) A. Troponin I B. Troponin T C. Plasma low-density (LDL) D. CPK E. Myoglobin

Troponin I, Troponin T, CPK, Myoglobin Rationale: Troponin I and Troponin T are myocardial muscle proteins that release when there's injury to cardiac muscle. Levels are elevated 2-3 hrs following MI. CPK is an enzyme that is elevated in the presence of muscle injury. Not specified to MI damage, but used in conjunction with other diagnostic tests. Myoglobin levels increase significantly within 3 hrs following MI

A nurse is caring for a client who is 1 hr postoperative following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider?

Urine output of 20mL/hr Rationale: Urine output less than 30mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture

A nurse is assessing a client who has left-sided heart failure. Which of the following manifestations should the nurse expect to find?

Weak peripheral pulses Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure. All other answers result from right-sided heart failure.