UACCB GEN RN HESI WEEK 11

The nurse develops a teaching plan for a client with diabetes who has been diagnosed with lower extremity arterial disease (LEAD). What measures should the nurse include to increase arterial blood flow to the extremities?

exercise that promotes muscular activity

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?

pulmonary embolism

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure?

"I wake up at night short of breath."

A nurse is discussing discharge instructions with a patient who had a coronary artery bypass graft (CABG). The client states, "My spouse is afraid to have sex with me. When will it be safe to have sex again?" Which is the most appropriate response by the nurse?

"You can resume sexual activity as soon as you can climb one flight of stairs without fatigue or discomfort."

While assessing a client's vascular system, the nurse finds that pulse strength is diminished or barely palpable. Which documentation is appropriate in this situation?

1+

A 16-year-old client has a blood pressure reading of 119/75. What is the approximate pulse pressure? Record your answer using a whole number. __________ mm Hg

44

A client who just returned from a cardiac catheterization reports to the nurse that the pressure bandage on the right groin is tight. What action should the nurse take?

Assess the pulses distal to the dressing

A client who is receiving atenolol for hypertension frequently reports feeling dizzy. What effect of atenolol should the nurse consider may be responsible this response?

Blocking the adrenergic response

A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient?

warmth of the toes of both feet

The nurse is assessing four clients in a healthcare setting who are at risk for developing a respiratory disorder. Which client's chest examination findings indicate pulmonary fibrosis?

Client 3

A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply.

Dependent edema Swollen hands and fingers Right upper quadrant discomfort

Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time?

Helping the client change her position

A 10-year-old child with sickle cell anemia is admitted to the unit in vaso-occlusive crisis (VOC). After the child has been given the prescribed analgesic, which intervention is the priority to minimize the effects of the crisis?

IV Fluids

A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated?

Identify the absence of a pulse

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)?

Inactivity

A healthcare provider prescribes enalapril for a client. Which is the most important nursing action?

Monitor the client's blood pressure during therapy.

A chest tube with an attached closed-drainage system is inserted into a client who was stabbed in the chest. Which is an important nursing intervention when caring for this client?

Observe for fluid fluctuations in the water-seal chamber.

A nurse is assessing an ECG rhythm strip. Which component of the tracing will the nurse observe to determine ventricular depolarization?

QRS complex

Late decelerations are present on the monitor strip of a client who received epidural anesthesia 20 minutes ago. What should the nurse do immediately?

Reposition the client from supine to left lateral.

The nurse notes that the client's ECG rhythm strips show more P waves than QRS complexes. When there are PR intervals, they are all consistent. How should the nurse interpret this strip?

Second degree AV block Mobitz II

A 3-year-old child is admitted to the pediatric unit with a hemoglobin level of 6.4 g/dL (64 mmol/L). What should the nurse's priority assessment be?

Signs of cardiac decompensation

A nurse on the Code Blue/Arrest team responds to a code that is called for a client with hyperkalemia who is experiencing cardiac standstill. What would an appropriate immediate treatment plan include?

Sodium bicarbonate

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen?

To increase oxygen concentration to heart cells

A nurse is working with a cardiologist for a client needing temporary pacing. Which methods are examples that the cardiologist with the assistance of the nurse might use? Select all that apply.

Transcutaneous pacing Transvenous pacing Epicardial pacing

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency?

practice relaxation techniques

The parents of a child who is scheduled for open-heart surgery ask why their child must be subjected to chest tubes after surgery. What should the nurse consider before responding in language that the parents will understand?

chest tubes facilitate drainage of air and fluid

The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client?

class 3

When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress?

climbing a flight of stairs to the bedroom

What assessment finding should a nurse expect to note in a child with chronic hypoxia?

clubbing of fingers

A client with a history of occasional pain in the left foot when walking now has pain at rest. The left foot is cyanotic, numb, and painful. The suspected cause is arteriosclerosis. Which information will the nurse share with the client to help decrease the pain?

comply with prescribed exercise program